Every finding on record at Slaton Care Center

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. 1. The facility failed to ensure dietary staff (DA C and [NAME] D) ensured food was stored, prepared, and served under sanitary conditions. Multiple food items which included cornbread mix, cooked cornbread, bread pudding, salad ingredients, and grilled cheese sandwiches were repeatedly left uncovered for extended periods while in the kitchen and on the serving line 2. The facility failed to ensure Dietary staff (Cook D) consistently performed required hand hygiene. The cook repeatedly donned and removed gloves without washing hands before or after glove use while preparing multiple food items. 3. The facility failed ensure resident drink cups were stored on 12/3/25: Trays were stacked directly on top of uncovered cups, exposing the rims of the cups to the unsanitary underside of serving trays. The DOR was later observed moving and serving these cups to residents without correcting the contamination risk. These failures could place residents at risk for food contamination and foodborne illness. The findings include:The following observations were made on 12/2/25 in Kitchen A between 10:19 AM-12:53 PM :-Cornbread mix was uncovered during the following times:-Dry cornbread mixture was observed uncovered upon entry into the kitchen at 10:32 AM. At 10:48 AM, [NAME] D poured milk and began mixing the cornbread mixture (16 minutes). -At 11:17 AM, [NAME] D was observed pulling the cornbread mixture out of the oven. He placed it on the serving table uncovered and went to complete other duties (obtaining other dishes and taking dishes to the dishwasher). The cooked cornbread remained uncovered until 11:23 AM, when the Dietary Manager walked by and placed foil on top of the cooked cornbread and then placed it on top of the oven (6 minutes). -The bread pudding was observed uncovered during the following times: At 11:05 AM, DA C pulled the bread pudding out of the oven and placed it on a side table within the kitchen uncovered. DA C did not start cutting the bread pudding until 11:23 AM. At 11:24 AM, DA C was observed placing the bread pudding on plates. Thirty eight plates of bread pudding remained uncovered from 11:24 AM until 11:41 AM (20 minutes). At 11:41 AM, 24 plates of bread pudding were observed covered while 14 plates of bread pudding remained uncovered. At 11:44 AM, DA C obtained two plates of bread pudding to puree. Twelve plates of bread pudding were observed uncovered. The 12 plates of regular bread pudding were observed uncovered from 11:41 AM to 11:44 AM (3 minutes). At 11:44 AM, DA C added one container of pureed bread pudding to the 12 regular plated bread puddings that were uncovered. The 12 plates plus the one pureed serving of bread pudding remained uncovered from 11:46 AM to 12:49 PM when the first plate was served (1 hour and 3 minutes). -The salad was observed uncovered during the following times: At 11:02 AM, [NAME] D was observed obtaining the green cutting board and the lettuce. [NAME] D chopped the lettuce and placed it in a metal bowl. The lettuce remained uncovered in the metal bowl until [NAME] D placed sliced tomatoes in the salad at 11:23 AM. The lettuce in the bowl remained uncovered while not being served or prepared for a total of 21 minutes. [NAME] D walked away from the salad at 11:23 AM, and 6 minutes later at 11:27 AM, he placed shredded cheese in the salad and then placed it in the refrigerator at 11:28 AM. -The grilled cheese sandwiches were observed uncovered during the following times: [NAME] D was observed making two grilled cheese sandwiches between 11:56 AM and 11:57 AM. He walked away, leaving one grilled cheese sandwich on the stove not being cooked, while the other grilled cheese sandwich remained on a plate uncovered on the table within the kitchen. The two grilled cheese sandwiches remained uncovered from 12:01 PM until 12:35 PM, when [NAME] D covered the two sandwiches with foil and placed them on the serving table. The two sandwiches remained uncovered for 34 minutes total. Observation on 12/02/25 at 11:02 AM revealed [NAME] D did not perform hand hygiene and placed a pair of gloves on before cutting the lettuce for the salad. [NAME] D removed the gloves at 11:04 AM and did not perform hand hygiene. At 11:20 AM, [NAME] D did not perform hand hygiene and placed a pair of gloves on before placing butter on the cornbread, pouring rice inside a serving container, and cutting tomatoes for the salad. At 11:25 AM, [NAME] D removed the pair of gloves and did not perform hand hygiene. At 11:57 AM, [NAME] D was observed not performing hand hygiene and placed a pair of gloves on to prepare two grilled cheese sandwiches. At 12:04 PM, [NAME] D removed the gloves and did not perform hand hygiene. The following observations were made on 12/3/25 in Kitchen A:-At 11:21 AM, on a rolling cart, two trays of cups were observed stacked on top of one another. The bottom tray had 24 clear glasses which contained what appeared to be water. The rims of the glasses were exposed to the bottom of the serving tray above them. On that serving tray, there were seven red glasses and 24 clear glasses that also appeared to have water in them. The rims of those glasses were exposed to the bottom of another serving tray. -At 12:22 PM, the DOR was observed filling the glasses that were placed on the cart at 11:21 AM without ice. The DOR was observed moving the bottom of the trays over the glasses that did not contain liquid, exposing the remainder of the glasses rims to the bottom of the serving tray. During an interview on 12/4/25 at 12:02 PM, the DM stated she was not aware of the cornbread, bread pudding, salad, and grilled cheese sandwiches being uncovered on 12/2/25. The DM stated she was unaware the cook did not perform hand hygiene before and after putting on gloves. The DM stated she was unaware the trays of cups were next to the ice bin and the bottom of the serving trays were exposed to the rims of the glasses. The cook stated she did not know she could not leave food uncovered in the kitchen. She stated she believed it only had to be covered when it went down the halls. She stated her system to monitor violations in the kitchen was to be present so she could intervene if needed. She stated she was trained in handwashing and not exposing cup rims to the bottom of serving trays but had not been trained that food must be covered while in the kitchen. She stated the expectation was she would start covering everything. She stated she expected handwashing always be done, especially with glove usage(before and after). She stated the cups should not have been exposed to the bottom of the serving tray because all cups had lids and staff should have used the lids. She stated the potential negative outcome of not covering food was that bugs or flying debris could get into it. She stated the potential negative outcome for placing the bottom of the serving tray on the rims of the glasses was the tray could contaminate the rims. She stated the potential negative outcome of not using proper handwashing was cross contamination, which could make residents sick depending on what was on the staff member's hands. She stated whoever was plating food was responsible for ensuring it was covered, but essentially it was everyone's responsibility. She stated the aide in the kitchen would be responsible for placing lids on the cups, but if aides in the dining room were filling the cups with tea or juice, they would be responsible. The DM stated there was no reason why the food observed was not immediately covered or properly stored. She stated there was no reason she could give as to why the glasses were exposed to the bottom of the serving tray or why the cook did not perform hand hygiene. The DM stated she was familiar with the food policy regarding the storage of food and handwashing.During an interview on 12/4/25 at 12:27 PM, the DOR stated she was the staff who filled the ice on 12/3/25 at 12:22 PM. She stated sometimes she assisted staff in the kitchen by filling ice when they needed help in the dining room. She stated when she entered the kitchen on 12/3/25, she was asked to fill the ice but was unsure which staff member asked her. She stated this was her third time overall filling ice in the dining room. She stated she could not recall if the trays were always stacked on top of the cups, exposing the rims to the bottom of the trays, but stated they were stacked that way on 12/3/25. She stated the potential negative outcome of the bottom of a tray touching the rims of glasses was it could make the rims dirty and potentially make residents sick. She stated all of the drinks on the rolling cart that day were served to the residents. She stated she did not recognize the stacking practice was improper because she did not regularly work in the dining room. She stated she had not been trained to look for issues like that in the kitchen. She stated she was not familiar with the dietary storage policy because she did not regularly handle kitchen items. During an interview on 12/4/25 at 12:52 PM, the ADM stated he was not aware of the observations made on 12/2/25 and 12/3/25 regarding uncovered food items, improper storage of resident cups, and poor hand hygiene. The ADM stated the system to monitor the kitchen relied on staff following policy and procedure regarding covering food, storing cups properly, and performing hand hygiene. He stated he was trained on dietary expectations and held a safe food certification, as did all dietary workers. He stated he expected all food not actively being served to be covered immediately and defined immediately as within 15 minutes. He stated very hot food may not be covered immediately due to steam. He stated he expected staff to follow policy regarding cup storage and to use the lids available for the resident cups. The ADM stated [NAME] D had been addressed regarding his hand hygiene during the survey. He stated dietary staff were expected to wash their hands before and after glove use. He stated the potential negative outcome of exposing the rims of cups to the bottom of the serving trays was contamination, which could expose residents to bacteria. He stated failing to perform proper hand hygiene could also transmit bacteria. He stated failing to cover food that was not actively being served or prepared could result in bugs or debris getting into the food. He stated dietary staff were responsible for covering food not being served, and both nursing and dietary staff were responsible for ensuring resident cups were properly stored. He stated dietary staff were responsible for the cups while they were in the kitchen and clinical staff while the cups were in the dining room. He stated all staff were responsible for proper hand hygiene. He stated he did not have a reason why handwashing was not conducted, food was uncovered, or cups were improperly stored. He stated he was familiar with the facility's food storage, labeling, and expectation policies. During an interview on 12/4/25 at 1:17 PM, [NAME] D stated he was not aware of his failure to perform hand hygiene before and after using gloves. He stated he realized he did not cover the cornbread only after seeing the DM cover it. He stated he was unaware of any other failures identified on 12/2/25 and 12/3/25. He stated he may need additional training because he did not know he was required to wash his hands before and after glove use. He stated he completed computer-based training. He stated he was trained to cover food not actively being served but may not have done so because he was moving fast and liked to finish tasks quickly. He stated he was trained to wash his hands when exiting the kitchen but not specifically before and after glove use. He stated failing to cover food could allow flies or unseen debris to get into the food. He stated failing to wash hands was gross and could cause residents to get sick. He stated he, as the cook, was responsible for handwashing and covering food that was not actively being served or prepared. He stated he did not cover food because he was distracted and forgot. He stated he was familiar with the food storage, labeling, and expectation policy. During an interview on 12/5/25 at 2:25 PM, DA C stated she was aware she did not cover the bread pudding because she was allowing it to cool. She stated she was trained to cover food not actively being served and normally covered it with saran wrap. She stated she covered some of the plated bread puddings because they were for residents who ate in their rooms. She stated she understood food had to be covered when transported down the halls. She stated the other plated bread puddings were for residents dining in the dining room. She stated she was aware she used trays to cover resident cups, which exposed the rims to the bottom of the tray. She stated she could not recall who told her that was acceptable, but she was told by a person before the current DM. She stated the potential negative outcome for not covering food was dust or flies could get into it. She stated stacking the cups and covering them with the tray could cause cross-contamination. She stated she did not know exposing the rims of the cups to the bottom of trays was a violation. She stated all trays went through the dishwasher. She stated all staff were responsible for covering food not actively being served. She stated they had two types of lids. She stated nurses or aides usually covered the cups, because they still needed ice. She stated she covered the other cups because they contained water. She stated she was responsible for storing the cups properly. She stated she did not cover the bread pudding because she was letting it cool, and she stacked the cups because she did not know she could not. She stated she was familiar with the facility policies and was trained to cover food immediately. Record review of the DM's food handler training revealed she completed the food handler training program on 8/26/24 (valid for 5 years).Record review of the [NAME] D's food handler training revealed he completed the food handler training program on 08/3/23 (valid for 3 years).Record review of DA C's food handler training revealed she completed the food handler training program on 7/22/23 (valid for 3 years).Record review of the DM's food handler training revealed he completed the food handler training program on 6/19/25 (valid for 3 years).Record review of the facility's, undated, policy Food Receiving and Storage revealed: Introduction: Specific procedures are required to maintain a safe food supply. The resident residents in our facilities tend to be at higher risk for infection and illness than are the rest of the population. Because of this, special care should be given to protecting the food supply so that our residents remain as healthy as possible.Outline: Meaning a safe food supply includes steps to prevent foodborne illness to include hand washing, kitchen sanitation, and proper food temperatures must be maintained to prevent bacteria and other organisms from growing in food.Storage and leftovers or open foods:leftovers are open food items should be completely covered in a clean approved container. Record review of the facility policy, Handwashing, dated 2012, revealed: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing.The facility's hand washing policy did not address hand hygiene expectations regarding glove usage. Record review of 2022 Food Code U.S. Food and Drug Administration revealed:Preventing Contamination from the premises (Food Storage):3-302.11(A)Food shall be protected from contamination by storing food: Where it is not exposed to splash, dust, or other contamination. This includes:Covering food using lids, wrappers, foil, sneeze guards, or other protective barriersPreventing exposure to dust, debris, insects, drips, splash, equipment surfaces, and employees3-303.12(A) Food on display shall be protected from contamination by packaging, sneeze guards, or other effective means.Sections 2-301.14 and 2-301.152-301.14 - When Handwashing Is RequiredEmployees shall wash their hands:Before donning gloves to initiate a task involving foodAfter removing glovesAfter engaging in activities that contaminate the handsBefore working with exposed food, clean equipment, or utensils2-301.14(I)After removing gloves.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #20) reviewed for infection control. LVN A failed to wear proper PPE (a gown) when providing wound care for Resident #20 who was on EBP. This failure could place residents at risk for the spread of infection and cross contaminationRecord review of Resident #20's face sheet, dated 12/03/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included: non-pressure chronic ulcer of right ankle, Type II Diabetes Mellitus (condition in which the body does not use insulin effectively), and cerebral infarction (stroke). Record review of Resident #20's annual MDS, dated [DATE], reflected a BIMS score of 09, which indicated the resident had moderate cognitive impairment. Section - M - Skin Conditions reflected the resident had an ulcer requiring a nonsurgical dressing.Record review of Resident #20's Comprehensive Care Plan, revised on 08/28/25, reflected the resident was on Enhanced Barrier Precautions with interventions: Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, trach care or other high-contact activity. The care plan further reflected the resident had a non-pressure wound to the right ankle with interventions: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #20's current physician's orders, dated 12/03/25, reflected an order with a start date of 11/12/25 to treat venous wound of the right ankle daily. During an observation on 12/03/25 at 11:09 AM, LVN A performed wound care to Resident #20's right ankle wound, per physician's orders. LVN A put on gloves but failed to put on a gown prior to performing wound care for Resident #20. Enhanced Barrier Precaution signage was noted to the door of Resident #20's room and a storage cart for PPE was noted sitting at the entrance to Resident #20's room. During an interview on 12/03/25 at 11:21 AM, LVN A stated she did not put on a gown prior to performing wound care for Resident #20 who was on EBP. She stated she did not think to put on the required PPE (gown) due to being focused on performing wound care correctly. She stated she was trained on EBP through in-services conducted by nursing administration, as well as by computer-based training. LVN A stated PPE should be worn when conducting direct care on any resident who was on EBP. She stated a potential negative outcome for failure to implement EBP would be contaminating wounds, passing bacteria between residents, and causing an infection. During an interview on 12/04/25 at 12:28 PM, the ADM stated he was not aware staff were performing wound care on EBP residents without utilizing proper EBP. He stated nursing administration was responsible for training staff on EBP and for assuring staff were following proper EBP guidelines. The ADM stated his expectation of staff was to follow the facility policy for EBP at all times. He stated a potential negative outcome for failure to properly observe EBP was the spread of infection. During an interview on 12/04/25 at 12:50 PM, the DON stated EBP should be implemented on a resident with a wound and staff should follow EBP guidelines when performing wound care. She stated nursing administration was responsible for training staff on the use of PPE for EBP residents. The DON stated staff were trained on EBP through in-services conducted by nursing administration. She stated EBP was monitored by random checks during the direct care of residents on EBP. The DON stated a potential negative outcome for failure to utilize PPE on a resident with EBP was infection. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated 04/01/2024 reflected: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient.EBP are indicated for residents with any of the following:.Wounds and/or indwelling medical devices .

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 2 medication carts (Medication Cart A, and Medication Cart B), reviewed for medication storage. 1. The facility failed to ensure Medication Cart B did not contain a loose pill. 2. The facility failed to ensure Medication Cart A did not contain a loose pill. These failures could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions.Observation on [DATE] at 3:09 PM, of Medication Cart B with MA A revealed a small, white, round, loose pill (1/2 pill) found in a drawer of the medication cart. MA A placed the pill in a dispensing cup and took it to the DON for identification. The DON identified the medication as Metoprolol 25mg tablet (1/2 tablet). MA A destroyed the loose pill by placing it in a bottle of liquid utilized for medication destruction. Observation on [DATE] at 3:21 PM, of Medication Cart A with MA A revealed a small, white, round, loose pill (1/2 pill) found in a drawer of the medication cart. MA A placed the pill in a dispensing cup and took it to the DON for identification. The DON identified the medication as Metoprolol 25mg tablet (1/2 tablet). MA A destroyed the loose pill by placing it in a bottle of liquid utilized for medication destruction. During an interview on [DATE] at 11:44 AM, MA A stated she was unsure why the carts (Medication Carts A & B) contained loose pills. She stated the blister packs could get bumped around and knock the pills loose. MA A stated she usually checked the medications carts daily for loose and expired pills and cleanliness. She stated she was trained on proper medication storage through in-services and through occasional cart audits conducted by the pharmacy consultant. MA A stated a potential negative outcome for loose pills on the cart was the resident could miss a dose of medication. During an interview on [DATE] at 12:28 PM, the ADM stated he was not aware there were loose pills on the medication carts. He stated nursing staff and nursing administration were responsible for assuring proper storage of medications on the carts. He stated monitoring of the medication carts was done through random cart audits conducted by nursing administration. The ADM stated a potential negative outcome for failure to properly secure medications on the carts was missed counts and not having enough medication for a resident. During an interview on [DATE] at 12:50 PM, the DON stated there should not be loose pills on the medication carts. She stated the nursing staff and MA's were responsible for the proper storage of medications on the carts. She stated nursing staff and MA's were trained on proper storage of medication through in services and annual competency checks conducted by nursing administration. The DON stated the pharmacy consultant conducted medication cart audits during monthly visits. The DON stated a potential negative outcome for failure to properly secure medication on the carts was a resident could get the wrong medication or miss a scheduled dose of medication. Record review of the facility's undated policy titled, PCU027 - Medication Storage in the Facility reflected: PolicyMedications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 1. [Dispensing Pharmacy] dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers.

Based on observation, interview and record review the facility failed to ensure menus were followed for 1(Resident #28) of 17 residents reviewed for food and nutrition services. The facility failed to follow the week 1 menu for one lunch service served at the facility on Tuesday 12/2/25 for the one and only resident (Resident #28) that was on a puree therapeutic diet. This failure could place residents at risk of poor intake, and/or weight loss. The findings include: Record review of Resident #28's face sheet, dated 12/02/25, reflected a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #28 had a diagnosis which included gastro-esophageal reflux disease without esophagitis (may experience heartburn, regurgitation, and chest pain with no visible damage or inflammation). Record review of Resident #28's Comprehensive Minimum Data Set, dated [DATE], reflected: -Section C Brief Interview for Mental Status score reflected a score of 01, which indicated the resident's cognition was severely impaired. -Section K Swallowing/Nutrition Status reflected Resident #28 was 115 pounds, no weight loss of 5% or more. -Section V reflected nutritional status was triggered on the CAAs. Record review of Resident #28's physician order, dated 12/2/25, reflected the following: Resident #28 was on a regular diet, pureed texture with a start date 11/05/25. Record review of Resident #28's care plan, dated 11/05/25, reflected the following: Resident #28 had a diet order other than regular and was at risk for unplanned weight loss. It was the goal for Resident #28 to maintain ideal weight and to receive proper nutrition for 90 days. Interventions included offering substitutions if Resident #28 ate less than 50 % and to serve diet and snacks as ordered. Record review of Resident #28's, undated, weight list, pulled from the EMR 12/3/25 reflected: Resident weighed 115. 5 lbs on 11/3/25, 115.00 on 11/5/23 and as of 11/18/25 she weighed 115.00. Record review of Resident #28's lunch ticket, dated 12/2/25, reflected:Entree: Chicken and Sausage GumboStarch: Steamed [NAME] Salad: Soft Cooked vegetable Bread: CornbreadCondiment: MargineDessert: Bread PuddingBeverage: Iced Tea Record review of the facility's weekly menu, dated 10/16/25, revealed the following would have been served for week 5 on Tuesday 12/2/25:Chicken and Sausage GumboSteamed RiceTossed SaladCornbreadMargarineBread Pudding Iced Tea The following observations were made on 12/2/25 between 11:41 AM and 12:20 PM in the kitchen: DA C pureed the bread pudding at 11:41 AM. [NAME] D pureed the rice at 12:07 PM and pureed the gumbo at 12:20 PM. [NAME] D, DA C, or the DM were not observed to puree a soft vegetable or cornbread. The following observations were made on 12/2/25 at 12:58 PM in the dining room: At 12:58 PM, Resident #28's lunch tray contained the following: a bowl of gumbo, a bowl of rice, and bread pudding. There was no cornbread or soft vegetable observed. During an interview on 12/4/25 at 2:09 PM, Resident #28 stated she did not remember whether she received all the items listed on the menu on 12/2/25. She stated she did not always receive bread. She stated she would like a whole piece of bread because she could dip it in the sauce to make it soft. She stated she could not remember if she received all menu items regularly. She stated she did remember not always receiving condiments such as butter and jelly. During an interview on 12/4/25 at 12:02 PM, the DM stated on 12/2/25 the facility menu reflected the residents should have received gumbo, rice, cornbread, salad, and bread pudding. The DM stated Resident #28 was on a puree diet, but she would have received the same items listed on the menu. The DM stated everyone in the facility who was able to eat would receive everything on the menu or something comparable. The DM stated she was familiar with the facility policy, which required staff to follow the menu. She stated the purpose of following the menu was that it was something they were required to do. The DM stated the potential negative outcome for not following the menu was residents may not receive adequate nutrition. The DM stated on 12/2/25 Resident #28 did not receive a vegetable or bread on her tray, and she became aware of this after the state surveyor left the kitchen. The DM stated she did not know who served the tray directly to the resident but she was the one who warmed it up and did not catch the mistake. She stated the nurse checked the tray, but she was not sure which nurse was working that day. She stated she was in the process of receiving items from the delivery truck and warming up items for the meal that day. She stated the system to ensure residents received what was on the menu or something comparable was that staff should follow the cards, read them, and prepare the tray as indicated. She stated the cook should follow the card, hand the tray to the aide, the aide would add her portion, and then the aide would hand the tray to the nurse. She stated the nurse should also read the card to ensure everything was on the tray. The DM stated she was trained to follow the menu and ensure all items on the dietary card were placed on the tray. She stated she expected all staff to follow the menu because it was easy to read. She stated she, as the DM, was responsible for ensuring the menu was followed. She stated she did not have a reason why Resident did not receive a vegetable or cornbread on 12/2/25. During an interview on 12/4/25 at 12:38 PM, the DON stated nurses should check the ticket while in the dining room. The DON stated the only time the meal on the tray would differ from the menu was if the resident requested an alternate, which would be indicated by an A on the ticket. The DON stated the nurse checked the tray, and if anything was missing, the nurse should notify dietary staff. The DON stated she was unaware Resident did not receive a vegetable or cornbread on 12/2/25. She stated their system to ensure residents received all menu items was that the nurse should check the tray before giving it to the resident. She stated the potential negative outcome of not following the menu was the resident could have a lack of nutrients, which could affect wound healing, leave the resident hungry, or affect mood. She stated she expected nurses to check the trays and address any issues. She stated she did not know why Resident did not receive all of her meal items. The DON stated staff were trained that before giving a meal tray to a resident, the tray should be checked in full. She stated the last person to check the tray, usually the nurse, would be responsible. During an interview on 12/4/25 at 12:52 PM, the ADM stated he did not know specifically what was served on 12/2/25 but he had the ability to see menus each morning. He stated everyone who consumed meals orally should receive everything on the menu or something comparable. The ADM stated he did not have a reason why Resident #28 did not receive cornbread or a vegetable on 12/2/25. He stated he was familiar with policy and procedure regarding following the menu. He stated diet texture would not prevent a resident from receiving all menu items. He stated failure to follow the menu could affect the resident's mood or weight. He stated he was unaware Resident #28 did not receive cornbread and a vegetable on 12/2/25 and did not know who checked her tray. He stated the system to ensure trays were correct was that trays were checked each time they moved down the serving line. He stated the resident trays started from the cook, to the aide, and ended at the nurse. He stated he and his staff were trained to follow the menu and expected all staff to follow it regardless of diet texture. He stated the cook, DM, and ADM were responsible for ensuring the menu was followed. During an interview on 12/4/25 at 1:17 PM, [NAME] D stated according to the facility menu for 12/2/25 the residents should have received gumbo, rice, salad, bread pudding, and cornbread. He stated all residents who consumed meals orally should have received everything on the menu or something comparable. He stated he was familiar with the facility policy requiring menu compliance. He stated if staff did not follow the menu, the resident could become sick or lose weight if they were not eating. He stated the system to ensure all residents received everything on the menu was staff would notify them if something was left off. He stated all staff who came in contact with the tray checked it. He stated he did not know who served Resident #28 her tray but believed LVN E may have done so. He stated he was responsible for ensuring the menu was followed. He stated he was unaware Resident #28 did not receive cornbread or a vegetable, until after the state surveyor left and the DM informed him. He stated he was trained to follow the menu. He stated Resident #28 did not receive the items because he did not read her ticket correctly and was reading quickly. During an interview on 12/5/25 at 2:25 PM, DA C stated she did not prepare Resident #28's tray but did place pureed bread pudding on it. She stated she did not know the tray lacked cornbread and a vegetable. She stated once the items reached the correct temperature the DM told her the tray was ready. She stated she did not know who served the tray. She stated the potential negative outcome of not following the menu was weight loss. She stated she was trained to follow the menu. She stated she did not have a reason why the menu was not followed on 12/2/25 for Resident #28. During an interview on 12/4/25 at 2:36 PM, LVN B stated she worked in the dining room on 12/2/25. She stated the facility process was for the nurse to check the tray before serving it to the resident. She stated she and LVN E worked in the kitchen that day, but did not recall which of them checked Resident #28's tray. She stated she knew all trays were checked but could not say who checked hers or why the issue was not caught. She stated she was trained that dietary staff should be notified if a tray was incorrect. She stated this had never been an issue before. During an interview on 12/4/25 at 4:02 PM, LVN E stated she worked in the dining room on 12/2/25 but believed she entered late. She stated she did not know who served Resident #28 her tray. She stated they were trained that a nurse must check trays before giving them to residents and trays not matching the menu should be returned. Record review of Resident Menus policy, dated 2012, revealed the following: We will strive to assure the residents nutritional needs are provided. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food and adequate amounts at each meal, and standardized group production. ProcedureMenus are planned to meet the recommended dietary allowances of the food and nutritional board, National Research council, adjusted to the age, activity, and environment of the group involved. A 5 week cycle of meetings are planned by the menu committee which may consist of facility dietary service managers and registered dietitians in conjunction with the food supplier. All dyes including therapeutic dyes are recognized in these names. Will be prepared as written using standardized recipes. The dietary service manager includes our training and responsible for the preparation and service of therapeutic diets as prescribed.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #44) reviewed for respiratory care. The facility failed to ensure Resident #44 had orders for the administration of oxygen. This failure could place residents at risk of not receiving the care and services to maintain their highest level of well-being. Record review of Resident #44's face sheet dated 12/02/25 reflected a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #44 had diagnoses which included: respiratory failure (lung condition causing lack of oxygen in the blood), congestive heart failure (heart condition in which the heart muscle does not pump adequate amount of blood), and hypertension (high blood pressure). Record review of Resident #44's EMR reflected he did not have a completed MDS assessment. Record review of Resident #44's physician's order listing report, dated 12/02/25, reflected no order of oxygen. Record review of Resident #44's comprehensive care plan, revised on 12/03/25, reflected the resident used oxygen therapy related to chronic respiratory failure with intervention, monitor for signs and symptoms of respiratory distress and report to MD PRN. During observations, Resident #44 had oxygen being administered as follows: 12/02/25 at 10:50 AM, O2 on via oxygen concentrator at 3 liters per minute via nasal cannula. 12/03/25 at 10:52 AM, O2 on via oxygen concentrator at 3 liters per minute via nasal cannula. 12/04/25 at 12:44 PM, O2 on via oxygen concentrator at 3 liters per minute via nasal cannula. During an interview on 12/03/25 at 12:46 PM with Resident #44, he stated he was admitted with oxygen and had worn it continuously since admission. He stated he had been dependent on oxygen for several years. During an interview on 12/04/25 at12:28 PM, the ADM stated he was not aware Resident #44 did not have an order for oxygen. He stated the admission charge nurse, who was no longer employed at the facility, was responsible for obtaining and entering orders. He stated nursing administration was responsible for monitoring orders for accuracy. He stated the facility had a form for new admissions and any concerns for a newly admitted resident were discussed in the morning meeting. The ADM stated a potential negative outcome for failure to obtain an order for oxygen therapy was that the resident would not receive the correct care as ordered by the physician. During an interview on 12/04/25 at 12:50 PM, the DON stated a physician's order was required for oxygen administration. She stated Resident #44 did not have an order for oxygen and had been on oxygen since being admitted to the facility. The DON stated the admitting nurse was responsible to clarify and obtain an order for oxygen administration. She stated she did not know how the order was missed. She stated nursing staff were trained to clarify and obtain orders and enter them in the EMR. The DON stated it was the responsibility of nursing administration to reconcile orders on new admissions. She stated a potential negative outcome for failure to obtain an order for oxygen therapy was the resident would not receive the oxygen he needed. Record review of the facility's undated policy titled, Oxygen Administration, reflected: . The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician.

Based on observation, interview and record review the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 17 semi-private (room shared by two people, typically with a curtain dividing the room and providing some privacy) rooms (room [ROOM NUMBER]) reviewed for useable living space. The facility failed to ensure room [ROOM NUMBER] (a semi-private room) provided 80 square feet per resident. The square footage was 153 instead of 160 square feet. This failure could place residents at risk of crowding in resident rooms and cause difficulty in providing resident care. The findings include: Observation on 12/3/25 at 3:50 PM revealed room [ROOM NUMBER] measured 153 square feet (14 feet x 10 feet) instead of the 160 square feet for a semi-private room for 2 residents using state issued apple phone. During an interview on 12/5/25 at 2:36 PM, the ADM stated during entrance conference, when the room waiver was discussed, he was aware room [ROOM NUMBER] was smaller than required. He stated he wished to continue filing the waiver. He stated room [ROOM NUMBER] was used as an office and he had no intention of using it for residents or remodeling it to meet the 160-square foot requirement. He stated if it were used for a resident in its current 153-square foot condition, the potential negative outcome would be limited space. He stated the facility did not have a policy regarding room size, but did have the room dimensions and would provide them. Record review of the ADM's email, dated 12/10/25, revealed the following measurements: for room [ROOM NUMBER] Width: 14 feet Depth: 11 feet Height: 8 feet Record review of Texas Health and Human Services Form 3762 (Room Size Waiver for Facilities) dated 12/2/25, documented room [ROOM NUMBER] did not meet the justification criteria. Record review of Texas Health and Human Services Form 3740 (Bed Classifications [Numbers andLocation]) dated 12/2/25, documented room [ROOM NUMBER] was listed as a Title 18 bed classification semiprivate room for two residents.

Based on observations, interviews, and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional or special dietary needs for 1 of 5 residents (Resident #1). The facility failed to provide Resident #1 with double portions at meals 3 times a day, per physician orders. This failure could place residents at risk for weight loss, altered nutritional status and diminished quality of life. Findings Included: Record review of Resident #1's face sheet, dated 01/28/2025, revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had the following diagnoses: quadriplegia (paralysis of all four limbs), Other Cystostomy Status (procedure wherein the urinary bladder and the skin are surgically connected to drain the urine through a tube that comes out through the abdominal wall), Seborrheic dermatitis (scaly patches, inflamed skin, and dandruff.), muscle weakness unspecified, unspecified lack of coordination, cognitive communication deficit (difficulty with any aspect of communication), major depressive disorder (mental health condition), Generalized Anxiety disorder (mental health condition), and personal history of traumatic brain injury (brain injury that is caused by an outside force). Record review of Resident #1's MDS dated [DATE] Section C- Cognitive patterns revealed a BIMS score of 15 which indicates resident was cognitively intact. Section GG- Functional Abilities - Functional Limitation in Range of Motion indicated the resident had impairment on both sides on upper and lower extremities. Section GG- Functional Abilities - OBRA/Interim, revealed resident was dependent on all assistance with eating. Record review of Resident #1's care plan dated 3/5/2024 revealed a focus area that indicated the resident had potential risk for malnutrition with a goal that stated, maintain stable weight and nutritional parameters, and the interventions included the following: offer diet as ordered by the physician. The care plan included a focus area that indicated the resident has a nutritional problem or potential nutritional problem with a goal that stated, the resident will maintain adequate nutritional status through review date, and interventions that included the following: provide and serve diet as ordered The care plan also included a focus area that indicated the resident has 3 pressure ulcers with a goal stating, the resident's Pressure ulcer will show signs of healing and remain free from infection through review date, and interventions that included the following: Monitor nutritional status. Serve diet as ordered, monitor intake and record Record review of Resident #1's order summary report dated 01/28/2025 revealed an order dated 04/25/2024 that stated DBL portions with meals three times a day. The order did not indicate an end date. During an interview on 01/29/2025 at 10:18 AM Resident #1 stated he was supposed to receive double portions at each meal, but he has only received regular portions. During an interview on 01/29/2025 at 11:55 AM the DM stated that the dietary staff were able to see a resident's portion size order for their meal on the resident's meal ticket. The DM stated a regular tray usually consisted of 4 oz of protein and a scoop of each side item. The DM stated if the meal card indicated large portions on the top, this indicated the resident received large portions of protein. The DM stated a large portion of protein is usually 6 oz of protein. The DM stated large portion on a resident's meal card only applied to the protein item on the meal and not the side items or desserts. The DM stated meatloaf was served on this day as the residents' protein. The DM stated the meatloaf squares were cut into 4 oz squares, so a large portion of meatloaf was 1 1/2 squares which equaled to 6 oz of meatloaf. During an observation on 01/29/2025 at 12:52 PM Resident #1's meal card indicated the following: Large Portions; [NAME] Texture - Regular; Entree - 1 Svg Large Portion, 4 oz Meatloaf; Starch - 1/2 c Black-eyed Peas; Vegetable - 1/2 c Braised Cabbage, Bread - 1 2x2 Square Cornbread; Condiment - 1 Ea Margarine; Dessert - 1/2 C Apple Cobbler; Beverage - 8 fl oz Iced Tea It was observed Resident #1 received one tray of food containing 1 1/2 squares of meatloaf, 1/2 cup of cabbage, 1/2 cup of black eyed peas, 1 2x2 square of cornbread, and 1/2 cup of pudding. The resident also received a side of margarine and a glass of iced tea. During an interview on 01/29/2025 at 1:02 PM the DM stated there were no residents on double portioned meals. The DM stated a resident required a physician's order to receive double portions. The DM stated double portioned meals were two trays of food and two servings of all food items for the meal. The DM stated there were numerous residents that received large portions, and large portions did not require a physician's order. The DM stated large portions could be requested from the resident. The DM stated if a resident was changed to double portions, the nursing staff completed a dietary slip and turned this into the dietary manager. The DM stated she obtained copies of all changes in her office. The DM stated all physician's orders for specific dietary needs were communicated by the DON or charge nurse via the dietary form, as the DM stated she did not have access to the resident's physician's order. The DM stated the DON or nursing staff were responsible for making sure the DM had accurate information regarding the resident's physician's orders. Record review of facility provided dietary communication forms revealed there were no communication forms found for Resident #1. During an interview on 01/29/2025 at 2:50 PM CNA A stated she assisted with feeding Resident #1 often. CNA A stated Resident #1 received double portions at meals. CNA A stated double portions were only one tray of food with extra portions of each item on the plate. CNA A stated she had observed the portions to appear more than an average tray, but she was not certain. CNA A was not certain the difference between large and double portions. CNA A stated she thought it meant the same thing. During an interview on 01/29/2025 at 3:22 PM CNA B stated she assisted with feeding Resident #1 often. CNA B stated Resident #1 was on a regular diet with regular portions. CNA A stated she had observed Resident #1's meals to be regular portions. CNA B stated Resident #1 was supposed to get double portions, so she has obtained more food for him if he is still hungry. During an interview on 01/29/2025 at 4:04 PM LVN A stated Resident #1 was on a regular diet with regular portions. LVN A stated the CNA assigned to Resident #1 was responsible for assisting Resident #1 with eating at each shift. LVN A stated a resident's dietary order should have been the same on the resident's meal card as it was in the resident's physician's order. During an interview on 01/29/2025 at 4:30 PM CNA C stated she assisted with feeding Resident #1 often. CNA C stated Resident #1 was on a normal diet. CNA C stated if Resident #1 requested additional food, he may have more portions on his plate, but it was normally a regular portion size. CNA C stated if Resident #1 was still hungry, he requested additional food and she obtained it for him. During an interview on 01/29/2025 at 05:30 PM the DON stated she was not certain what Resident #1's dietary orders stated. The DON stated there were no residents at the facility with double portions. The DON stated there were several residents at the facility that received large portions. The DON stated she was not certain what the measurements were for large or double portions. The DON stated dietary orders were communicated to the dietary manager via a dietary form for each resident. The DON stated the charge nurses or DON was responsible for communicating dietary orders to the dietary manager. The DON stated the dietary orders from a resident's physician should have been reflected on the resident's meal card at each meal. The DON stated dietary orders were reviewed during care plan meetings to ensure accuracy. The DON stated she has not reviewed all residents' dietary orders since she began working at the facility in November 2024. The DON stated if a resident's dietary order was not followed it would be a concern for the resident's health. During an interview on 01/29/2025 at 5:49 PM the AIT stated he had worked at the facility for over 6 years and was currently the administrator in training as well as being over the therapy department. The AIT stated he was familiar with Resident #1. The AIT stated Resident #1 was on a regular diet with large portions. The AIT stated there were no residents at the facility that received double portions of meals. The AIT stated large portions were a portion and a half of each item and double portions were two portions of each item. The AIT stated dietary forms were updated with the dietary staff when a resident was admitted or when a change was made. The AIT stated dietary orders were also reviewed at care plan meetings to ensure they were being followed. The AIT stated the resident's meal card should have reflected the resident's physician order for the resident's diet. The AIT stated he was not aware Resident #1 had an order for double portions at each meal. The AIT stated if Resident #1's physician order was not being followed for double portions it could lead to weight loss for Resident #1. During an observation and interview on 01/29/2025 at 6:10 PM Resident #1's meal tray was observed empty as it was picked up by staff. Resident #1 stated he did not receive double portions at dinner. Resident # 1 stated he only received one portion of food at dinner. During an interview on 01/29/2025 at 6:35 PM the NP stated she was familiar with Resident #1. The NP stated the facility should have followed the physician order for Resident #1's diet to include double portions. The NP stated there was a potential for weight loss with Resident #1 if he did not receive the physician's order of double portions at meals. The NP reviewed and verified Resident #1's recent weights and stated his weights have been consistent with no significant changes. The NP stated she has not had concerns with weight loss for the resident. During an interview on 01/29/2025 at 7:30 PM the Interim ADM was unable to provide a policy specifically related to following physician orders in relation to dietary orders for residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep refrigerator, oven handles, freezer handles, and microwave handles clean. 2) The facility failed to keep all foods completely sealed when stored in the pantry and freezer. 3) The facility failed to store bowls upside down. 4) The facility failed to keep the kitchen free of expired food items. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation during a kitchen tour on [DATE] at 9:50 AM revealed 2 refrigerator door handles had hard, dried substances stuck on the inside of the handles, 1 white freezer door handle had hard, dried substances stuck to the inside and outside of the handle, 1 microwave handle had hard, dried substances on it, 2 oven handles had a sticky substance on the inside of the handles, 7 medium to large silver bowls were stored on the bottom shelf of a preparation table with the bowls facing up, 1 bag of dry granola, dated [DATE] was in the pantry in a bag that was unsealed, and 1 pie crust, dated [DATE] , was in the white freezer in a bag that was unsealed. Interview on [DATE] at 9:50 AM, the DM stated all the dietary staff were responsible for doing daily and weekly cleaning in the kitchen. The DM stated she has had cleaning issues with her staff and has been doing ongoing verbal training with them. The DM stated all dietary staff are responsible to keeping food items completely sealed during storage. The DM stated the 7-silver bowls should have been stored upside down and not right side up. The DM stated she did not know why the handles in the kitchen were not clean, why some food items were not completely sealed or why the bowls were stored right side up. The DM stated a potential negative outcome to the residents was it could make them sick or cross-contamination issues. Interview on [DATE] at 10:38 AM, the ADM stated the DM and the cooks were responsible for kitchen cleanliness and for ensuring foods were stored appropriately. The ADM stated she knows one of the kitchen staff is new and they are doing daily training with her being new to the facility. The ADM stated she expects the kitchen staff to follow all policies and expectations. The ADM stated she expects the kitchen staff to follow the food storage policy and keep the kitchen up to standard. The ADM stated the kitchen last had an audit at the end of March /2024 and she did not know why the kitchen handles were not clean or why some food items were stored open. The ADM stated there is a possible cross-contamination risk and possible bacteria for unsealed food items. Record review of the facility's policy and procedure titled, Equipment Sanitation dated 2012, reflected the following: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner Record review of the facility policy and procedure titled, Food Storage and Supplies dated 2012, reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin and insects. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened Record review of the facility policy and procedure titled, Cleaning the refrigerator, dated 2012, reflected the following: Refrigerators are maintained in a clean, sanitary condition free of offensive odors. Cleaning of the reach in refrigerator will be done on a daily or as needed basis

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 2 of 3 food forms (regular, mechanical soft) for 1 of 1 meal reviewed for palatability. 1. The facility lunch trays had vegetables that were lukewarm, the gravy for the meat was too salty, and the potatoes were too spicy for the regular texture and mechanical soft texture meals at lunch on 9/10/24. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 3 residents voiced concerns related to food palatability. The residents stated the food did not taste good and sometimes the food is cold. On 09/10/24 at 10:45 AM the Dietary Manager was informed of a request for a test tray for the noon meal. On 09/10/24 at 12:41 PM the test trays arrived at the conference room and sampling began at 12:43 PM with the following results: Alternate meal plate - Regular Texture Tortellini - no issues Green beans - lukewarm and bland to taste Garlic bread - tough to tear/chew. Regular Meal - Regular Texture Mississippi Roast with gravy - gravy was very salty Roast potatoes - lukewarm - strong flavor of pepper, spicy Carrots - no issues Roll - soggy/wet with carrot juice Regular Meal - Mechanical Soft Texture Mississippi Roast with gravy - gravy was very salty Roast potatoes - strong flavor of pepper, spicy Carrots - lukewarm Roll - soggy/wet with carrot juice and gravy Interview on 09/10/24 at 12:56 PM, the ADM stated the gravy was salty and the potatoes were spicy with a strong pepper flavor. Interview on 09/12/24 at 2:49 PM, the DM stated she and the cook were responsible for tasting the meals before they were served. The DM stated the noon meal was not tasted prior to being served and she does not know why. The DM stated the cook has been working hard at making the meals and she does not know why the gravy was salty or the potatoes were over seasoned with black pepper. The DM stated cold food can grow bacteria if not at the right temperature and the residents could possibly get sick. Interview on 09/12/24 at 10:54 AM, the ADM stated she expects the DM and cook to follow the recipe and expectations for food palatability. The ADM stated the DM should go visit with the residents if they have complaints about the food and stated the facility also offers alternatives to the meals. The ADM stated she did not know why the test meal had problems and stated the kitchen staff are new and still getting training. The ADM stated a possible negative outcome to the residents was they may not eat the food because they did not like how it tasted. Record review of the facility policy and procedure titled, Preparation of Food, dated 2012, reflected the following: We will establish safe and nutritional preparation of food. Food is to be prepared in a manner as to maximize flavor, appearance, and nutritional value. Procedure: 2. All food will be prepared by methods that preserve nutritive value, flavor, appearance with variety of color, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident. 6. The Dietary Service Manager and cooks will taste and test meals daily. The administrator and DON may taste test meals if requested.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 treatment carts (Treatment Cart A) reviewed for pharmacy services 1. The facility failed to ensure the treatment carts were free of expired medical supplies. These failures could place all residents at risk of harm or decline in health due to expired medical supplies. Findings included: During an observation on 9/11/2024 at 10:42 AM of Treatment Cart A the following expired items were revealed: - Self-Cath 14Fr (tube to drain urine from the bladder) foley catheter with an expiration date of 7/6/2024. - Catheter Stabilization Device with an expiration date of 3-27-2023 - Hypafix (adhesive bandage) with an expiration date of 2024-06 - Urinary leg bag medium 600-ml with an expiration date of 2023-12-20 During an interview with DON on 9/12/24 at 11:11AM she stated she does weekly audits of the treatment carts and medication carts. She stated she assigns the nurses a cart to do a check of all the items and medications. She stated after they do their audits, she will do a second inspection to ensure it had been thoroughly monitored. She stated she is not sure how those items were missed. She stated those items were not items the facility orders and they may have belonged to a resident who gave the nurses those items for holding. She stated the last training they did for treatment carts and medication carts was in August of 2024. She stated the potential negative outcomes could be, depending on the item, not providing the protection that is needed. The DON said it could be old or weathered and it could become an issue if it is a wound dressing that is not providing the protection needed. She stated compliance is monitored by doing the checks behind the nurses and educating, re-education and coaching the nursing staff. During an interview with the ADM on 9/12/2024 at 11:30AM she stated the nurses are responsible for ensuring the carts are free of expired items. She stated audits are conducted weekly and the last in-service she believes was 9/11/2024. She stated the DON and ADON will pull the Medication Cart Inspection sheet and conduct their own inspections. She stated they utilize the checklist for both medication carts and treatment carts. She stated central supply does weekly sweeps of their storage. During an interview with LVN A on 9/12/24 at 11:46 AM, she stated the nurses and administration staff are responsible for ensuring the carts are kept free of expired items and medications. She stated checks of the carts are done once a month. She stated she did not believe she had any training on checking the carts for expired drugs or medication. She stated she had not received an in-service on the medication or treatment carts. She stated the potential negative outcome of utilizing expired items could be the expired item not working at its top functionality. Record review of blank undated facility checklist document titled Medication Cart Inspection revealed, Individual Patient medications (Cart) Are all ordered medications available and in date? Is overflow medication properly organized to avoid duplication? Have discontinued drugs been removed and/or destroyed? Are external drugs separated from internal drugs? Are patient's inhalers, eye gtts (drops), otics (relating to, located in, or of the ear), & ointments separated from other patients to avoid intermingling / cross contamination? Are open eye gtts open dated and < 90 days old from open date? Are open insulin vials open dated and < 30 days old from open date? Are open injectables open dated? Medication Cart Is the cart clean inside? Are liquid med bottles wiped off before returning to cart? Is the cart clean outside? Is the sharps container overfull? Record review of facility policy titled Monthly CS (Central supply) Sweep Instructions dated 10/2023 revealed. It is our company guideline that a complete sweep of all areas that contain nursing supplies is done at least monthly to ensure that nothing expired is in place on our shelves Checking expirations dates-ALL Closets, all shelves, all bins, as well as the crash cart will be checked for expired items.

Based on observation, interview, and record review the facility failed to ensure a resident has a right to a safe, clean, comfortable and homelike environment for 1 of 37 residents reviewed for physical environment. 1. The facility failed to ensure Resident #12 had a functioning bathroom light switch. 2. The facility failed to ensure Resident #12 had a safe and secure toilet in the shared bathroom. These failures could place residents at risk for injuries and falls. Findings included: Record review of Resident #12's electronic face sheet dated 9/11/2024 revealed a [AGE] year-old female, admitted to the facility on [DATE]. The face sheet indicated, under Diagnosis Information, diagnoses that included transient cerebral ischemic attack (short period of symptoms similar to those of a stroke caused by a brief blockage of blood flow to the brain), type 2 diabetes mellitus without complications (when body's cells resist the normal effect of insulin and glucose builds in blood), Zoster Keratitis (inflammation of the cornea), and unspecified lack of coordination. Record review of Resident #12's Annual MDS assessment dated [DATE], revealed under Section C Cognitive Patterns, a BIMS score of 13 indicating the resident was cognitively intact. The MDS assessment indicated under Section H, H0300, Resident #12 was always urinary and bowel continent. Record review of Resident #12's most recent care plan, dated 7/1/2024, reflected a focus area ADL Self Care Performance Deficit Impaired balance, Limited Mobility. The goals for the focus area included, The resident will maintain or improve current level of function through the review date. The Interventions/Tasks for the focus area included, Toilet use: requires staff x1 for assistance, with a date initiated of 07/14/2023. An interview with Resident #12 on 9/10/2024 at 10:07 AM revealed Resident #12 stated her toilet was wobbly and her light switch was not functioning properly to the bathroom that she shared with the resident next to her. Resident #12 stated she had to either leave her door open and use the bedroom light, or she had to use the toilet without a light. The resident reported the other resident's light switch worked to control the bathroom light. Resident #12 stated she was told there was a wiring issue with the light, but she could not remember who she reported this to. Resident #12 stated she had not reported the loose toilet yet. Resident #12 stated she had not had an accident because of the loose toilet or the light switch not functioning. An observation on 9/10/2024 at 10:25 AM revealed the toilet shared by Resident #12, and the room next to her, was not secure and could be moved from side to side, by several inches, with only a gentle nudge. It was also observed that the bathroom light switch did not turn on the bathroom light in Resident #12's shared bathroom. It was observed that the light switch to the bathroom, inside of Resident #12's neighbor's room controlled the light to the bathroom. It was also observed that when the light switch to the bathroom, in in Resident #12's neighbor's room, was switched to on, the light switch in Resident #12's room was then able to turn off and on the bathroom light. It was observed that when the light switch, in Resident #12's neighbor's room, was switched to off, the light switch in Resident #12's room would not function to control the bathroom light. An interview on 09/10/24 at 12:30 PM with the ADM revealed the ADM stated she was unaware of the concerns with Resident #12's toilet not being secure and the bathroom light switch not functioning properly. The ADM stated she did not believe there were any open or prior work orders for these issues. The ADM stated this would be looked at as soon as possible. The ADM reported the resident next to Resident #12 was not in the facility and was in the hospital for treatment. An observation on 9/11/2024 at 1:30 PM revealed the toilet shared by Resident #12 was secure and stable. An observation on 9/11/2024 at 1:33 PM revealed the light switch to the shared bathroom of Resident #12's was functioning properly. An interview on 09/12/24 at 11:00 AM with the Maintenance Director revealed the maintenance director reported he was unaware of the light switch to the bathroom of Resident #12 was not functioning properly, and he was unaware that the toilet in the bathroom shared in Resident #12's room was loose and unstable. The maintenance director reported there were no open work orders for the two needed repairs, to his knowledge. The maintenance director stated he has worked for the facility for a month and was trained on completing repairs and work orders with his new hire training. The maintenance director stated there was not a procedure in place prior to that day to check toilets or working light switches in residents' rooms. However, he stated he will begin weekly room checks to ensure everything is safe and functioning properly in each resident's room. The maintenance director stated he was able to fix the light switch in Resident #12's room to control the bathroom light, and he was able to fix the toilet in the shared bathroom for Resident #12, and it was no longer loose. An interview on 09/12/24 at 11:20 AM with the DON revealed the DON stated she was unaware of the toilet being loose in the bathroom shared by Resident #12 and her neighbor. The DON stated the maintenance director is responsible for ensuring toilets are safe and stable and light switches are functioning properly. The DON stated Resident #12 does use the toilet in her shared bathroom. An interview on 09/12/24 at 12:00 PM with the ADM revealed the ADM stated it was the maintenance director's responsibility to ensure toilets were secured properly and to ensure light switches were functioning in each resident's room. The ADM stated there was not a policy or system in place previously that specifically applied to the functioning of toilets or light switches, but a policy was since developed, and the maintenance director will do weekly checks of each resident's room beginning 9/12/2024. The ADM stated there was a system in place for reported repairs that was monitored by the maintenance director and the administrative staff. The ADM stated residents, family, and staff could report any needed maintenance using a QR code (quick-response code, a type of two-dimensional matrix barcode) that was posted throughout the facility. The ADM stated there were no reported repairs for the bathroom toilet shared by Resident #12 and her neighbor, via that system. The ADM stated the maintenance director did receive training when he was hired, one month ago, that included initiating and completing necessary repairs in residents' rooms. The ADM stated the head of each department for the facility was in each resident's room daily and they were also responsible for ensuring the resident's rooms were safe and functioning. The ADM stated resident's rooms were also inspected at the time the resident was admitted to ensure everything was safe and functioning properly. The ADM stated residents were at risk of falls and/or injuries if the resident's toilet was loose and if their light switches were not functioning properly in the bathroom. Review of facility's policy, Policy for Weekly Inspection of Lavatory Sinks and Toilets, effective 9/12/2024 revealed the following: Purpose: To ensure the safety, hygiene, and proper functioning of lavatory sinks and toilets, and to prevent potential issues that may impact the health and comfort of employees, visitors, and other facility users. Scope: This policy applies to all lavatory sinks and toilets within organization's facilities, including all offices, buildings, and other locations managed by the organization. Policy: 1. Inspection Frequency: o Lavatory sinks and toilets must be inspected on a weekly basis. 2. Inspection Responsibilities: o The Facilities Management team or designated maintenance personnel are responsible for conducting and documenting the weekly inspections. o Each facility manager or supervisor is responsible for ensuring that inspections are completed as scheduled. 5. Corrective Actions: o Any issues identified during the inspection must be addressed promptly. o Major issues or those requiring specialized repair should be reported to the Facilities Management team for further action. o Follow-up inspections should be scheduled as needed to ensure that corrective actions have been effective. 6. Training: o All personnel involved in inspections must receive training on proper inspection techniques and safety protocols. o Training should be updated regularly to incorporate any changes in procedures or safety guidelines. 7. Compliance: o Adherence to this policy is mandatory. Non-compliance will be addressed through appropriate corrective measures, which may include additional training or disciplinary action. 8. Review and Revision: o This policy will be reviewed annually and updated as necessary to ensure continued relevance and effectiveness. Effective Date: This policy is effective as of 9/12/2024 Purpose: To ensure that all lighting systems within organization's facilities are functioning properly, enhancing safety, security, and productivity by maintaining optimal lighting conditions. Scope: This policy applies to all lighting fixtures and systems across organization's facilities, including office spaces, common areas, and outdoor areas. Review of facility's policy, Policy for Weekly Inspection of Lighting, effective 9/12/2024 revealed the following: Policy: 1. Inspection Frequency: o All lighting systems must be inspected on a weekly basis. 2. Inspection Responsibilities: o The Facilities Management team or designated maintenance personnel are responsible for conducting and documenting the weekly inspections. o Each facility manager or supervisor must ensure that inspections are completed as scheduled. 3. Inspection Checklist: o General Lighting Inspection: ? Verify that all light switches and controls operate correctly. 5. Corrective Actions: o Any issues identified during the inspection must be addressed promptly. o Follow-up inspections should be scheduled as needed to confirm that corrective actions have been effective. 6. Training: o All personnel involved in inspections must receive training on proper inspection techniques, safety protocols, and the use of any necessary tools or equipment. o Training should be updated regularly to incorporate any changes in procedures or safety guidelines. 7. Compliance: o Adherence to this policy is mandatory. Non-compliance will be addressed through appropriate corrective measures, which may include additional training or disciplinary action. 8. Review and Revision: o This policy will be reviewed annually and updated as necessary to ensure continued relevance and effectiveness. Effective Date: This policy is effective as of 9/12/2024

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure foods were processed under sanitary conditions. 2. The facility failed to ensure dietary staff maintained quaternary sanitizer levels within acceptable ranges and sanitizing solutions were tested according to manufacturer guidelines. 3. The facility failed to ensure food and non-food contact surfaces were cleaned. 4. The facility failed to ensure food was protected from possible contamination. 5. The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness. The findings include: -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 10:05 AM and concluded at 10:50 AM: During an observation and interview on 8/1/23 at 10:10 AM, Dietary Staff C stated the dishwasher was not dispensing any sanitizer. She stated they were rinsing and letting dishes dry until the dishwasher was repaired. She tested the dishwasher final rinse, and the test strip was a very light purple color. The test strips used had no color scale for comparison and no instructions. Observation revealed Dietary Staff A tested the three compartment sink quaternary sanitizer with quaternary test strips. The sanitizer level was less than 150 ppm after being tested twice. During an interview on 8/1/23 at 10:17 AM Dietary Staff A stated the quaternary sanitizer should be between 150 ppm and 200 ppm to be correct. Dietary Staff A did not correct the sanitizer level. Observation revealed Dietary Staff A rinsed a knife and placed it in the sanitizer in three compartment sink. He then set it to dry down on the drain board. This was the same sanitizing solution that was less than 150 ppm. Observation of the quaternary sanitizer label for the three compartment sink, reflected KQuat No Rinse, documented the correct level of sanitizer for the solution was 150 to 400 ppm. Observation revealed a grease buildup on the sides of the fryer. During an interview on 8/1/23 at 10:30 AM, Dietary staff A stated nothing was added to the sanitizer he tested , which was less than 150 ppm in the three compartment sink. Observation on 8/1/23 at 10:38 AM revealed the Dietary Manager tested the chlorine level in the dishwasher with test strips had a color comparison and instructions included. She asked Dietary Staff A how long she should dip the strip into the final rinse to test it. Dietary staff C responded, 10 seconds. The final rinse sanitizer level for chlorine indicated 10 ppm. Record review of the Hydrion Chlorine test strips package revealed documentation that stated, When testing, dip and remove immediately. Observation revealed the Dietary Manager was observed washing pans in the three-compartment sink which had a sanitizer level of less than 150 ppm quaternary sanitizer as previously tested . -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Observation revealed the Dietary Manager picked up cooked rolls with her bare hands and placed them in another pan. The Dietary Manager had long nails that were approximately a quarter of an inch above the end of her finger. An interview on 8/1/23 at 11:40 AM with the Dietary Manager revealed she picked up the rolls with her bare hand because she thought staff could not use gloves. Observation of the interior of the processor pot revealed it was wet. Dietary staff C placed milk and two fried apple pies into the wet processor and pureed the mixture. Observation revealed Dietary staff A wiped his hands inside the clean processor pot that was drying on the drain board. Observation revealed Dietary staff A, after washing his hands, dried them on a paper towel and then placed the used paper towel on the prep table and then handle beans that were in bowls. He then pureed the baked beans with chicken broth and placed the mixture in pan. The underside of the upper shelves of the steam table and the stove had an accumulation of dried spills. The Dietary Manager was holding the processor blade with her bare hand and swinging it in the air to get the water off it and dry it after washing it in the 3 compartment sink. Dietary staff A picked up the processor blade with his bare hands and put it in the processor. He added potato salad and chicken broth and pureed the mixture. He then pulled the blade out of the processor with his bare hands then put the pureed potato salad in a pan. Observation revealed Dietary staff A scratching his back and then picking up the processer pot and swinging it in the air to dry it. He washed a spatula in the 3 compartment sink, then washed his hands and then returned to place the blade in the processor. Dietary staff A wiped his hands on his apron, then put on a pair of gloves. He then picked up pork ribs with his gloved hands from a pan on the steam table, and then placed them in the processor. He removed his gloves and then placed the blade in the process of pot with his bare hands. He then added chicken broth to the pork ribs and pureed the mixture. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 4:30 PM and concluded at 5:35 PM: Interview on 8/1/23 at 4:35 PM with Dietary staff A revealed he wiped his hand inside the processor pot because he was checking to see if it was dry. He stated he was told by staff not to wear gloves unless staff were prepping food. He added all the staff were new. He stated he had his Food Handler's certificate. He further stated his experience was not like what he was tested on for his Food Handler's certificate and not like a restaurant. He stated he received general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner Dietary Staff A stated the dietary sanitation issues that occurred could cause cross-contamination. Observation revealed eight sets of kitchen fluorescent lights, one set had one of four lights with no stabilizing caps. Three sets of lights had four of four lights with no stabilizing cap to prevent breakage. Interview on 8/3/23 at 10:54 AM with the Dietary Manager, she stated she had conducted in-services a week ago. She stated training for new employees lasted two weeks with monitoring. She stated none of the current employees had training before she came. The Dietary Manager stated she had not conducted any in-services on hygienic practices. She stated she had conducted in-services on handwashing and sanitizing. She stated staff should be changed every two hours. She stated some staff were not previously trained on the quaternary sanitizer. The Dietary Manager stated she expected staff to correct the problems and find a solution. The Dietary Manager stated these issues happened in the kitchen because of improper training. She stated the result of the issues in the dietary department regarding sanitation could cause sanitation problems and residents get sick germs. She further stated staff were cleaning and they would conduct cleaning of the steam table and stove shelves one time a week. Interview on 8/3/23 at 12:57 PM with the Administrator, she stated she expected staff to use gloves. she stated the issues related to dietary sanitation could cause the spread of contamination. Record review of the dietary department in-services for the last three months(May - July 2023) revealed there was an in-service conducted on 7/18/23 with the topic, wearing aprons, hairnets according to the in-service training attendance roster. The in-service was given by the Dietary Manager. Dietary staff C was present for this in-service and the in-service training was documented as one on one in-service. Record review of the Record of Departmental In-Service and Meetings revealed there was an in-service conducted on 7/29/23 by the Dietary Manager. The title of the in-service was Food Temps, Sanitation, Infection, Control, Dishwashing. The documented summary of the in-service was as follows, Educate on temps of food, sanitation, infection, control, dishwashing, and preparation. Dietary staff A attended this in-service. Record review of the facility policy titled, Dietary Services Policy and Procedure Manual 2012, IC 00-7.0, revealed, Dishwashing, Preparation, And Dishwashing. The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure . 10. Manual dishwashing of eating utensils will be used only in the event of dish machine failure . e. All equipment and utensils will be sanitized by one of the following methods . 2. Immersion for a period of at least one minute in a sanitizing solution containing . c. At least 150-400 ppm of a quaternary ammonium compound a temperature of around 70 F Record review of the facility policy, titled, Dietary Services Policy and Procedure Manual 2012, IC 00-6.0, revealed, Equipment, Sanitation. We will provide clean and sanitized equipment for food preparation. Facility will clean all food service equipment in a sanitary manner. Procedure . 8. Blenders and the food processor. Bowls should be inverted after cleaning to drain dry on shelves or trays with vented slots or bar netting Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC 00-4.0, revealed the following documentation, Handwashing. We will ensure proper handwashing procedures are utilized. Employees are to frequently perform handwashing as outlined Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC00-5.0, revealed, Food Safety. We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. Procedures . 11. Gloves must be worn for preparation and service of foods that do not require further cooking. Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC00-1.0, revealed the following documentation, Infection Control. We will ensure that all employees practice infection control in the dietary service department and maintain sanitary food preparation. All dietary service employees will follow infection control policies as established and approved by the infection control committee. Procedure . 2. Careful handwashing by personnel will be done in the following situation. b. Between handling of soiled dishes, boxes, or equipment and handling clean food or utensils . e. After each instance of coughing, sneezing, touching face and/or hair . 5. Equipment Sanitation. a. All kitchenware and food contact used in the preparation and/or service serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces. b. After cleaning, equipment and utensils are stored so as to prevent contamination. 6. Food Preparation . c . There shall be no bare hand to food contact . 8. Sanitation of Food Preparation surfaces. a. All kitchen ware and food contact surfaces will be cleaned and sanitized after each use . d. Each dietary employee must be instructed on how to properly use and test the sanitizing solution. e. Random checks testing the PPM are to be done by the Dietary Service Manager. Record review of the facility guidance document dated 2014, revealed the following documentation, Training, Staff on Pureed Foods . 6. The food processor must be washed and sanitized before you puree the next food, and between each food thereafter. You must also allow some time for it to air dry and be sure there is no water inside when you begin to use it again

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager had not completed any Dietary Managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager's Application for Employment revealed no documentation that she had completed the certified Dietary Manager course, had experience as a Dietary Manager or other qualifying credentials. She had a date of hire of 07/5/23. Record review of the personnel file for the Dietary Manager revealed that she had a Texas Food Handlers certificate of completion, dated 7/22/23 which was current. Record review of the facility's Dietician documentation revealed that the Dietician was on contract and not full-time. On 8/1/23 at 10:07 AM an interview was conducted with the Dietary Manager. She stated that she started the position of Dietary Manager three weeks ago and had not completed the certified Dietary Manager course. She stated she had a food handler certificate. She also stated that she had not been a Dietary Manager before this position. On 8/2/23 at 5:45 PM an interview was conducted with the Administrator, and she stated that the facility Dietitian was on contract and was not full-time. On 8/3/23 at 10:54 AM an interview was conducted with the Dietary Manager regarding her not being a qualified Dietary Manager. She stated this issue could result in not providing the correct food groups to residents and could affect their health. On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues about the Dietary Manager qualifications. She stated the facility's procedure was to hire a Dietary Manager which would work on their Certified Dietary Manager credentials. The Dietary Manager would be required to complete the course in a year. Regarding what could result from this issue, she stated, the Dietary Manager may not understand the nutrition side of dietary. On 8/3/23 at 3:13 PM an interview was conducted with the Administrator regarding the Dietary Manager's qualifications. She stated, the Dietary Manager had not taken the Certified Dietary Manager course. She added that she and the Dietary Manager had talked about it, and she would now take the course. Record review of the facility policy, titled Human Resources Manual 2014, JD 11.0, revealed the following documentation, Job Description. Dietary Service Manager. The following is a non-exhaustive criteria that relates to the job of a Dietary Service Manager, and it is consistent with the business needs of the facility. These are legitimate measures are the qualifications for a Dietary Service Manager and are related to the functions that are essential to the job of a Dietary Services Manager. Knowledge base: current certification by state as required.

Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #33) reviewed for supervision, 1)The facility failed to provide effective monitoring and interventions to reduce Resident #33's wandering which was intrusive to other residents' privacy and unsafe for Resident #33 and other residents, 2)The facility failed to maintain the facility as free of accident hazards as possible, in that; oxygen was not stored in a safe manner, chemicals were not stored in a manner to prevent contamination of resident use items, hot water temperatures were not maintained in a safe range, and hazardous areas were not secured. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals. The findings include: 1)Record review of the Order Summary Report for female Resident #33, dated 8/1/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety (cognitive disorder), and cognitive communication deficit (cognitive disorder). Record review of the admission MDS assessment for Resident #33 dated 5/18/23 revealed that the resident had a BIMS score of six, indicating the resident had severe cognitive impairment. No behavior issues were documented. A documented Active Diagnosis was non-Alzheimer's dementia. Record review of the current care plan for Resident #33 revealed the following Focus, The resident is at risk for wandering. Resident wanders aimlessly, significantly intrude on the privacy or activities of other residents at times. Date initiated: 6/28/23. Revision on: 6/28/23. The Goal for this, Focus was documented as, The resident's safety will be maintained through the review date. Date initiated: 6/28/23. Revision on: 7/13/23. Target date: 8/18/23. Interventions/tasks listed for this Focus were as follows, Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Date initiated: 6/28/23. Revision on: 6/28/23. Redirect resident and help her find her room if she is entering other resident's rooms. Date initiated: 6/28/23. Resident has a sign outside of her door to assist her with finding her room when she is moving about the facility. Date initiated: 6/28/23. An additional cognitive related Focus was as follows, The resident has impaired cognitive function/dementia or impaired thought processes Dementia, Disease Process DX: CAD, impaired decision making, long term memory loss. Date Initiated: 05/15/2023. Revision on: 05/15/2023. The Goals listed were: Goal The resident will remain oriented to nursing home placement spatial time through the review date. Date Initiated: 05/15/2023. Revision on: 07/13/2023. Target Date: 08/18/2023. o The resident will maintain improve memory level of cognitive function through the review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. o The resident will be able to communicate needs to staff on a daily basis through the review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. o The resident will practice safety skills and cope with cognitive decline and maintain safety by the review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. Interventions included, Administer meds as ordered. Date Initiated: 05/15/2023. o COMMUNICATION: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Date Initiated: 05/15/2023 Revision on: 05/23/2023. o Engage the resident in simple, structured activities that avoid overly demanding tasks. Date Initiated: 05/15/2023. o Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Date Initiated: 05/15/2023. o Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 05/15/2023. A record review was conducted of the Progress Notes for Resident #33 from 5/24/23 thru 7/20/23. There were no progress notes after 7/20/23 as of downloading of the document on 8/03/23 at 10:25 AM. Resident #33's behaviors and interactions were documented as follows: Effective Date: 05/24/2023 1:20 PM Type: Social Service Note. Note Text: Resident at SW office confused bit but upset about (Family Member) resident not being at home. Resident expressed 'You know my son. I need him the police. We need to straighten some shit out. I need to know where my house is. SW facilitated a phone call to residents son. Resident conversed with son. Resident expressed I need to get out I'm at the hospital. Resident handed phone off to SW . Then resident expressed I need a shot of whiskey. Resident oriented to notify her charge nurse. Per charge nurse resident asked for whiskey. Author: Social Worker [e-SIGNED] Effective Date: 05/25/2023 4:42PM Type: Social Service Note. Note Text: Resident confused in SW office asked Where my home. Will you call (son) tell him his mother has lost her . mind. I have can't remember. SW assist resident to her room. Effective Date: 05/25/2023 6:05 PM Type: Nursing Progress Note. Note Text: Resident appears to become increasingly verbally aggressive and angry. She is stating that she is not supposed to be here, she owns the place and needs to go home. She is constantly wandering and ignoring prompts to stay in her wheelchair. She is observed wandering into a resident's room telling the resident to be quiet. She has been offered snacks, staff have sat and talked with resident to calm her as well as offer activity however resident refuses. Author: RN A [e-SIGNED] Effective Date: 05/26/2023 1:16 AM Type: Nursing Progress Note. Note Text: Resident is noted to be getting out of bed and wandering in facility, nursing staff redirect back in to room. Moments later she is found doing the same behavior, she is also going into different resident rooms, she is continued to be redirected by nursing staff, she easily follows command, resident is also noted to have flight of ideas, loose of thought, and concentration, nurse unable to ask questions due to noticeable increased agitation during her thought process During the night she shows to be no threat to herself, others and staff. Nursing staff educated on ways to redirect without having resident show increase in agitation. She may also benefit to have her check by provider due to lack of sleep due to her repetitive behavior she displays at night. Author: RN B [e-SIGNED] Effective Date: 06/25/2023 7:42 AM Type: Nursing Progress Note. Note Text: resident has been going into other residents' room, residents have become very upset. Redirected resident to stay out of other residents' room. will continue to monitor. Author: LVN A [e-SIGNED] Effective Date: 06/25/2023 4:19 PM Type: Nursing Progress Note. Note Text: resident kept pushing doors to get out and set off door alarms, resident was redirected. will monitor resident and pass on to oncoming shift. Author: LVN A [e-SIGNED] Effective Date: 06/26/2023 4:30 PM Type: Nursing Progress Note. Note Text: resident calling staff a bitch, explained to resident that she cannot be calling staff names. Resident then began to grab my arm with force, told resident let go, and talk calmly. will pass on to ADON. Author: LVN A [e-SIGNED] Effective Date: 07/04/2023 5:35 AM Type: Nursing Progress Note. Note Text: Resident was awake et wandering around the facility throughout the night. Resident redirected to her room several times. Wandering into other resident rooms et attempting to open multiple doors stating she needed to go home. Staff able to prevent resident from going to doors leading to outside. Resident extremely confused et agitated. Author: LVN B [e-SIGNED] Effective Date: 07/12/2023 9:49 PM Type: Behavior Note. Note Text: ATTEMPTED 4 DIFFERENT TIMES TO DRAW LABS FROM PATIENT. SHE WAS ALREADY AGITATED AS SHE SUNDOWNS HEAVILY WITH HER DEMENTIA. PATIENT BECOMING AGGRESSIVE. I WOULD LEAVE AND WAIT FOR 20 MINUTES OR SO AND TRY AGAIN, POSSIBLY DAY SHIFT TOMORROW WILL HAVE BETTER SUCCESS Author: ADON [e-SIGNED] Effective Date: 07/16/2023 9:07 PM Type: Activity. Note Text: patient continuously roams about both in her wheelchair and with ambulating. She will go into other resident's rooms and go through the drawers, closets, etc. (Resident #28) yelled at her this evening when she went into her room. This evening she is not having aggressive behaviors. Author: ADON [e-SIGNED] Effective Date: 07/19/2023 9:32 AM Type: Teaching with Resident/Family. Note Text: Resident oriented to not go into other resident rooms due to privacy for another resident. Resident expressed We've got to shower them. Resident oriented staff assist with resident showers. Reoriented resident not to go into another resident room. Resident appears to have understood to stay out of other resident rooms. Author: Social Worker [e-SIGNED] Effective Date: 07/20/2023 8:43 AM Type: Nursing Progress Note. Note Text: resident exit seeking going to all the doors and pushing and banging on doors, stated she is going to get out, one way or another. Redirected resident this is her home, resident stated she has a home, and this is not it. Will continue to monitor resident. Author: LVN A [e-SIGNED]. Record review of the July 2023 MAR for Resident #33 revealed that the resident had documented behaviors on 21 of 31 day shifts and 27 of 31 night shifts. There were only three days where the resident did not exhibit behaviors. On the dayshift, the resident exhibited agitation five days, false beliefs four days, wandering nine days, anxiety two days, hallucinations/paranoia one day, restlessness one day, and pacing one day. On the night shift the resident exhibited agitation six days, false beliefs five days, wandering 15 days, anxiety two days, hallucinations/paranoia one day, restlessness one day, pacing one day and insomnia two days. Record review of the MAR for August 2023 for Resident #33 regarding behaviors revealed documentation that on August 1st and 2nd the resident was documented as wandering on the day and night shifts. Record review of the Order Summary Report dated 8/3/23, which included discontinued medications, for Resident #33 revealed that the resident had an order for Xanax oral tablet 0.25 mg (alprazolam) give one tablet by mouth every eight hours as needed for anxiety related to unspecified, dementia, unspecified, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety for 14 Days. Order status completed. Order date 5/12/23. Start date 5/15/23. End date 5/29/23. Further record review of the Order Summary Report revealed that the resident currently had no orders for any psychoactive medications, and there was no documentation of an order for any psychiatric intervention such as a psychiatric consult. Record review of the resident's current clinical record revealed no documentation of psychiatric intervention. On 8/01/23 at 2:05 PM the confidential Resident Council Meeting was held. A Resident stated that Resident #33, goes through the kitchen and curses residents. Resident #33 comes in resident rooms and turns on the lights at night. She likes to go through everybody's stuff. Another Resident stated, It happens all the time. Regarding the intrusive wandering, 6 of 7 residents stated that Resident #33 wanders daily and nightly. Another Resident stated Resident #33 came into her room two times last night (7/31/23). She added You cannot get a good night's rest. She turns on the lights. An additional Resident stated that Resident #33 had been in the facility approximately a month. She further stated that the resident tries to feed other residents. A Resident stated that When staff see her, they try to redirect her. She further stated that sometimes when residents are here (common areas), and staff are not; they don't see what she does. She added that the resident wandered vacant halls. One Resident added It's driving us nuts since she's been here. She tries to answer the facility phones. A Resident also stated, She wanders at night. She cusses you out. Regarding interventions for the wandering residents, residents were asked whether any physical deterrents had been used, such as Stop Signs placed across the resident doors. Residents stated they were not aware of any physical deterrents being tried to prevent room entry. They also stated that they were not aware of any other solutions being tried regarding the residents wandering except to redirect her. On 8/2/23 at 8:57 AM a confidential interview was conducted with a Resident regarding Resident #33. The resident stated there was one lady (Resident #33) that wandered every night. The resident added he had seen her going through Resident #18's room and going through her drawers. On 8/2/23 at 1:26 PM a confidential interview was conducted with another Resident regarding Resident #33. The Resident stated the night before, Resident #33 grabbed his roommate's foot. He stated that these intrusive issues did not happen daily to him. On 8/3/23 at 9:58 AM a confidential interview was conducted with one other Resident regarding Resident #33. She stated, Yesterday I saw her almost come to blows with another resident because the resident told her to stop doing something she should not do. They just cussed each other. I see her six or eight times a day in and out of rooms and sometimes walking without a wheelchair. Her cursing and being aggressive is about 4 to 5 times a day. It happens when residents stop to tell her not to do things or she will hurt herself. On 8/1/23 at 6:13 PM Resident #33 was in the dining room, confused and wheeling herself in her wheelchair. She was reaching for other resident's food on the table after the meal and was redirected by staff. Observation on 8/2/23 at 11:40 AM Resident #33 was in the dining room and there was no staff present. She was in her wheelchair and confused and talking to random residents. When she spoke to them, she was very close and in their personal space. Observation on 8/2/23 at 1:19PM Resident #33 was in the front hallway in a wheelchair alone with no issues only wandering. Observation on 8/2/23 at 1:30 PM Resident #33 was in the dining room, wheeling herself and wandering. On 8/3/23 at 9:34 AM an interview was conducted with LVN A regarding interventions for Resident #33's wandering. She stated staff were to re-educate the resident and redirect; there were no other interventions. She added, the resident wandered as soon as she got up. She goes in resident rooms on this and the other (vacant) hall. She stated she documented the behaviors and told the Administrator. She added that the resident was exit seeking. Regarding what resulted from her reports to the Administrator about the residents wandering, she stated there was no changes in interventions. She further stated that Resident #33 had encounters with residents daily; taking their stuff and residents yell at her. Resident #33 would respond to them by telling them it was her room. Staff would show her to her room. Regarding how she became aware that the resident has had an encounter with a resident, she stated, staff would hear them yelling. Regarding how many yelling encounters were average for Resident #33, she stated approximately three times during the shift. She added, she worked days, but had worked Monday night (7/31/23). She stated the resident was up and down the halls and saying that she owned the place. The resident was going into rooms and saying she would call the cops. LVN A added the Monday night behaviors occurred between 10 PM and 12 AM. Regarding where staff documented the resident's behaviors, she stated the documentation was in the progress notes or EMAR. She further stated regarding Resident #33's behavior, that she cursed residents and would get in resident faces and staff faces too. She stated this behavior occurred a few times a shift. She added the resident's name was in large letters on her door so she could see it. During an interview on 8/3/23 at 9:35 AM, CNA A stated Resident #33 would go in the dining room and get into the countertop refrigerated milk dispenser. On 8/3/23 at 9:47 AM an interview was conducted with CNA B regarding Resident #33. She stated, the resident usually woke up before lunch and then would be all riled up. She added Residents would get upset with her and she would continually mess with people and their stuff. CNA B stated that the resident thought she worked in the facility and would bother the residents, and they would be mean to her. She further stated the resident tried to clean the dishes and could be sweet at times. She stated staff tried to keep her in her wheelchair to prevent falls. She stated she thought the resident was a Sundowner (cognitively impaired resident that is more active at night). She added the resident tried to elope too. She further stated Resident #33 argued with everyone; staff and residents and exit sought on her very bad days. She stated the very bad days happened every few days. Regarding her very bad days, the CNA stated most days she was sweet, but she cursed people out and gets in their face and said she would fire all of us. She further stated the redirection was every day. She added the resident had moved rooms two times so maybe she did not remember her room. CNA B stated she redirected the resident at least four or five times herself per shift and others also do. On 8/3/23 at 12:26 PM an interview was conducted with LVN A regarding Resident #33. Regarding how often she had reported to the Administrator regarding the resident's behaviors, she stated, she reported to the Administrator and documented in the progress notes. She stated she reported approximately once each rotation about the resident's behavior. Regarding their discontinuation of Xanax, she stated, she did not know of any reason why it was discontinued. She also stated she had not seen any documentation of a psychiatric consult for the resident. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding Resident #33. She stated, staff conducted one-on-one monitoring for two or three days starting 7/20/23. She added after the two or three days she stopped trying to get out. She further stated the resident seemed to get confused after smoking. The DON stated the resident was sweet, but residents did not like her. She added there had been a previously discussion about possibly moving the resident to another facility where there was a secure unit. On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the wandering situation with Resident #33, she stated the Resident Council had mentioned she gets into things. She added she had seen Resident #33 in the dining room cleaning things, mostly in the common areas. Regarding this situation with wandering, she stated she expected staff to report to the DON and report to administration and try other interventions. Regarding whom was responsible for ensuring that the residents wandering was not harmful to her or others, she stated it was ultimately her, the charge nurse, and aids. Regarding what could result from this situation she stated, it could cause harm to Resident #33 or others. Regarding why the issue of Resident #33's invasive wandering happened, she stated she was trying to know residents better. She added that the behaviors for Resident #33 was due to her sundowning and she may be regressing cognitively. She stated, staff reported things to her about Resident #33; she gets in the dining room and gets into plates. She stated she was aware the resident went to the back hall, was aggressive and got into in drawers. She added the Activity Director stated in Resident Council that residents had mentioned Resident #33's behaviors. Record review of the facility policy titled Nursing Policy and Procedure Manual 2003, Revised February 1, 2007, MM TIW WA 03-1.0, revealed the following documentation, Wandering. Policy Statement. Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Intervention strategies. 6. Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., Hey, come with me instead of a don't go outside). 7. Approach wanderer in a non-threatening manner. 8. Do not confront or argue with resident. Acknowledge the residents' concerns and gently redirect the resident. 9. Follow the resident to see where he/she goes. If the destination is safe, consider using a volunteer companion or family member as a suitable escort. 10. Give the resident something to do that makes him/her feel useful (e.g., [NAME] yarn or folding towels) . Environmental Modifications. 3. Use full length mirrors, black doormats, or black tap grid pattern on floor to discourage demented residents from approaching door. 4. Use signs with large letter stating a No/No Entry/Sorry Door Closed. Stress During Admission. 6. consider teaming the new resident with another resident who is comfortable and oriented in the facility. (i.e., The buddy system). 2) During a confidential interview on 8/2/23 at 9:14 AM a resident stated that the water in room [ROOM NUMBER] was never hot. Observation on 8/2/23 at 9:23 AM the hot water in room [ROOM NUMBER] was 116.1 F and was witnessed by Housekeeper A. On 8/2/23 at 10:07 AM an observation and interview were conducted in the central bath with CNA A. The lower shelf of the wall cabinet had a bottle of K Quat Plus Cleaner and Disinfectant lying on its side on top of a packet of resident use wipes. It was also under washcloths and next to the shampoos and body wash. The cabinet was unlocked. Record review of the label of the KQuat Plus Cleaner and Disinfectant revealed the following, Danger. Corrosive. Causes irreversible eye damage. On 8/2/23 at 10:12 AM, CNA A was interviewed. She stated staff were told they could place the cleaner in the wall cabinet as long as the cabinet was locked. She stated she had asked this yesterday (8/01/23) but could not remember who she had told her this. Observation on 8/2/23 at 10:29 AM, in the dining room, revealed the dining room heater closet door was unlocked. The facility had a wandering resident. Observations were made of Resident #33 wandering and confused in the dining room on 8/1/23 at 6:13 PM, 8/2/23 at 11:40 AM and 8/2/23 at 1:30 PM. Record review of the Order Summary Report for female Resident #33, dated 8/1/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety (cognitive disorder), and cognitive communication deficit (cognitive disorder). Record review of the admission MDS assessment for Resident #33 dated 5/18/23 revealed that the resident had a BIMS score of six, indicating the resident had cognitive impairment. No behavior issues were documented. A documented Active Diagnosis was non-Alzheimer's dementia. Observation on 8/2/23 at 11:28 AM revealed Floor Tech A was on the patio and supervising smokers. At the same time, there were two oxygen tanks in black bags with tubing and freestanding in the dining room. One was propped on top of an oxygen tank storage rack, leaning on the wall behind the public double door to the dining room. This tank was reading 1000 on the gauge (contained an amount of oxygen). The other oxygen tank was freestanding on the floor next to the wall and the tubing was on the floor. There were residents in the dining room at this time. On 8/2/23 at 11:33 AM an interview and observation were conducted with CNA A regarding the oxygen tanks in the dining room. She stated the tanks belonged to the residents smoking. She added residents left them there and then go outside to smoke with staff. She stated the tanks belonged to Residents #18 and #87. These residents were observed outside, smoking supervised by the Floor Tech A. Regarding what could result from that way the oxygen tanks were stored, she stated the tanks could fall over and blow up and the tubing should not be on the floor. On 8/2/23 at 11:37 AM, an interview was conducted with Floor Tech A. Regarding the oxygen storage in the dining room, he stated staff normally remove the oxygen from the wheelchairs, prior to residents smoking. He stated he and a CNA had stored the oxygen tanks in the dining room. Regarding what could result from the way the oxygen tanks were stored, he stated the tanks could fall and cause an explosion. On 8/3/23 at 11:20 AM an interview and observations were conducted with the Maintenance Supervisor regarding maintenance issues found. Regarding hot water he stated that he had issues with the water temperatures mostly in the shower room and it had been happening for approximately a month. He stated that he tried to maintain water temperatures at 110 F. He added complaints had been received about water temperatures in room [ROOM NUMBER]. He stated he took water temps one time a week. He stated the area in the facility from the showers to room [ROOM NUMBER] was the problem area. He stated that he usually conducted water temperature checks in the morning and that the water was usually 108 to 112 F. On 8/3/23 at 11:30 AM an interview and observations were conducted with the Maintenance Supervisor regarding repair issues observed in the facility: Regarding how oxygen tanks should be stored, he stated, oxygen had to be in a rack. Regarding why he felt these maintenance issues happened in the facility, he stated wear and tear overtime, past maintenance neglect, and staff not reporting. Regarding what could result from the maintenance issues mentioned, he stated it could be a safety issue. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding observed issues. Regarding oxygen storage, she stated oxygen should be secured. Regarding the cleaning items stored with washcloths and wipes, she stated cleaners should be locked separately. On 8/3/23 at 12:57 PM interview was conducted with the Administrator regarding issues found in the facility. Regarding the maintenance and environmental issues, she stated she expected staff to call a plumber and she expected the maintenance staff to report and follow through on repairs. Regarding oxygen storage, she expected it should be secured. Regarding chemical storage she stated chemicals should be properly stored (separate from resident items). Regarding repairs problems, she stated it could affect quality of life. On 8/3/23 at 1:33 PM the Maintenance Supervisor was interviewed regarding the facility water temperature documentation he presented, which included no documented temperatures only room numbers. He stated, in March he received the current form. The issues with the water temperature started on 6/19/23 and he documented issues in the comments area of the form. Record review of the Water Temperature Check log dated 3/14/23 through 7/31/23. Review of the following, documentation weekly temperature checks of the hot water. Outgoing, water temperature for the hot water faucet (should be at least 100 to 110 C). Record review of the weekly checks revealed that there was no documentation of individual temperatures in any of the rooms tested . There was documentation in the comment section on 6/19/23 which stated shower not up to temp. Another comment documented on 7/3/23 revealed the following, temp fluctuating adjustment made. Further documentation on 7/17/23 revealed the following, adjusted temp. Documentation on 7/24/23 revealed the following in the comment section, shower, hot adjusted temp. There was no documentation of any temperatures regarding the adjustment. Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information. The basis of the information is from research conducted by [NAME], AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, [NAME] J, [NAME] J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. Record review of the facility policy, titled Environment of Care Policy and Procedure Manual 2003, HM 03-1.0, revealed the following documentation, Hazardous Communications Program. Statement of purpose: hazardous chemicals and materials are used throughout the facility. The Occupational Safety and Health Administration require each employer to communicate information about hazardous materials in the workplace to each employee. The policy will establish, maintain, evaluate and communicate information concerning hazardous chemicals in an effort to reduce or prevent injury or illness to employees in a manner consistent with the requirements of OSHA 29 CFR 1910.1200 regulations. Definition: hazardous chemicals, and materials according to 29 CFR 1910.1200 include any chemical or material that presents either a health or physical hazard. These include chemicals and materials that are . irritants, corrosives. and agents that damage, the lungs, skin, eyes, or mucous membranes, . Policy. 22. The receiving department will store and label the hazardous chemicals or materials, according to manufacturer's recommendation in a secure area, designated by the facility. 39. The facility will provide adequate and appropriate space and equipment for safe handling and storage of hazardous materials and waste. Record review of the facility policy, titled Manual Title: Respiratory Policies and Procedures, Policy Title: 10.2 High-Pressure, Oxygen Cylinders. R [TRUNCATED]

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 16 residents (Residents #8, #26, and #29) reviewed for advanced directives, in that: Residents #8, #26 and #28 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored. Findings included: Resident #8 Record review of Resident #8's face sheet, dated [DATE], revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia (cognitive loss), muscle weakness, anxiety, and hypertension (high blood pressure). The face sheet also revealed under the advance directive section - DNR. Record review of Resident #8's physician order summary dated [DATE] revealed the following order: DNR dated [DATE]. Record review of Resident #8's care plan, dated [DATE], revealed care plan for DNR. Record review of Resident #8's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician's statement that the date, printed name and license number was blank. Resident #26 Record review of Resident #26's face sheet, dated [DATE], revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include cognitive decline, muscle weakness, congestive heart failure (heart does not pump enough blood to body), COPD (lung disease), and atrial fibrillation. The face sheet also revealed under the advance directive section - DNR. Record review of Resident #26's physician order summary dated [DATE] revealed the following order: DNR dated [DATE]. Record review of Resident #26's care plan, dated [DATE], revealed care plan for DNR. Record review of Resident #26's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician's statement that the date, printed name and license number was blank. Resident #29 Record review of Resident #29's face sheet, dated [DATE], revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Parkinson's disease (brain disorder), muscle weakness, dementia (cognitive loss), and hypertension (high blood pressure). The face sheet also revealed under the advance directive section - DNR. Record review of Resident #29's physician order summary dated [DATE] revealed the following order: DNR dated [DATE]. Record review of Resident #29's care plan, dated [DATE], revealed care plan for DNR. Record review of Resident #26's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under A. Declaration of the adult person that the date and printed name was blank. During an interview on [DATE] at 10:20 AM with the DON, she stated the social worker was responsible for completing the OOH DNR form. She stated a DNR was a do not resuscitate order. She stated the social worker does a monthly audit to make sure all DNR's were completed accurately. She stated an OOH DNR was not vailed unless the form was completely filled out. She verified Resident's #8, #26 and #29 had DNR orders in the EMR and verified the missing information on the OOH DNR. She stated the potential negative outcome could be not following through with not doing CPR and the residents wishes not being honored. She stated the DNR were no accurate due to human error. During an interview on [DATE] at 10:20 with the Regional Compliance Nurse, surveyor requested policy for DNR. During an interview on [DATE] at 10:37 AM with the SW, she stated she was responsible for completing OOH DNR accurately. She stated a DNR was a do not resuscitate order. She stated, I just did an audit of all OOH DNR in the facility a few days ago and they were all complete, unless I messed someone. She stated she has been trained on how to properly complete an OOH DNR. She verified Residents #8, #26 and #29 had missing information on their OOH DNR forms. She stated an OOH DNR was not vailed unless the form was completely filled out. She stated the reason why the OOH DNR was not complete was due to her not catching the missing information and human error. During an interview on [DATE] at 12:10 PM with the ADMIN, she stated the social worker was responsible for completing the OOH DNR form. She stated the DNR was a do not resuscitate order. She stated audits of EMR was done by the ADMIN and Regional Compliance Nurse. She stated the OOH DNR was not vailed unless it was completely filled out. She stated she has had no trained training on how to complete an OOH DNR. She stated all appropriated spaces should be filled in. She stated the potential negative outcome could be resuscitating someone who does not want to be or going against their wishes. She stated the missing information was an oversight. During an interview on [DATE] at 12:30 with the Regional Compliance Nurse, she stated they do not have a policy specific to OOH DNR but provided a policy for resident's rights. No additional guidance regarding the instructions in completing the DNR form within the policy. Record Review of the Instructions for Issuing An OOH-DNR Order (Revised [DATE]) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals .

Based on observation, interview and record, review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 9 of 18 resident rooms (40, 42, 44, 46, 51, 52, 54, 56 and 62) reviewed for environment, The facility failed to ensure resident use common areas and rooms were clean and did not need repair, These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings include: Observation on 8/2/23 at 9:08 AM in room [ROOM NUMBER], revealed one of two grab bars were loose in the restroom. One of two lights above the sink was out. One of two over bed light shields, at the bed B, had an approximate 2x 4section that was missing. The restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:18 AM, room [ROOM NUMBER] had a center 3 foot section of the restroom door that was missing and the door panels were loose. This restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:27 AM room [ROOM NUMBER]'s the wallboard surrounding the sink was swollen and peeling from the surface. It was an approximately 1.5' x 1'area to the side and approximately 1'x 8on the back of the sink. Observation on 8/2/23 at 9:34 AM in room [ROOM NUMBER], one of two over bed light shields, at the B bed, had a hole in the cover which was approximately 2x 2and one of two over bed lights at the sink was out. The string was missing from the call system in the restroom and one of two grab bars was loose. This restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:41 AM., in room [ROOM NUMBER], there was a lingering urine odor in the restroom and the sink was clogged and drained very slowly. Observation on 8/2/23 at 9:47 AM in room [ROOM NUMBER], the wallboard surrounding the sink was swollen and frayed. The sink was also clogged and drained extremely slowly . During a confidential interview with a resident regarding the sink, the resident stated they were on a list to get it repaired, but the facility had no drain cleaner. The resident stated they had been waiting a week, but the maintenance staff were working on other resident sinks. Confidential interview on 8/2/23 at 10:01 AM was conducted with another resident regarding the slow drain in room [ROOM NUMBER]. The resident stated, the sink did not drain very good and that it had been that way forever. The resident stated he had asked two weeks ago for it to be repaired. On 8/2/23 at 10:07 AM an observation and interview were conducted in the central bath with CNA A. There were three shower chairs in the central bath. The bariatric shower chair had a heavy accumulation of dirt and residue on the mesh back and underside. The underside was soiled with a brown buildup and hair buildup. There were also three areas on the padded seat top surface that were approximately 1 inch in diameter that were cracked and expose the interior of the padded seat. The lounge chair shower had a padded seat that was soiled with dried brown smears on the top surface. The regular shower chair (blue) had a buildup of brown residue/BM on the underside of the frame . On 8/2/23 at 10:12 AM, CNA A was interviewed. Regarding deep cleaning of the shower chairs, she stated, staff sprayed and cleaned the shower chairs after each use. She did not know if the shower chairs were deep cleaned. Regarding the cracked seat, she stated, the condition had been present for weeks. Regarding what could result from residents using the shower chair that was cracked on the seat. She stated skin tears. There was also no toilet tissue holder at the central bath toilet. On 8/2/23 at 10:42 AM an interview was conducted with the Housekeeping Supervisor regarding the cleaning of showers. She stated housekeeping staff sweep, mop, disinfect twice a day in the showers. Housekeeping, and nursing, cleaned the chairs. Housekeeping staff deep cleaned shower chairs Monday, Wednesday and Friday. She further stated the facility were to replace some of the shower chairs and that the bariatric shower chair was super old. Regarding what could result from the unclean shower chairs, she stated infection control problems could result. On 8/3/23 at 11:20 AM an interview and observations were conducted with the Maintenance Supervisor regarding maintenance issues found. Regarding his process for knowing when repairs were needed in the facility, he stated, the facility used the Maintenance Care online system and staff issue work orders. He also stated the system generated routine scheduled items. He stated that staff did not use the Maintenance Care system a whole lot, and that he received most request verbally from residents and staff. He added, he usually took notes on the verbal request. Staff were encouraged to use the online system. He stated that the notes that he made from verbal request did not go into the Maintenance Care system. He stated the Maintenance Care system had approximately four staff-initiated requests in the last 40 to 60 days. Regarding the drain problem, he stated had drain problems at the facility went to a new purchasing system which had delayed getting the drain cleaner. On 8/3/23 at 11:30 AM an interview and observations were conducted with the Maintenance Supervisor regarding repair issues observed in the facility: room [ROOM NUMBER] - the grab bar was still loose and there was still a hole in the light shield. room [ROOM NUMBER] - door still had loose and missing sections. The Maintenance Supervisor stated, he was surprised no one said anything about this. room [ROOM NUMBER] - the wall board was still swollen and frayed, and the Maintenance Supervisor stated the wallboard repair was on his list of things to do and was slowly replacing them. room [ROOM NUMBER] - still had a loose restroom grab bar and missing call system string. He was also shown the central bath cracked seat cushion on the bariatric shower chair. He stated the cracked areas were pinch points for the residents (causing skin to be pinched). On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding observed issues. Regarding shower chairs, she stated that they should be cleaned between uses. On 8/3/23 at 12:57 PM interview was conducted with the Administrator regarding issues found in the facility. Regarding the maintenance and environmental issues, she stated she expected staff to call a plumber and she expected the maintenance staff to report and follow through on repairs. She further stated staff should clean the shower chairs after each use. Regarding the result of these environmental issues, she stated regarding the shower chairs it could cause infection control problems. Regarding repairs problems, she stated it could affect quality of life. Record review of the Maintenancecare.com Task documentation revealed there was only three documented maintenance requests from facility staff. All others were system generated for regular scheduled maintenance tasks. The documentation presented was between 6/27/23 and 8/1/23. All three requests came from the kitchen. Record review of the facility policy, titled Environment of Care Policy and Procedure Manual 2003, PM 03-1.0 revealed the following documentation, Preventive Maintenance. Preventive maintenance is an undeniable critical component to any maintenance strategy. It is key to lowering maintenance costs, reducing equipment downtime, improving asset lifespan, efficiency and increasing environmental safety. Maintenance employees will take the necessary precautions and actions to reduce equipment failures from occurring before they happen. For example, performing regular, business and equipment inspections, cleaning and lubricating essential equipment, tidying the facility grounds are such examples of preventative maintenance. Facility maintenance will ensure that they utilize (facility) comprehensive preventative maintenance program that is in place for essential operating equipment. Preventative maintenance will be completed routinely, and according to protocol by the maintenance supervisor, or a qualified designee. 1. Maintenance care is (the facility) preferred maintenance system. 3. Maintenance task will be accessed by facility staff via the kiosk or PC. 4. Maintenance will access the system daily to review preventative and compliance test due. 5. Maintenance task input by facility will be received via PC or cell phone. 6. Task will be completed and closed in a timely manner or paused. If not current. 7. Administrator to review system weekly to ensure completion of tasks.

Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals observe for 2 3 of 2 residents with orders for pureed diet (Residents #20 and 23 and 27 ) reviewed for nutrition services and one resident on a mechanical soft diet (Resident #27); in that: The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (8/01/23 and 8/02/23 - Lunch) for 2 of 2 residents with the orders for pureed diets (Residents #20 and 23) and one resident on a mechanical soft diet (Resident #27). Foods were not in a pureed form and mechanical soft foods were not in the form called for on the menu. This failure could place residents at risk of decreased food intake and choking. The findings include: Resident #23 Record review of the diet Order Summary Report dated 8/1/23 for female Resident #23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of mood disorder due to non-physiological condition with major depressive like episodes (mental disorder), dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux, disease, without esophagitis (heartburn), hyperlipidemia (high cholesterol), unspecified dementia, and other diseases classified elsewhere with behavioral disturbance, anxiety disorder, unspecified (cognitive disorder), unspecified protein - calorie, malnutrition (nutrition deficiency), Alzheimer's disease with late onset (cognitive disorder), dysphagia unspecified (swallowing disorder). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, pureed texture, regular consistency. Order date 2/7/22. Start date 2/7/22. Record review of the quarterly MDS assessment for Resident #23 dated 6/23/23 revealed that the resident had a BIMS score of 99 which indicated the resident had a short term and long term memory problems. It further documented that the resident was moderately impaired cognitively. Further record review of the MDS documented that the resident had an active diagnosis of Alzheimer's disease, dementia and malnutrition. There were no documented swallowing issues. Record review of the current care plan for Resident #23 included a Focus that documented, Resident has a diet order other than regular and is at risk for unplanned, weight loss or gain. Pureed. Date initiated: 2/7/22. Revision on: 2/15/22. Interventions documented included, Serve diet and snacks as ordered. Date initiated 2/7/22. Record review of the Nutritional Risk Assessment V3 for a Resident #23, dated 2/28/23, revealed the resident was on a regular pureed diet. Physical and mental functioning was documented as .supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill fitting, dentures, or refusal to wear, dentures, and dentulous. 9. Relevant medical condition. 3. Palliative care. Additional documentation revealed the following, 14. Swallowing difficulties. Resident appears to have some swallowing difficulties. Resident #20 Record review of the Order Summary Report for female Resident #20 dated 8/2/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of major depressive disorder, recurrent, mild (mental disorder), Vitamin D deficiency, unspecified, hyperlipidemia (high cholesterol), unspecified iron deficiency, unspecified proteins - calorie malnutrition (nutrition deficiency), dysphagia, unspecified (swallowing disorder), type two diabetes mellitus with diabetic neuropathy, unspecified (blood sugar imbalance). Further record review of the Order Summary Report revealed that the resident had a diet order documented as, Regular diet, puree, texture, regular consistency. Order date 8/22/22. Start date 8/22/22. Record review of the quarterly MDS assessment for Resident #20 dated 7/4/23 revealed that the resident had a BIMS score of zero indicating that the resident was cognitively impaired. Active diagnosis listed for the resident included malnutrition. Further record review revealed no documentation of a swallowing Issue. Record review of the Nutritional Risk Assessment, V3 dated 2/28/23 revealed that Resident #20 was on a regular pureed diet. It further documented Physical and Mental Functioning. Supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill-fitting dentures or refusal to wear dentures, and dentulous. 9. Relevant medical condition. 3. Palliative care. It further documented, 14. Swallowing difficulties. Resident appears to have some swallowing difficulties. Resident #27 Record review of the Order Summary Report dated 8/1/23 for female Resident #27 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of mixed, hyperlipidemia (high cholesterol), abnormal weight loss, dental caries (tooth decay), unspecified, dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux disease with esophagitis (heart burn), unspecified protein-calorie malnutrition (nutrition deficiency), other vitamin B, 12 deficiency anemia, Alzheimer's disease with late onset (cognitive disorder). Further record review of the Order Summary Report revealed that the resident had a diet documented as Regular diet, mechanical soft texture, regular consistency Order date 12/2/20. Start date 12/2/20. Record review of the annual MDS assessment dated [DATE] revealed that Resident #27 had a BIMS score of 15 indicating that the resident was cognitively intact. Active diagnoses listed included Alzheimer's disease and malnutrition. There was no documentation of swallowing or dental issues for the resident. Record review the current care plan for Resident #27 revealed a Focus stating, Potential risk for malnutrition related to diagnosis of malnutrition and history of alcohol abuse. Date initiated: 10/29/19. Revision on: 6/7/21. Interventions listed included, Diet mechanical, soft. Date initiated: 12/3/20. Revision on 6/7/21. Offer diet as ordered by the physician. Date initiated: 10/29/19. Revision on 6/7/21. Record review of the Nutritional Risk Assessment V3 for Resident #27 dated 7/14/23 documented, The resident was on a regular mechanical soft diet and further documentation revealed the following, 8. Physical and mental functioning. 2. Supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill-fitting dentures, or refusal to wear dentures, and dentulous. 14. Swallowing difficulties. 2. Resident appears to have some swallowing difficulties. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Dietary staff C was observed preparing the pureed fried apple pie. She placed an unknow amount of milk and two fried apple pies into the processor and pureed the mixture. The results looked coarse and lumpy. She dispensed one scoop in each of the two bowls of the puree. On 8/1/23 at 11:50 AM a sample of the pureed fried apple pie was sampled and observed by the surveyor, and it was coarse with of apple bits. Dietary staff A was observed taking regular pork ribs (including bone and gristle) from the steam table and then placed them in the processor. He added chicken broth to the pork ribs and pureed the mixture. During the pureeing process the processor blade continued to jam and hard pieces of food could be heard hitting the sides of the processor during the puree. He then placed the puree in a pan. On 8/1/23 at 12:25 PM the Surveyor observed and sampled the pureed pork ribs, and there were whole bits of gristle and sharp bits and slithers of bone fragment tasted. The surveyor intervened and the staff did not to serve this food. During an interview on 8/1/23 at 12:28 PM Dietary staff A stated, he did not realize it was bone and gristle making the noise and hitting the sides of the processor; now knew it was. He further stated he understood the bones and gristle were why the blade jammed during processing. The Dietary Manager was observed reprocessing the pureed pork ribs without bones and gristle. On 8/01/23 at 12:31 PM temperatures and other observations were made of the steam table with the following results: Pureed baked beans Puree potato salad Pureed pork ribs On 8/1/23 at 12:39 PM the new pureed pork ribs were observed and sampled the surveyor, and the pureed pork ribs had to be chewed to be consumed. The puree was coarse. Observation on 8/1/23 at 1:04 PM, the meal tray for Resident #20 was prepared. The resident received pureed beans, pureed pork ribs, puree potato salad, and pureed bread which had a coarse appearance. Observation on 8/1/23 at 1:07 PM, the meal tray was prepared and served and prepared for Resident #27. She received a scoop of potato salad, fried apple pie and beans. (The resident only wanted vegetables). On 8/1/23 at 1:34 PM an interview and observation were was conducted with Resident #27. Observation of her tray card revealed that she was on a mechanical soft diet. She stated, she could not eat the fried apple pie because she had no teeth. Observation of the resident's mouth revealed she had missing teeth. Further observation of the tray card revealed that the resident should have received a soft fried apple pie. The resident then dropped the fried pie on the plate, and it made a hard clanking sound. She broke it open, and the interior with soft, but the exterior was hard. On 8/1/23 at 4:35 PM an interview was conducted with Dietary staff A regarding food form issues observed . Regarding training, he stated he worked in a couple of kitchens as a teen. He added everyone in dietary was new. He further stated he had his food handler's certificate. He stated he had not received any training on puree preparation. He stated he received general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner . -The following observations were made, and interviews conducted during a kitchen tour on 8/02/23 that began at 12:27 AM and concluded at 12:29 PM: The pureed three foods were tested and 2 of the 3 were not in a pureed form: Pureed Hamburger patty was thin, flat on the plate and watery. Pureed cream corn was thinner than pudding consistency. On 8/2/23 at 12:28 PM an interview was conducted with a Dietary Manager regarding the pureed beef patty and pureed corn. She stated, this was Dietary staff B's second week of employment. She further stated the pureed beef patty was thin. On 8/3/23 at 10:54 AM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding food form, she stated that she had given training on purees. Regarding why the foods were not in a puree or mechanical soft form, she stated Dietary staff A had only worked two days and staff needed more practice and more monitoring . Regarding what she expected of staff related to purees, she stated they should have pureed the foods correctly. Regarding what could result from an incorrect food form, she stated residents could choke and could receive incorrect portions. Regarding the mechanically altered food that was not in the correct form, she stated residents could choke. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding the reason Residents #20 and #23 were ordered a pureed diet. She stated, more than likely it was due to their diagnoses of dysphagia (swallowing disorder). On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding food form, she stated she expected staff not to puree bones and expected them to produce foods that were in the appropriate thickness. She added these issues could result in residents choking. Record review of the Resident Roster: Tuesday, 8/1/23 Breakfast list documented 9 residents in the facility had physician orders for mechanical soft diets, three residents had orders for pureed diets and 25 had orders for a regular diet. Record review of the facility guidance document dated 2014, revealed the following documentation: Training, Staff on Pureed Foods. Pureed diets should receive food that is according to the menus. It should taste the same as the regular food and should contain the same seasonings and ingredients as the food served to the regular texture diet. Only the texture should be altered. It is important that shortcuts not be taken because it will alter the calories and nutritional value of the product, as well as the color and the taste. 3. Blend product until smooth, adding additional liquid as needed to keep the product, moist and soft. There should be no lumps or texture when the blending is complete. If you have problems, process it longer, or have maintenance sharpen the blade.

Based on observation, interview and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and pureed) for 3 residents (Residents #20, #23 and #27) reviewed for during mealtime. The facility failed to ensure Resident's #20, #23 and #27 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger. The findings include: 1. Record review of the diet Order Summary Report, dated 8/1/23, for Resident #23 revealed an [AGE] year-old female who was admitted to the facility on [DATE] . The resident had diagnoses which included mood disorder due to non-physiological condition with major depressive like episodes (mental disorder), dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux, disease, without esophagitis (heartburn), hyperlipidemia (high cholesterol), unspecified dementia, and other diseases classified elsewhere with behavioral disturbance, anxiety disorder, unspecified (cognitive disorder), unspecified protein - calorie, malnutrition (nutrition deficiency), Alzheimer's disease with late onset (cognitive disorder), dysphagia unspecified (swallowing disorder). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, pureed texture, regular consistency. Order date 2/7/22. Start date 2/7/22. 2. Record review of the Order Summary Report for Resident #20, dated 8/2/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included major depressive disorder, recurrent, mild (mental disorder), Vitamin D deficiency, unspecified, hyperlipidemia (high cholesterol), unspecified iron deficiency, unspecified proteins - calorie malnutrition (nutrition deficiency), dysphagia, unspecified (swallowing disorder), type two diabetes mellitus with diabetic neuropathy, unspecified (blood sugar imbalance). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, puree, texture, regular consistency. Order date 8/22/22. Start date 8/22/22. 3. Record review of the Order Summary Report, dated 8/1/23, for Resident #27 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included mixed, hyperlipidemia (high cholesterol), abnormal weight loss, dental caries (tooth decay), unspecified, dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux disease with esophagitis (heart burn), unspecified protein-calorie malnutrition (nutrition deficiency), other vitamin B 12 deficiency, anemia, Alzheimer's disease with late onset (cognitive disorder). Further record review of the Order Summary Report revealed the resident had a diet documented as Regular diet, mechanical soft texture, regular consistency . Order date 12/2/20. Start date 12/2/20. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Dietary staff C was observed placing milk and two fried apple pies into the wet processor and pureed. The results looked coarse and lumpy. She dispensed one #12 scoop (1/3 cup), in each of the two bowls of the puree. Observation on 08/01/23 at 12:31 PM revealed the steam table with the following results: Baked beans served with a 4 ounce ladle. Ham and cheese sandwich Potato salad on ice and served with a #16 scoop. Barbecue sauce serve with a 3 ounce ladle. Ground pork rib served with a #8 scoop. Pureed baked beans served with a #10 scoop. Puree potato salad served with a #20 scoop. Ribs served with a tongs. Pureed pork ribs were still heating in the oven. Rolls were placed on the steam table Pureed Fried Apple pie #12 scoop served in bowl (previously observed preparation) Dietary Staff A was observed, during meal service, serving one scoop of each food on the trays for the menus/diets. Regular and mechanical soft trays were served #16 scoop (1/4 cup) potatoes salad instead of a 1/2 cup as called for on the menu. Pureed diets received #10 scoop (3/8 cup) of baked beans instead of a #8 (1/2 cup) scoop and received a #20 scoop (1/5 cup) of pureed potato salad instead of a #8 (1/2 cup). Observation on 8/1/23 at 1:04 PM revealed the meal tray for Resident #20 was prepared and the resident received pureed beans, pureed ribs. There was no tomato juice or margarine served. Observation on 8/1/23 at 1:07 PM revealed the meal tray was served and prepared for Resident #27. She received a #16 scoop of potato salad and one 4 ounce serving of beans. Staff stated she only wanted vegetables. Observation on 8/1/23 at 1:11 PM revealed Resident #20 feeding herself in the dining room and the meal tray was served as previously prepared; and the resident received pureed beans, pureed ribs. There was no tomato juice or margarine served. Observation on 8/1/23 at 1:12 PM revealed Resident #23 in the dining room being fed by staff. The resident received pureed beans, puree pork rib, pureed bread, and puree potato salad. The resident did not receive any tomato juice or margarine. Observation on 8/1/23 at 1:18 PM revealed 14 of 14 resident trays in the dining room had not been served any margarine with their meal. It was also observed that 13 of 13 resident trays, that were regular diets, had not been served the barbecue relish tray. -The following observations were made during a kitchen tour on 8/01/23 that began at 4:30 PM and concluded at 5:35 PM: Observation on 8/1/23 at 5:20 PM revealed the following: Pureed Chicken fried steak served in bowls. Pureed French fries served in a bowl. Pureed Cabbage served in a bowl on the steam table. Observation on 8/1/23 at 5:46 PM revealed Resident #23 in the dining room fed by staff. The resident received tea, puree cabbage, pureed chicken fried steak, pureed French fries and pureed Jell-O. The resident did not receive any pureed bread as documented on the menu. The resident tray card documented the following: regular/puree, Entree - cream gravy pureed beef steak finger, Starch - pureed crinkle cut fries, soft cooked slaw, pureed Texas toast one each, Margarine and Gelatin. During an interview on 8/1/23 at 1:06 PM, Dietary Staff A stated he served each tray with one scoop of food and two ribs were a serving unless the ribs were small and he added additional ribs. During a confidential interview revealed It would be nice if the facility had butter for the rolls. The resident had not received any margarine with the regular diet meal. During observation and interview on 8/1/23 at 1:23 PM the Dietary Manager stated, she forgot to get the barbecue relish tray and margarine out of the refrigerator. Observation of the refrigerator revealed there were containers of pickles and onions that were to be used for a BBQ relish tray. During observation and interview on 8/1/23 at 1:34 PM with Resident #27 revealed her tray card documented the resident was on a mechanical soft diet. Resident #27 stated she could not eat the fried apple pie because she had no teeth. Observation of the resident's mouth revealed she had missing teeth. Further observation of the tray card revealed the resident should have received a soft fried pie. The resident then dropped the fried pie on the plate, and it made a hard clank. She broke it open, and it was noted that the interior was soft, but the exterior was hard. The fried pie was hard and not soft fried as called for on the menu. Interview on 8/1/23 at 4:35 PM with Dietary Staff A stated everyone in dietary was new. He stated he had his food handler's certificate. He stated he had general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner. Regarding training on scoop sizes, he stated they had not gone over scope sizes or matching it to the diet spreadsheet. He stated residents not receiving the correct portions of food would not be following the physician's orders and could affect the residents weight. Observation and interview on 8/1/23 at 6:05 PM with Dietary Staff B revealed there were two bowls of puree bread observed left in the refrigerator. Dietary staff B stated the pureed bread was in the refrigerator in crystal bowls along with an extra serving; meaning two of the three residents with pureed diets received pureed bread, but one did not (Resident #23). Interview on 8/3/23 at 10:54 AM with the Dietary Manager, she said she had done a little training regarding scoop and portion sizes. She added she was also working as a cook and did not have sufficient time to devote to staff training on following the menu. The Dietary Manager stated the issues happened because staff were not paying attention. The Dietary Manager stated she expected staff to have used the correct scoops and serve the correct foods. The Dietary Manager stated a result from not following the menu could be residents could choke and would not be provided the correct foods as required. Interview on 8/3/23 at 12:57 PM with the Administrator, she stated she expected the staff to serve the correct foods and portions. She stated not following the menu could result in residents experiencing nutritional imbalance. Record review of the Tuesday (facility) 2023, Week 3 Lunch menu for residents on regulars/puree diets revealed the residents should receive one #8 scoop (1/2 cup) pureed apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 menu Lunch revealed for lunch residents on regular diets received 3 ounces barbecue ribs, half a cup potato salad, half cup baked beans, one each fluffy wheat roll, one each margarine, one serving barbecue, relish plate, and one each apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 menu Lunch revealed residents on a regular/mechanical soft diet received for lunch, 3 ounces ground barbecue ribs with sauce, 1/2 cup potato salad, 1/2 cup baked beans, one each fluffy wheat roll, one each margarine, 1/2 cup tomato juice and one each soft fried apple pie. Record review of the Tuesday (facility) 2023, Week 3 Lunch menu for residents on regular/puree diets revealed the following: one #10 scoop, pureed, barbecue rib, one #8 scoop pureed, potato salad, one #8 scoop pureed baked beans, one #10 scoop, pureed, fluffy wheat roll, one each margarine, 1/2 cup tomato juice and one #8 scoop pureed apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 Supper menu revealed residents on a regular pureed diet should have received, one #10 scoop of pureed beef steak fingers, two fluid ounces with cream gravy, one #8 scoop puree crinkle cut fries, one #10 scoop of pureed soft cooked slaw (substituted cabbage) and one #16 scoop puree Texas toast. Record review of the Resident Roster: for Tuesday, 8/1/23 list documented 9 residents in the facility had physician orders for mechanical soft diets, three residents had orders for pureed diets and 25 had orders for a regular diet. Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, FP 00-6.0, revealed, Resident Menus. We will strive to assure the residents nutritional needs are provided based on the Recommended Daily Allowances. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production. Procedure . 4. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log. 5. The menus will be prepared as written, using standardize recipes. The Dietary Service Manager and cooks are trained and responsible for the preparation and service of the therapeutic diets as prescribed Record review of the facility's guidance document, dated 2014, revealed the following documentation, Training, Staff on Pureed Foods 9. Check the scoop sizes on the menu and serve the proper portions . 10. Be sure to include puree bread on the trays per menu

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Residents #32) and 1 of 1 staff (CMA A) reviewed for infection control. 1. CMA A failed to properly clean multi-use equipment between each resident. 2. CNA A failed to perform hand hygiene between glove changes when providing wound care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination during incontinent care and medication administration. Findings include: 1. During an observation of medication pass on 08/02/23 at 08:59 AM revealed CMA A took a wrist blood pressure device into resident #21's room and took his blood pressure on his right wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. She prepared medications for Resident #9 and took the wrist blood pressure device to resident #9 who were outside smoking and took his blood pressure on right wrist. She took the wrist blood pressure device and placed on top of medication cart. She picked up the wrist blood pressure device off top of medication cart and went to resident #136 room and took his blood pressure on the right wrist. She then took wrist blood pressure device back to medication cart and placed it on top of cart . No observation of CMA A sanitizing the blood pressure device. During an interview on 08/02/23 at 11:44 AM with CMA A, she stated she did not clean the wrist blood pressure device between each resident. She stated she forgot. She stated there was no cleaning wipes on her medication cart and she was going to replace them but forgot. She stated the wrist blood pressure device was to be cleaned between each resident. She stated the potential negative outcome could be the transfer of germs between residents. She stated she was trained to clean the blood pressure device between residents. During an interview on 08/03/23 at 10:20 AM with the DON, she stated multi use equipment should be cleaned between each resident. She stated staff were trained to clean multi-use equipment. She stated they had Santi wipes or soap and water to clean equipment. She stated the potential negative outcome would be passing communicable diseases to each other, make someone sick or death. During an interview on 08/03/23 at 12:10 PM with the ADM, she stated multi-use equipment should be cleaned between each resident use. She stated the equipment should be cleaned with Santi-wipes. She stated the potential negative outcome could be spread of infectious disease. Record review of the facility's policy titled Fundamentals of Infection Control Precautions, dated 2018, revealed: . 6. Resident care equipment and articles . 3. Non-invasive care equipment is cleaned daily or as need between use by the nursing assistant 2. Record review of Resident #32's, undated, face sheet, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnosis which included anxiety (feeling of fear, dread and uneasiness) , dysphagia (swallowing difficulties), depression (sadness and a loss of intrest), hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease). Record review of Resident #32's Comprehensive Minimum Data Set, dated dated [DATE], revealed she was cognitively intact. She required extensive assistance of one person for bed mobility, dressing and personal hygiene. She required total assistance with two-person assistance for transfers, and toilet use. Resident #32 was always incontinent of bowel and bladder. Record review of Resident #16's Comprehensive Care Plan, dated 05/30/23, revealed the resident had bladder and bowel incontinence and was provided incontinent care at least every 2 hours or assisted with toileting as needed. During an observation of incontinent care on 08/02/23 at 10:00 AM, CNA A provided incontinent care for Resident #32. CNA A cleaned the resident front side handing used wipes to CNA B. CNA B placed used wipes in a trash bag on the bed. After cleaning the front side, CNA A doffed gloves and donned new gloves and turned Resident #32 onto her side. CNA A cleaned the back side area handing used wipes to CNA B to throw in trash bag on bed. CNA A removed the soiled brief and doffed gloves and donned new gloves. CNA A handed clean brief to CNA B and CNA B held brief with dirty gloved hand. CNA B handed clean brief to CNA A and she placed brief under resident and completed incontinent care. CNA B doffed gloves and took trash down the hall to the yellow bin. CNA B went to the linen cart and touched several items on the bottom shelf. CNA B then pushed the yellow bin down the hall to CNA A. CNA B was then headed into a room across the hall when CNA A intervened and told CNA B to wash her hands . CNA B observed washing her hands after intervention. During an interview on 08/02/23 at 11:50 AM with CNA B, she stated she did not wash her hands after doffing gloves and should have. She stated she also contaminated the clean brief by touching it with the dirty glove. She stated she had been trained on incontinent care, handwashing and infection control. She stated she should have washed hands after glove changes and before touching clean brief. She stated she got nervous and forgot. She stated the potential negative outcome could be cross contamination . During an interview on 08/02/23 at 02:02 PM with CNA A, she stated she did not wash her hands between glove changes because she forgot. She stated she should have washed her hands between glove changes. She stated she was trained on proper incontinent care, handwashing and infection control. She stated the potential negative outcome could be cross contamination and spreading infection. During an interview on 08/03/23 at 10:20 AM with the DON, she stated her expectations during incontinent care was for CNA's to wash their hands between glove changes. She stated she monitored and trained the CNA's skills competences annually. She stated she was responsible for monitoring CNA's to ensure they were following infection control. She stated handwashing was monitored monthly and incontinent care was monitored annually and as needed. She stated there was no reason why any staff would be exempt from handwashing. She stated all staff were trained on handwashing and infection control. During an interview on 08/03/23 at 12:10 PM with the ADM, she stated hands should be washed after each glove change. She stated the DON/ADON monitored skills competences annually and handwashing monthly. She stated the infection preventionist, ADM and DON/ADON were responsible for monitoring staff to ensure they were following proper infection control. She stated the DON/ADON monitored CNA's for proper incontinent care and infection control. She stated there was no reason any staff would be exempt from handwashing. Record review CNA Proficiency Audit provided by the facility, dated 01/20/23, for CNA B reflected skills completed in handwashing and incontinent care. Record review the Post-Test Infection Control and Universal Precautions provided by the facility dated 1/26/23 for CNA B revealed education on infection control and universal precautions. Record review CNA Proficiency Audit provided by the facility, dated 03/21/23, for CNA A , reflected skills completed in handwashing and incontinent care. Record review of the facility's policy titled Perineal Care, dated 5/11/22, reflected: Procedure Content . 10) perform hand hygiene 11) Don gloves . 24) Doff gloves and PPE 25) Perform hand hygiene . 30) tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Important points . Always perform hand hygiene before and after glove use

Based on observation, interview and record review the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 61 semiprivate rooms (room [ROOM NUMBER]) reviewed for useable living space. The facility failed to ensure Room # 7 (a semi-private room) provided 80 square feet per resident. The square footage was 153 instead of 160 square feet. This failure could place residents at risk of crowding in resident rooms and cause difficulty in providing resident care. The findings include: Observation on 8/02/23 at 10:37 AM of room [ROOM NUMBER] revealed the room measured 153 square feet instead of the 160 square feet for a semi-private room for 2 residents. Interview on 8/2/23 at 5:45 PM, the Administrator stated she wanted to apply for the room waiver for room seven. Interview on 8/3/23 at 12:57 PM with the Administrator revealed the result could be inadequate space, quality of life and depression, if residents had inadequate room square footage. Interview on 8/3/23 at 2:16 PM, with the Regional Compliance Nurse revealed the facility had no policy related to room square footage. Record review of current CASPER 3 report, dated 7/26/23, during preparation for survey revealed a waiver for room size requirements was granted on 6/22/22. Record review of Texas Health and Human Services Form 3740 (Bed Classifications [Numbers and Location]) dated 8/03/23, documented room [ROOM NUMBER] was listed as a Title 18 bed classification semiprivate room for two residents.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent injuries for 1 of 5 residents (Resident #1) reviewed for injuries. The facility failed to use a Hoyer lift as indicated in Resident #1's care plan, during a transfer which resulted in a fracture. This failure could result in decreased quality of life and risk of injury due to lack of supervision and assistance devices. Findings include: Record review of a face sheet dated indicated Resident #1 was an [AGE] year-old female admitted to the facility initially on 01/20/2021. Her diagnoses were Type 2 diabetes, Unspecified dementia, Hypothyroidism, Major Depressive disorder, and Hypertension. Record review of a Resident #1's quarterly MDS dated [DATE] indicated a BIMS of 4 indicating a severe cognitive impairment. Her bathing self-performance indicates a score of 4 indicating total dependence. Her chair/bed to chair mobility: the ability to transfer to and from bed to chair (or wheelchair) indicated a score of 01 and documents that she was dependent: Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity. Record Review of Resident #1's Occupational Therapy Evaluation, dated: 1/12/23 for certification period: 1/12/23-2/10/23, revealed: -Clinical Impressions: Decreased mobility and function -Reason for Skilled Services: Patient requires skilled OT services to assess safety and (I) with ADLs, increase safety awareness and minimize safety hazards/barriers. -Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: further decline in function, anxiety, and immobility. Resident requires total dependance for mobility. Record Review of Resident #1's Physical Therapy Evaluation, dated 1/10/23 for certification period: 1/10/23-2/8/23, revealed: -Clinical Impressions: Pt with recent UTI with need for antibiotics. Pt with noted deficits in strength, balance, and safety. -Reason for Skilled Services: Skilled PT services are warranted to assess functional abilities, promote safety awareness, enhance rehab potential, increase coordination, improve dynamic balance, enhance fall recovery abilities, increase functional activity tolerance, increase LE ROM and strength and minimize falls in order to enhance patient's quality of life by improving ability to perform functional mobility w/less risk for falls. -Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls, further decline in function and immobility. -Skilled Intervention Focus = Restoration, Compensation Record review of Resident #1's care plan dated 02/13/23 indicated she had a Focus area ADL Self-Care Performance Deficit with weakness and poor safety awareness. The goals included, will maintain, or improve current level of function in bed mobility transfers, eating, dressing, toilet use, and Personal hygiene through the review date. Interventions for Resident #1 included: Transfer: The resident requires use of a mechanical aid for transfers. The resident requires mechanical lift and 2 CNAs for transfer. Record Review of the facility provided Resident #1's Nurses note on 3/11/23 at 21:30,with no documented nurse name, revealed that the resident had a fall on 3/10/23 when 2 facility staff members were transferring resident from a wheelchair to a shower chair; and Resident #1 had bruising and a fracture to the right ankle. During an interview on 3/28/23 at 9:30 a.m. the ADM stated that on 3/10/23 Resident #1 had an assisted fall during a transfer by CNA A, CNA B, MA and the Hospice CNA and that they did not use a Hoyer lift as required during the transfer. The ADM stated that the fall was not reported to the nurse on shift by any of the staff involved (CNA A, CNA B, MA and Hospice CNA). The ADM stated that all staff, including Hospice staff are required to report all falls to the nurse and not to move a resident until a nurse assesses the Resident. The ADM stated that all staff, including Hospice staff are trained to report falls to the nurse and all staff, including Hospice staff are aware and trained that Resident #1 requires a two person assist with Hoyer lift. The ADM stated that on 3/11/23, Resident #1 was found with bruising and swelling on Resident #1's right ankle and an x-ray revealed a right heel fracture. The ADM stated that the DON immediately started to investigate how the resident fractured her right heel and during that investigation it was determined that the resident was transferred on 3/10/23 without a Hoyer lift and had an assisted fall during the transfer performed by CNA A, CNA B, MA and the Hospice CNA. The ADM stated that the fall should have been reported immediately and staff failed to follow their training by not notifying the nurse immediately and by not using the Hoyer lift as required. During an interview on 3/28/23 at 9:55 a.m., the DON stated when she became aware of the unreported fall after she began investigating Resident #1's right ankle fracture on 3/11/23. when she was notified that Resident #1 had a fracture on her right ankle. The DON stated that during her investigation, CNA A told her that CNA B asked her to assist with transferring Resident #1 without the Hoyer lift and CNA A had stated to the DON, she knew better but went along with it. The DON stated this incident occurred on 3/10/23. The DON stated CNA B stated she felt they were okay to not use Hoyer and it would be easier not to use lift with Resident #1. The DON stated Resident #1 is heavy set and cannot bare weight during transfers. The DON stated there were Hoyer lifts available and there was no reason not to use a Hoyer lift as required with Resident #1. The DON stated CNA B had told her when they attempted to transfer Resident #1 without the Hoyer, Resident #1 went to the ground and CNA A and CNA B assisted the resident to the ground. The DON stated she was told by CNA B Resident #1 yelled out after she went to the ground. The DON stated the hospice aide was also in the room and after the resident went to the ground, the MA was called into the room by one of the CNAs. The DON stated she was told by CNA A, CNA B, and the MA then they assisted Resident #1 into the shower chair and the Hospice CNA took Resident #1 for her bath. The DON stated all of the staff involved should have not lifted or moved Resident #1 without a Hoyer lift and when Resident #1 went to the ground, they should have called immediately for a nurse and waited to move Resident #1 until after the nurse assessed Resident #1 for injuries. The DON stated CNA B reported on 3/11/23 Resident #1 had bruises and swelling to her right ankle when she performed a brief change. The DON stated an X-ray was ordered that revealed a fracture to Resident #1's right ankle. The DON stated Resident #1 was on Hospice and the physician ordered a soft splint and brace and pain control for Resident #1. The DON stated she questioned Resident #1 about the injury and Resident #1 reported she hit her foot on the floor and also said it occurred during the transfer. The DON stated CNA A, CNA B, and the MA all have been trained to use the Hoyer lift and to report any incident of a resident going to the ground, regardless of if it was assisted, witnessed, or not witnessed. The DON stated all 3 (CNA A, CNA B, MA) and the Hospice CNA knew the resident was a Hoyer lift and they were required to report the fall. The DON stated that all 3 of the facility staff (CNA A, CNA B and MA) were written up and in-serviced. During an observation and attempted interview on 3/28/23 at 10:52 a.m.; Resident #1 was observed sleeping in her bed with a blanket covering her torso and lower body. Resident #1 opened her eyes and looked at the HHSC Investigator but did not respond to verbal questions regarding her treatment, fall history, or current injury to her right heel. During an interview on 3/28/23 at 11:25 a.m. with CNA A stated on 3/10/23 she was working with CNA B in Resident #1's room. The CNA A stated Resident #1 was in her wheelchair and the Hospice CNA entered the room stating she needed to shower Resident #1. The CNA A stated CNA B stated they would transfer Resident #1 from her wheelchair to the shower chair without the Hoyer lift. The CNA A stated she did not think it was a good idea, but she assisted CNA B. The CNA A stated during the transfer Resident #1 went to the ground when they stood Resident #1 up and both CNA A and CNA B assisted the resident to the ground. The CNA A stated the Hospice CNA was prepping for Resident #1's shower and did not assist with the transfer. The CNA A stated the Hospice CNA called out in the hall to the MA for help. The CNA A stated the MA came into the room and all 4 of them (CNA A, CAN B, MA, and Hospice CNA) each grabbed onto a limb to lift Resident #1 into the shower chair. The CNA A stated the Hospice CNA then took Resident #1 for a shower and Resident #1 had stated she was really tired after the transfer. The CNA A stated she did not report the assisted fall to the nurse because she didn't think to notify anyone. The CNA A stated the Hoyer lift was outside Resident #1's room and she had been trained Resident #1 was a 2-person life with a Hoyer. The CNA A stated Resident #1 required a Hoyer lift because staff cannot lift her properly without the lift. The CNA A the Hoyer lift provides a safe method to lift and transfer Resident #1 because Resident #1 cannot bare weight on her legs for a long time and was unable to walk or transfer herself. The CNA A stated the risk of not using the Hoyer lift could result in a resident having a fall that could result in an injury. The CNA A stated she has been trained on reporting falls, Hoyer lifts, transfers, and Resident #1's care plan. She stated resident falls which could turn into injuries. CNA A stated that I believe we neglected Resident #1; we failed to report it and she has injuries. During an interview on 3/28/23 at 11:48 a.m. with the Director of Rehab; stated that Resident #1 is a Hoyer lift due to safety and that Resident #1 can become very confused and does not stand well. The Director of Rehab stated that when the rehabilitation department worked with Resident #1, she had a hard time doing sit down to stand up movements with two rehabilitation department staff assisting. The Director of Rehabilitation stated staff are trained to use the Hoyer lift and there are 2 Hoyer lifts available in the facility. The Director of Rehabilitation stated that the risk of not using a Hoyer lift included falls, fractures, tears, or employee injuries. The Director of Rehabilitation stated that if a resident has a fall, or an assisted fall staff are required and trained to notify the nurse immediately. The Director of Rehabilitation stated that the staff involved in the incident with Resident #1 neglected to follow her care plan requiring a 2 person transfer with the use of the Hoyer and stated that it is possible that the fracture occurred during transfer or fall. The Director of Rehabilitation stated that if a staff member witnesses another staff not using a Hoyer lift on a resident who requires a Hoyer, they should immediately report to the charge nurse, Director of Nurses, or the Rehabilitation department to address it. During an interview on 3/28/23 at 1:31 p.m. with CNA B; stated that on 3/10/23 she was working in Resident #1's room with CNA A assisting Resident #1's roommate to bed. The CNA B stated that the Hospice CNA came in and stated she needed to shower Resident #1 and entered the room with the shower chair. The CNA B stated Resident #1 was in her wheelchair and CNA A and CNA B decided to transfer Resident #1 to the shower chair. The CNA B stated that she and CNA A stood behind Resident #1 and used Resident #1's arms to lift her while the hospice CNA attempted to pull down Resident #1's pants. The CNA B stated that during that transfer, Resident #1 must have gotten tired being in a standing position and started going to the ground and she and CNA A assisted Resident #1 to the ground. The CNA B stated she then stepped into the hallway and asked the MA to come and assist with Resident #1, stating that then they CNA A, CNA B, Hospice CNA, and the MA all grabbed one of Resident #1's limbs to transfer her to the shower chair. CNA B stated that the shower chair moved but they were able to get Resident #1 in the shower chair. CNA B stated that Resident #1 requires two people to transfer and the use of a Hoyer lift. CNA B stated there was a Hoyer lift in the hallway and they were in a hurry and chose not to use it. CNA B stated, I don't know why we didn't use the Hoyer, I know it was wrong. We were just trying to hurry up and help the hospice lady so she could shower and bathe her. The CNA B stated after Resident #1 was in the shower chair, she left the room, and the MA took Resident #1 to bathe. The CNA B stated she never reported to the nurse that Resident #1 went to the ground and did not have a reason for not reporting to the nurse. The CNA B stated she knows that she should have reported to the nurse, and she is trained to do so. The CNA B stated that staff are not supposed to move a resident during an assisted fall because the nurse needs to assess for injuries. The CNA B stated that she has been trained on Resident #1's care plan and did not follow the plan when she did not use a Hoyer lift. The CNA B stated that Resident #1 relies on staff to do all transfers, incontinence care and bathing. The CNA B stated that on 3/11/23 she observed bruising and swelling to Resident #1's ankle when she attempted incontinence care and that is when she notified the nurse of her observations but did not tell the nurse about the fall the previous day. The CNA B stated that neglect is not following a resident care plan or using a Hoyer lift. I don't know why we didn't use the Hoyer. I feel bad. It hurt me to see Resident #1 hurt. We didn't want that to happen to her. Every time I think about it, I feel awful that we didn't use the lift and she got hurt. It makes me cry to know we did that, and she got hurt. During an interview on 3/28/23 at 1:50 p.m. with the MA, stated that he was working on 3/10/23 in the hallway and heard someone call out his name to Resident #1's room. The MA stated that when he entered Resident #1's room he observed Resident #1 on the floor and CNA A, CNA B and Hospice CNA were in the room. The MA stated he knew that Resident #1 was a Hoyer lift but didn't think of that when he saw Resident #1 on the floor and he assisted CNA A, CNA B and the Hospice CNA lift Resident #1 off the floor and attempted to put her in the shower chair. The MA stated that the shower chair slid back, and Resident #1 was assisted by them again to the floor. The MA stated then they lifted Resident #1 up and placed her in the shower chair for the Hospice CNA to bathe her and he left the room. The MA stated he has been trained to notify the nurse if a resident has a fall or is on the ground and not to move the resident until a nurse assesses the resident. The MA stated he believed one of the CNAs would have notified the nurse. The MA stated that the purpose of having a nurse assess a resident after a fall is for the nurse to determine if there are any injuries. During an interview on 3/28/23 at 2:06 p.m., Corporate nurse stated staff should have used a Hoyer and 2 people assist with Resident #1. Corporate nurse stated that staff should have reported when Resident #1 went to the ground. Corporate nurse stated that CNA A, CNA B, and MA were trained during orientation to notify the nurse after a fall and to use the Hoyer lift. During a phone interview on 4/4/23 at 9:41 a.m. the Hospice CNA stated that she was working at the facility on 3/10/23 and walked into Resident #1's room to prepare her for a shower. The Hospice CNA stated she walked into the room and observed CNA A and CNA B in the room assisting another resident to bed. The Hospice CNA stated she had worked with Resident #1 five times before 3/10/23 and had been trained that the Resident required a Hoyer lift and 2 persons for all transfers and lifting. The Hospice CNA stated that staff told her that they didn't need the lift and the CNA A and CNA B lifted Resident #1 from her wheelchair and she attempted to pull down Resident #1's pants before they transferred her to the shower chair. The Hospice CNA stated that the resident went to the ground, and they assisted her to the ground. The Hospice CNA stated Resident #1 made a aah sound when she was on the ground. The Hospice CNA stated that the MA was called into the room and they (CNA A, CNA B, MA, and herself) lifted Resident #1 by each of them holding onto a limb and placed her in the shower chair. The Hospice CNA stated the shower chair did go back several inches, but she does not remember the resident going to the ground again. The Hospice CNA stated that she then took Resident #1 to bathe and during the bathing, Resident #1 stated that her right heel hurt. The Hospice CNA stated she called her supervisor and notified her that the resident was complaining about heel pain, and she was advised to check for pressure sores. The Hospice CNA stated that she did not observe any pressure sores and Resident #1 stated her heel hurt on the inside, not on the skin. The Hospice CNA stated she did not report the fall to any one at the facility and waited several days before reporting to her agency. The Hospice CNA stated that she thought she told a facility charge nurse that Resident #1 complained about her heal hurting but does not remember who or when she notified someone at the facility. The Hospice CNA stated she had been trained to immediately notify a nurse when a resident has a fall or goes to the ground because a nurse has to assess a resident for injuries. The Hospice CNA stated that she also knew Resident #1 required a Hoyer lift but went under the direction of the facility CNAs during the transfer. The Hospice CNA stated that by not following the care plan that stated that Resident #1 was a 2 person transfer with Hoyer lift, it placed the resident at risk of falls and injuries. The Hospice CNA stated she was not aware that Resident #1 fractured her right ankle until the facility contacted the hospice agency and notified them of the incident. During a phone interview on 4/4/23 with Hospice LVN; stated that the Hospice CNA called her on 3/10/23 to notify her that Resident #1 stated that her right heel was hurting, and she(Hospice LVN) advised her to check for pressure ulcers or sores. The Hospice LVN stated she never got back with the Hospice CNA to determine if there were any pressure ulcers or sores. The Hospice LVN stated that the Hospice CNA never informed her that Resident #1 had an assisted fall during a transfer, nor did the Hospice CNA inform her that a transfer was done without the Hoyer lift. The Hospice LVN stated that the Hospice CNA has been trained that Resident #1 requires a two-person lift and a Hoyer lift during all transfers. The Hospice LVN stated that the Hospice CNA should not have participated in a transfer of Resident #1 without utilizing the Hoyer lift as required. The Hospice LVN stated she was notified of the incident that occurred on 3/10/23 by the facility and that Resident #1 had a fractured right heel. The Hospice LVN stated that the Hospice CNA was trained prior to 3/10/23 that Resident #1 required a 2 person transfer and Hoyer lift, to notify both the facility nurse and the hospice agency of any resident falls and not to move a resident who has had a fall. Record review of the facility's Abuse, Neglect policy dated 05/2017 indicated neglect means failure of the facility, its employees , or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Employees must report suspected abuse, neglect, mistreatment, or injury of unknown origin of a potential victim immediately to the DON and Administrator. Record review of the facility provided Provider Investigation Report, report date to HHSC 3/11/23 revealed the following: -Incident date: 3/10/23 at 3:30 p.m. in Resident #1's room. Description of the allegation: Failure to follow resident care plan for transfers. Failure to report an assisted fall. Injury of unknown origin. -Description of injury: Right and lateral fracture of right malleolus. -Assessment on 3/11/23 at 11:12 a.m.: Green bruise to lower shin 7.4 cm X 4 cm, dark purple bruising rt ankle. Rt elbow 1 cm x 2.4 cm skin tear. Investigation Summary: It was determined that on 3/10/23, CNA A, CNA B and Hospice CNA transferred resident without a mechanical lift from w/c to shower chair. During the transfer they struggled, and resident was assisted to floor. MA went in room and all 4 assisted residents to shower chair. -Investigation Findings: Confirmed -Provider Action Taken Post-Investigation: Suspended CNAs during investigation. Written disciplinary action against CNA A and CNA B involved in transfer. MA received one on one coaching for not reporting the incident to the charge nurse. Training/In-services for CNAs/MA on transfers, mechanical lift,. In-services on transfers, mechanical lifts, notifying supervisor of accidents and events, abuse, neglect and injury of unknown origin. In-services signed by CNA A, CNA B and MA on 3/11/23. Record review of the facility provided, undated, Hydraulic Lift policy indicated: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer's recommendations. Goals include: The resident will achieve safe transfer to bed or chair via a mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift. (see training record) Record Review of facility provided SNFCLINIC training transcript for CNA A revealed the following completed training: What is Abuse; Lifting Machine, Using a Mechanical; Transferring from a Bed to Wheelchair using a transfer belt; Using a Hydraulic Lift; CNA-Safely Moving residents-Lifting and Transferring; Abuse, Neglect and Exploitation Fall Prevention Record Review of facility provided SNFCLINIC training transcript for CNA B revealed the following completed training: Fall Prevention, Slip, Trip and Fall Prevention, What is Abuse; Using Restraint Alternatives; Lifting Machine, Using a Mechanical; Using a Hydraulic Lift; Abuse, Neglect and Exploitation; Transferring from a Bed to Wheelchair using a Transfer Belt; CNA Safely Moving residents-Lifting and Transferring Record Review of facility provided SNFCLINIC training transcript for MA revealed the following completed training: Fall Prevention, Slip, Trip and Fall Prevention, What is Abuse, Using Restraint Alternatives. Lifting Machine, Using a Mechanical; Using a Hydraulic Lift; Abuse, Neglect and Exploitation.

Based on observation, record review and interviews, it was determined the facility failed to implement their written policies and procedures that prohibit abuse/neglect for 4 of 10 residents (Resident #1, #3, #5, and #8) reviewed as evidence by: Resident #1's had three non-stageable pressure sores, which declined into one large pressure sore measuring 14 x 10 cm; however, her physician was not notified for 5 days (05/07/16 to 05/11/16). Residents #3, and #5 and #8 did not have their pressure ulcer on their feet and/or ankles floated to prevent rubbing against mattress and/or recliner's footrest. These failures resulted in identification of an Immediate Jeopardy (IJ) on 5/12/16. While the IJ was removed on 05/13/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. This deficient practice affected 4 residents #1, #3, #5 and #8, and had the potential to place 6 residents at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, pain, possible amputation and death. The evidence is as follows: Review of resident #1's current Admission Record documented an initial admitted [DATE] and a re-admitted [DATE], and this [AGE] year old resident's [DIAGNOSES REDACTED]. Review of resident #1's current Admission Minimum Data Set (MDS) resident assessment dated [DATE], documented Brief Interview For Mental Status (BIMS) cognitive assessment score of 9, (Moderate cognitive loss = 8-12). In addition this MDS indicated resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting use, personal hygiene, locomotion on and off the unit and could not walk; resident was totally dependent on staff for bathing; resident used a wheelchair; resident was occasionally incontinent of bladder and frequently incontinent of bowel, and resident was at risk for pressure ulcers having 1 non-stageable - deep tissue injury (present at admission). Review of resident #1's current Quarterly MDS dated [DATE] indicated a decline in her status as follows: she was unable to complete the BIMS cognitive assessment, which was due to being severely impaired in cognitive skills for daily decision making. Resident was totally dependent on staff for activities of daily living skills (ADLs), and always incontinent of bladder and bowel. This MDS indicated resident #1 had 4 unstageable- Slough and/or Eschar unhealed pressure ulcers and 1 unstageable deep tissue injury (upon readmission) with the dimensions of the largest surface area being 5.5 cm x 4.5 cm, the most severe tissue type for any of the pressure ulcers being slough. Review of resident #1's active Care Plan dated 4/06/16 documented that resident #1 had deep tissue pressure ulcer to coccyx: Intervention - Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, and report declines to the MD (physician). Review of resident #1's Physician Telephone Orders documented the following: On 4/20/16: d/c previous tx (treatment) to bilateral buttocks cleanse wound to bilateral buttocks, pat dry, apply santyl to wound bed, cover and secure. On 5/11/16: stat (immediately) CBC, CMP dx- wound, and notify FNP #2 for wound consult. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/4/16 documented the following; One unstageable pressure ulcer was on her left buttocks with a size of 2.4 x 2.1 cm (centimeter). The wound bed color was listed as red, pink, and yellow; the most severe tissue type present was slough at 25% with a light amount of yellow exudate. One unstageable pressure ulcer was on her left superior (upper) buttocks with a size of 0.7 x 1.0 cm. The wound bed color was yellow; the most severe tissue type was slough at 100% with a light amount of yellow exudate. One unstageable pressure ulcer was on her right buttocks with a size of 6 x 5 cm. The wound bed color was pink, red, and yellow; the most severe tissue type was slough at 50% with a light amount of yellow exudate. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/10/16 (one week later) documented the following: The three pressure ulcers as described on Weekly - Ulcer Assessment - V 3 5/04/16 had developed into the following: One unstageable pressure ulcer on the buttocks with the size as 14 x 10 cm; the wound bed color was pink, red, yellow and black; the most severe tissue type was eschar at 75% with a moderate amount of pink exudate. Observation on 5/11/16 at 2:25 pm for resident #1 revealed she had a large pressure ulcer on her buttocks/coccyx areas. There was about 75 % of the wound bed that was covered with black and tan eschar with yellow slough present. The surrounding edges of the wound bed were [DIAGNOSES REDACTED]tous. The old dressing dated 05/10/16 was removed by LVN #1 on 5/11/16, which revealed a moderate amount of purulent (thick or thin, opaque tan to yellow) drainage on it. Record review of resident #1's medical chart revealed there was no documentation made over the weekend (5/7/16 through 5/8/16) on her declining condition of pressure sores, nor was physician and resident's legal representative notified for 5 days; even though LVN #1, LVN #2 and RN #1 reveal they were aware of resident 1's change in condition, as follows: During an interview on 5/11/16 at 1:25 pm, LVN #1 (Wound Care Nurse) stated that resident #1 pressure ulcer was 3 individual pressure ulcers on Friday 5/6/16. She stated that when she returned to work on Monday 5/9/16 the 3 pressure ulcers had turned into 1 large pressure ulcer. In addition LVN #1 indicated she did not contact the physician on Monday to notify him of resident 1's change in condition, because honestly I just didn't call on it, I just wanted to monitor it, her stuff changes all the time, but now I'm going to call Family Nurse Practioner (FNP) #2 to come and look at it. During an interview on 5/11/16 at 2:11 pm with weekend RN #1 (Wound Care Nurse) said she was shocked when she saw the pressure ulcer on Saturday 5/7/16 compared to the previous weekend. She said it was black on Saturday (5/7/16) when I took the dressing off, the whole area was black, and I've never seen it like that. RN #1 stated she asked LVN #2, who was also the charge nurse (CN), if she had seen resident #1's pressure ulcer, and LVN (CN) #2 replied that she knew what it looked like. RN#1 indicated she if a resident's wound deteriorates on weekends I tell the charge nurse and she will call whoever's on call and tell them. Everyone said they know it's bad, it's changed, obviously everyone knew about it. They said something like she'll (nurse practitioner) be here at the beginning of the week. During an interview on 5/11/16 at 4:20 pm LVN #2 said last weekend (5/7 5/8/16) RN #1 asked her if she had seen resident #1's pressure ulcer and she replied yes, that she had looked at it on Friday (5/07/16) with LVN #1. LVN #2 said RN #1 told her she thought it had gotten worse since the last time she saw it, and LVN #2 agreed. LVN #2 indicated resident #1's pressure ulcer was black on Friday, and that's when LVN #1 wanted me to see it (the pressure ulcer on resident #1's buttock/coccyx area) and if I thought it was getter worse because she thought it was LVN #1 asked LVN #2's opinion on whether she should get a consult with FNP #2, who cares for wounds, and LVN #2 said she agreed with the idea that it needed to be consulted. LVN #2 indicated RN #1 did not ask her to call the physician to report the decline in the pressure ulcer. LVN #2 added that RN #1 usually does not ask her to call the physician. LVN #2 indicated she had not called the doctor on Saturday (5/7/16) about resident #1's worsening condition of the pressure ulcers, because I didn't think about it. During an interview on 5/11/16 at 5:08 pm the ADON was asked if the nurses are supposed to report change in conditions to her and she said yes. She said that she had just found out about the pressure ulcers going from 3 pressure ulcers to 1 large pressure ulcer until today (05/11/16). During an interview on 5/11/16 at 5:25 pm the wound care consultant; FNP #2 was asked if she was informed of resident #1's pressure ulcer, and she replied that she couldn't remember exactly what the nurse had said but that she didn't make it seem urgent. FNP #2 stated that if she is following a wound she wants to know all changes in condition. This FNP #2 indicated she was not informed of the pressure ulcer measurements, and when informed of documented measurements, she replied oh my gosh! No, I didn't know it was that bad. During an interview on 5/11/16 at 5:34 pm Certified Nurse Aide (CNA) #1 was asked if she saw resident #1's pressure ulcer on her buttocks/coccyx this past weekend (5/7/16 - 5/8/16) and she replied I saw it and thought it looked pretty bad. It's gotten bigger and blacker. During an interview on 5/12/16 at 9:15 am FNP #2; the primary care physician's nurse practitioner replied yeah, I can't believe they didn't call me on that (resident 1's pressure ulcer). They call me on everything else. That would've been nice (to be notified about resident #1's change in condition for her pressure ulcers). During an interview on 5/12/16 at 11:15 am the DON was asked if she was contacted this past weekend concerning resident #1's worsening pressure ulcers and she replied no. During an interview on 5/12/16 at 11:30 am the ADON stated that skin issues are a big deal, it's a failure to notify the doctor, plainly black and white. During an interview on 5/12/16 at 11:44 am the Administrator indicated his expectations of the facility's staff, concerning resident #1's pressure ulcers, was that her physician be notified; however, the physician was not notified. During an interview on 5/12/16 at 11:54 am resident #1's primary care physician (and facilities medical director); Physician #1 replied no, I was not notified that resident 1's pressure ulcers had worsen. Physician #1 added that he expected the facility's staff to notify him of this change and he said yeah, I'd expect them to call FNP #1 or Physician #2 if the pressure ulcer had gotten worse. Physician #1 said the wound care has been as issue and a problem (for this facility), and an area that needs improvement. Review of resident #3's current Admission Record indicated she was an [AGE] year old female, who was admitted into this facility on 07/02/12. This report included her [DIAGNOSES REDACTED]. Review of resident #3's Care Plan dated 03/08/16 indicated he pressure ulcer onhis left heel and his pressure ulcer to his left inner heel would be floated with the use of pillows. Observation of resident #3 on 05/12/16 at 10:00 am indicated she was wearing blue (Podus) boots on her feet; however, the boot's straps that went across the top of the foot were loose and dangling due to straps not adhering onto velcro. On 05/13 16 at 9:48 am resident #3's left heel was lying/rubbing directly on her mattress, and she had no pillows to float her heel. Review of resident #5's current Admission Record indicated he was a [AGE] year old male, who was admitted into this facility on 12/17/16 and readmitted on [DATE]. This report included resident #5's [DIAGNOSES REDACTED]. Review of resident 5's Care Plan dated 03/16/16 indicated his right ankle deep tissue injury pressure ulcer, would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #5's Weekly-Ulcer Assessment - V3 dated 05/10/16 indicated he had pressure ulcer - deep tissue injury to his right ankle. This ulcer measured 1.2 centimeters in length, by 0.6 centimeters in width, and unable to determine depth, wound color was black, had eschar - black, brown or tan adhere to the wound bed at 100 percent of approximate amount of necrosis. The intervention for this ulcer was noted as turn ever two hours, [MEDICATION NAME] daily, pillows to float heels, and pillow boots while out of bed. Observation of resident #5 on 05/11/16 at 12:27 pm and on 05/12/16 at 10:05 am indicated his ulcer on his right ankle was lying/rubbing directly on his mattress. Review of resident 8's current Admissions Record indicated she was a [AGE] year old female, who was admitted into this facility on 04/02/09. This report included resident 8's [DIAGNOSES REDACTED]. Review of resident #8's Care Plan dated 05/11/16 indicated her left unstageable pressure ulcer to her left heel would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #8's Weekly Ulcer assessment dated [DATE] indicated she had a pressure ulcer - deep tissue injury that measured 4 centimeter in length, 3 in width, unable to determine depth, wound bed moist, and skin intact over blister. This report indicated resident #8's pressure ulcer should be provided with pillows to float heels and Podus boot, when out of bed. Observation of resident #8 on 05/12/16 indicated on 05/12/16 at 10:08 am, and on 05/13 16 at 9:51 am indicated she was lying on her recliner with her heels directly touching the recliner's footrest, and she had no pillows to float her heels. During an interview with CNA #3 on 05/13/16 at 10:26 am indicated she assisted resident #8 to her recliner, and she failed to place a pillow under resident #8, in an attempt to float her feet. During an interview with CNA #1 on 05/12/16 at 10:25 am indicated she knows residents with pressure ulcers on their feet and/or ankles should have these feet floating; however, this is not always possible due to needing help on the floor. During an interview with Family Nurse Practioner #1 on 05/12/16 at 10:14 am indicted residents at risk for pressure ulcers, and/or have wounds on feet/ankles, should have these areas floated. During an interview with Physician #1 (Medical Director) on 05/12/16 at 12:03 pm indicated he expect his staff to float resident's feet as much as possible, when they have wounds to feet and/or ankles. Record review of the facilities' policy and procedure dated 2/13/2007 and titled Notifying the Physician of Significant Change in Status documented the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The resident's family member or legal guardian should be notified of significant change in resident's status, unless the resident has specified otherwise. Record review of the facilities' policy and procedure dated 4/2016 and titled Pressure Injury: Prevention, Assessment and Treatment documents the following procedures: The treatment nurse/designee will: Notify the physician of pressure sore and obtain an order to implement the appropriate treatment etc. Nursing Action/Rationale: Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet ant treatment completed (i.e., Stage I through Stage IV). Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages; Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be unstageable. Staging definitions are per guidelines of the national Pressure Injury Advisory Panel February 2016 definitions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed etc. Review of the facility's policy and procedure for Abuse/Neglect dated 01/08/03 included the Definition of Neglect as: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101 (81). On 5/12/16 at 12:57 pm an Immediate Jeopardy (IJ) was identified, and the Administrator, Regional Compliance Registered Nurse, Vice President of Clinical Services, Director Of Nurses, Assistant Director of Nurses was informed of this IJ due to the above failures. On 5/13/16 at 12:25 pm the Administrator, Corporate Registered Nurse, Area Director, Director Of Nurses, Assistant Director of Nurses were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern, due to facility monitoring Plan of Removal. On 5/13/16 at 12:25 the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy included the following: Problem: Notification of physician or nurse practitioner of decline in wound. Interventions included in Plan Of Removal were as follows: The physician for resident 1's was notified of the change in condition related to her coccyx wound on 5/11/16 at 1:20 pm. New orders were received and implemented. All resident pressure ulcers were assessed on 5/12/16 by the DON for potential decline in wound status. No other wounds were assessed as declined in status The following in-services were initiated by the DON, ADON and Regional Nurse on 5/12/16: Any staff member not present at in-service on 5/12/16, will not be allowed to assume their duties until in-serviced. On 5/12/16 residents at a high risk to develop pressure ulcers were identified. Those residents with current pressure ulcers and those considered high risk according to the last completed Braden scale (score or 10 or less) were determined High Risk to develop pressure ulcers. Licensed nurses received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Licensed nurses will immediately reporting negative changes in skin condition to the physician or nurse practitioner i.e. a new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two week time period should be reported immediately to the physician or nurse practitioner Non-licensed nursing staff received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Non-licensed nursing staff are to report changes in a resident's skin condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to immediately report verbally the change to the nurse. The Medical Director was notified of the immediate jeopardy situation on 5/12/16 at 2:55 pm. Monitoring will be conducted by DON and /or designee, who will monitor those residents considered high risk for pressure ulcers at least 5 times per week to ensure that they are being turned and repositioned timely. The DON will monitor all wound assessments each week to monitor for negative changes and if so, that the physician was notified. The DON will visually observe all ulcer wounds at least weekly to monitor for negative changes. The DON and/or designee(s), through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. The QA committee will review findings and makes changes as needed. During an interviews on 05/13/16 with facilities' nurses LVN #3 at 9:48 am, LVN #1 at 9:55 am , LVN #4 at 10:05 am, LVN #5 at 10:09 am, LVN #6 at 10:52, ADON at 10:15 am, and DON at 10:22 am, indicated they observed pressure ulcer presentation, which included turning residents every two hours, elevating heels on pillows, and using cushions as directed in bed or in wheelchair. In addition these staff was in-serviced to report immediately negative changes to physician and/or nurse practitioner, which included new wounds, decline of current wounds, or wounds that do not improve over a two week period. This plan included a Monitoring Sheet to be noted by DON, which would include residents considered high risk for pressure ulcers. This report which would be noted at least five times per week, to ensure these residents were repositioned, and their wounds were assessed for changes. If changes were noted this report would include notifying physician. During in interviews on 05/13/16 with Certified Nurse Aides, #2 at 9:47 AM, #3 at 10:28 AM, #4 at 10:30 AM, #5 at 10:52 AM, indicated they received training to ensure residents were repositioned every two hours, and their feet were floated as needed to prevent further decline of pressure ulcers. Observation on 05/13/16 for of residents #3 at 9:48 am, #5 at 9:54 am, and #8 at 9:51 am indicated they were lying in their beds or sitting in their recliners, while their feet and/or ankles were floated with pillows, which prevent rubbing against mattress or recliner's foot rest. Review of the facility's Roster/Sample Matrix - Form CMS 802 (Resident Census and Conditions of Residents) dated 05/11/16, confirmed a census of 57. Review of this form revealed facility had 8 residents that were hi-risk pressure ulcers (stage 2 - 4). However, this report did not match hand written sheet provided by facility on 05/12/16, and included the following residents: Review of this sheet dated 05/12/16 indicated there were 10 residents with wounds. 4 of these 10 residents had pressure ulcers on their coccyx (resident #1 had unstageable ulcer, resident #7 had stage 4, nonsample resident had one stage 3, and nonsample resident had one stage 2). Further review of these sheet indicated 7 of these 10 residents had wounds to their feet and/or ankles (resident 1 had one stage 1 to right foot, resident 8 had one stage 2 to left heel, resident 4 had one stage 2 to right ankle, resident 3 had one stage 2 to left inner heel and one stage 3 to left outer heel, resident 5 had one stage 2 to right ankle, nonsample resident had one unstageable to right ankle, and resident 1 one unstageable to right and to left heel.)

Based on observation, interview, and record review, it was determined the facility failed to implement their policy and procedure that prohibits neglect for 4 of 10 residents (#1, #3, #5 and #8) reviewed for neglect as evidence by: Resident #1's had three non-stageable pressure sores, which declined into one large pressure sore measuring 14 x 10 cm; however, her physician was not notified for 5 days (05/07/16 to 05/11/16). Residents #3, and #5 and #8 did not have their pressure ulcer on their feet and/or ankles floated to prevent rubbing against mattress and/or recliner's footrest. These failures resulted in identification of an Immediate Jeopardy (IJ) on 5/12/16. While the IJ was removed on 05/13/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. This deficient practice affected 4 residents #1, #3, #5 and #8, and had the potential to place 6 residents at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, pain, possible amputation and death. The evidence is as follows: Review of resident #1's current Admission Record documented an initial admitted [DATE] and a re-admitted [DATE], and this [AGE] year old resident's [DIAGNOSES REDACTED]. Review of resident #1's current Admission Minimum Data Set (MDS) resident assessment dated [DATE], documented Brief Interview For Mental Status (BIMS) cognitive assessment score of 9, (Moderate cognitive loss = 8-12). In addition this MDS indicated resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting use, personal hygiene, locomotion on and off the unit and could not walk; resident was totally dependent on staff for bathing; resident used a wheelchair; resident was occasionally incontinent of bladder and frequently incontinent of bowel, and resident was at risk for pressure ulcers having 1 non-stageable - deep tissue injury (present at admission). Review of resident #1's current Quarterly MDS dated [DATE] indicated a decline in her status as follows: she was unable to complete the BIMS cognitive assessment, which was due to being severely impaired in cognitive skills for daily decision making. Resident was totally dependent on staff for activities of daily living skills (ADLs), and always incontinent of bladder and bowel. This MDS indicated resident #1 had 4 unstageable- Slough and/or Eschar unhealed pressure ulcers and 1 unstageable deep tissue injury (upon readmission) with the dimensions of the largest surface area being 5.5 cm x 4.5 cm, the most severe tissue type for any of the pressure ulcers being slough. Review of resident #1's active Care Plan dated 4/06/16 documented that resident #1 had deep tissue pressure ulcer to coccyx: Intervention - Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, and report declines to the MD (physician). Review of resident #1's Physician Telephone Orders documented the following: On 4/20/16: d/c previous tx (treatment) to bilateral buttocks cleanse wound to bilateral buttocks, pat dry, apply santyl to wound bed, cover and secure. On 5/11/16: stat (immediately) CBC, CMP dx- wound, and notify FNP #2 for wound consult. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/4/16 documented the following; One unstageable pressure ulcer was on her left buttocks with a size of 2.4 x 2.1 cm (centimeter). The wound bed color was listed as red, pink, and yellow; the most severe tissue type present was slough at 25% with a light amount of yellow exudate. One unstageable pressure ulcer was on her left superior (upper) buttocks with a size of 0.7 x 1.0 cm. The wound bed color was yellow; the most severe tissue type was slough at 100% with a light amount of yellow exudate. One unstageable pressure ulcer was on her right buttocks with a size of 6 x 5 cm. The wound bed color was pink, red, and yellow; the most severe tissue type was slough at 50% with a light amount of yellow exudate. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/10/16 (one week later) documented the following: The three pressure ulcers as described on Weekly - Ulcer Assessment - V 3 5/04/16 had developed into the following: One unstageable pressure ulcer on the buttocks with the size as 14 x 10 cm; the wound bed color was pink, red, yellow and black; the most severe tissue type was eschar at 75% with a moderate amount of pink exudate. Observation on 5/11/16 at 2:25 pm for resident #1 revealed she had a large pressure ulcer on her buttocks/coccyx areas. There was about 75 % of the wound bed that was covered with black and tan eschar with yellow slough present. The surrounding edges of the wound bed were [DIAGNOSES REDACTED]tous. The old dressing dated 05/10/16 was removed by LVN #1 on 5/11/16, which revealed a moderate amount of purulent (thick or thin, opaque tan to yellow) drainage on it. Record review of resident #1's medical chart revealed there was no documentation made over the weekend (5/7/16 through 5/8/16) on her declining condition of pressure sores, nor was physician and resident's legal representative notified for 5 days; even though LVN #1, LVN #2 and RN #1 reveal they were aware of resident 1's change in condition, as follows: During an interview on 5/11/16 at 1:25 pm, LVN #1 (Wound Care Nurse) stated that resident #1 pressure ulcer was 3 individual pressure ulcers on Friday 5/6/16. She stated that when she returned to work on Monday 5/9/16 the 3 pressure ulcers had turned into 1 large pressure ulcer. In addition LVN #1 indicated she did not contact the physician on Monday to notify him of resident 1's change in condition, because honestly I just didn't call on it, I just wanted to monitor it, her stuff changes all the time, but now I'm going to call Family Nurse Practioner (FNP) #2 to come and look at it. During an interview on 5/11/16 at 2:11 pm with weekend RN #1 (Wound Care Nurse) said she was shocked when she saw the pressure ulcer on Saturday 5/7/16 compared to the previous weekend. She said it was black on Saturday (5/7/16) when I took the dressing off, the whole area was black, and I've never seen it like that. RN #1 stated she asked LVN #2, who was also the charge nurse (CN), if she had seen resident #1's pressure ulcer, and LVN (CN) #2 replied that she knew what it looked like. RN#1 indicated she if a resident's wound deteriorates on weekends I tell the charge nurse and she will call whoever's on call and tell them. Everyone said they know it's bad, it's changed, obviously everyone knew about it. They said something like she'll (nurse practitioner) be here at the beginning of the week. During an interview on 5/11/16 at 4:20 pm LVN #2 said last weekend (5/7 5/8/16) RN #1 asked her if she had seen resident #1's pressure ulcer and she replied yes, that she had looked at it on Friday (5/07/16) with LVN #1. LVN #2 said RN #1 told her she thought it had gotten worse since the last time she saw it, and LVN #2 agreed. LVN #2 indicated resident #1's pressure ulcer was black on Friday, and that's when LVN #1 wanted me to see it (the pressure ulcer on resident #1's buttock/coccyx area) and if I thought it was getter worse because she thought it was LVN #1 asked LVN #2's opinion on whether she should get a consult with FNP #2, who cares for wounds, and LVN #2 said she agreed with the idea that it needed to be consulted. LVN #2 indicated RN #1 did not ask her to call the physician to report the decline in the pressure ulcer. LVN #2 added that RN #1 usually does not ask her to call the physician. LVN #2 indicated she had not called the doctor on Saturday (5/7/16) about resident #1's worsening condition of the pressure ulcers, because I didn't think about it. During an interview on 5/11/16 at 5:08 pm the ADON was asked if the nurses are supposed to report change in conditions to her and she said yes. She said that she had just found out about the pressure ulcers going from 3 pressure ulcers to 1 large pressure ulcer until today (05/11/16). During an interview on 5/11/16 at 5:25 pm the wound care consultant; FNP #2 was asked if she was informed of resident #1's pressure ulcer, and she replied that she couldn't remember exactly what the nurse had said but that she didn't make it seem urgent. FNP #2 stated that if she is following a wound she wants to know all changes in condition. This FNP #2 indicated she was not informed of the pressure ulcer measurements, and when informed of documented measurements, she replied oh my gosh! No, I didn't know it was that bad. During an interview on 5/11/16 at 5:34 pm Certified Nurse Aide (CNA) #1 was asked if she saw resident #1's pressure ulcer on her buttocks/coccyx this past weekend (5/7/16 - 5/8/16) and she replied I saw it and thought it looked pretty bad. It's gotten bigger and blacker. During an interview on 5/12/16 at 9:15 am FNP #2; the primary care physician's nurse practitioner replied yeah, I can't believe they didn't call me on that (resident 1's pressure ulcer). They call me on everything else. That would've been nice (to be notified about resident #1's change in condition for her pressure ulcers). During an interview on 5/12/16 at 11:15 am the DON was asked if she was contacted this past weekend concerning resident #1's worsening pressure ulcers and she replied no. During an interview on 5/12/16 at 11:30 am the ADON stated that skin issues are a big deal, it's a failure to notify the doctor, plainly black and white. During an interview on 5/12/16 at 11:44 am the Administrator indicated his expectations of the facility's staff, concerning resident #1's pressure ulcers, was that her physician be notified; however, the physician was not notified. During an interview on 5/12/16 at 11:54 am resident #1's primary care physician (and facilities medical director); Physician #1 replied no, I was not notified that resident 1's pressure ulcers had worsen. Physician #1 added that he expected the facility's staff to notify him of this change and he said yeah, I'd expect them to call FNP #1 or Physician #2 if the pressure ulcer had gotten worse. Physician #1 said the wound care has been as issue and a problem (for this facility), and an area that needs improvement. Review of resident #3's current Admission Record indicated she was an [AGE] year old female, who was admitted into this facility on 07/02/12. This report included her [DIAGNOSES REDACTED]. Review of resident #3's Care Plan dated 03/08/16 indicated he pressure ulcer onhis left heel and his pressure ulcer to his left inner heel would be floated with the use of pillows. Observation of resident #3 on 05/12/16 at 10:00 am indicated she was wearing blue (Podus) boots on her feet; however, the boot's straps that went across the top of the foot were loose and dangling due to straps not adhering onto velcro. On 05/13 16 at 9:48 am resident #3's left heel was lying/rubbing directly on her mattress, and she had no pillows to float her heel. Review of resident #5's current Admission Record indicated he was a [AGE] year old male, who was admitted into this facility on 12/17/16 and readmitted on [DATE]. This report included resident #5's [DIAGNOSES REDACTED]. Review of resident 5's Care Plan dated 03/16/16 indicated his right ankle deep tissue injury pressure ulcer, would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #5's Weekly-Ulcer Assessment - V3 dated 05/10/16 indicated he had pressure ulcer - deep tissue injury to his right ankle. This ulcer measured 1.2 centimeters in length, by 0.6 centimeters in width, and unable to determine depth, wound color was black, had eschar - black, brown or tan adhere to the wound bed at 100 percent of approximate amount of necrosis. The intervention for this ulcer was noted as turn ever two hours, [MEDICATION NAME] daily, pillows to float heels, and pillow boots while out of bed. Observation of resident #5 on 05/11/16 at 12:27 pm and on 05/12/16 at 10:05 am indicated his ulcer on his right ankle was lying/rubbing directly on his mattress. Review of resident 8's current Admissions Record indicated she was a [AGE] year old female, who was admitted into this facility on 04/02/09. This report included resident 8's [DIAGNOSES REDACTED]. Review of resident #8's Care Plan dated 05/11/16 indicated her left unstageable pressure ulcer to her left heel would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #8's Weekly Ulcer assessment dated [DATE] indicated she had a pressure ulcer - deep tissue injury that measured 4 centimeter in length, 3 in width, unable to determine depth, wound bed moist, and skin intact over blister. This report indicated resident #8's pressure ulcer should be provided with pillows to float heels and Podus boot, when out of bed. Observation of resident #8 on 05/12/16 indicated on 05/12/16 at 10:08 am, and on 05/13 16 at 9:51 am indicated she was lying on her recliner with her heels directly touching the recliner's footrest, and she had no pillows to float her heels. During an interview with CNA #3 on 05/13/16 at 10:26 am indicated she assisted resident #8 to her recliner, and she failed to place a pillow under resident #8, in an attempt to float her feet. During an interview with CNA #1 on 05/12/16 at 10:25 am indicated she knows residents with pressure ulcers on their feet and/or ankles should have these feet floating; however, this is not always possible due to needing help on the floor. During an interview with Family Nurse Practioner #1 on 05/12/16 at 10:14 am indicted residents at risk for pressure ulcers, and/or have wounds on feet/ankles, should have these areas floated. During an interview with Physician #1 (Medical Director) on 05/12/16 at 12:03 pm indicated he expect his staff to float resident's feet as much as possible, when they have wounds to feet and/or ankles. Record review of the facilities' policy and procedure dated 2/13/2007 and titled Notifying the Physician of Significant Change in Status documented the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The resident's family member or legal guardian should be notified of significant change in resident's status, unless the resident has specified otherwise. Record review of the facilities' policy and procedure dated 4/2016 and titled Pressure Injury: Prevention, Assessment and Treatment documents the following procedures: The treatment nurse/designee will: Notify the physician of pressure sore and obtain an order to implement the appropriate treatment etc. Nursing Action/Rationale: Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet ant treatment completed (i.e., Stage I through Stage IV). Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages; Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be unstageable. Staging definitions are per guidelines of the national Pressure Injury Advisory Panel February 2016 definitions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed etc. Review of the facility's policy and procedure for Abuse/Neglect dated 01/08/03 included the Definition of Neglect as: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101 (81). On 5/12/16 at 12:57 pm an Immediate Jeopardy (IJ) was identified, and the Administrator, Regional Compliance Registered Nurse, Vice President of Clinical Services, Director Of Nurses, Assistant Director of Nurses was informed of this IJ due to the above failures. On 5/13/16 at 12:25 pm the Administrator, Corporate Registered Nurse, Area Director, Director Of Nurses, Assistant Director of Nurses were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern, due to facility monitoring Plan of Removal. On 5/13/16 at 12:25 the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy included the following: Problem: Notification of physician or nurse practitioner of decline in wound. Interventions included in Plan Of Removal were as follows: The physician for resident 1's was notified of the change in condition related to her coccyx wound on 5/11/16 at 1:20 pm. New orders were received and implemented. All resident pressure ulcers were assessed on 5/12/16 by the DON for potential decline in wound status. No other wounds were assessed as declined in status The following in-services were initiated by the DON, ADON and Regional Nurse on 5/12/16: Any staff member not present at in-service on 5/12/16, will not be allowed to assume their duties until in-serviced. On 5/12/16 residents at a high risk to develop pressure ulcers were identified. Those residents with current pressure ulcers and those considered high risk according to the last completed Braden scale (score or 10 or less) were determined High Risk to develop pressure ulcers. Licensed nurses received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Licensed nurses will immediately reporting negative changes in skin condition to the physician or nurse practitioner i.e. a new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two week time period should be reported immediately to the physician or nurse practitioner Non-licensed nursing staff received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Non-licensed nursing staff are to report changes in a resident's skin condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to immediately report verbally the change to the nurse. The Medical Director was notified of the immediate jeopardy situation on 5/12/16 at 2:55 pm. Monitoring will be conducted by DON and /or designee, who will monitor those residents considered high risk for pressure ulcers at least 5 times per week to ensure that they are being turned and repositioned timely. The DON will monitor all wound assessments each week to monitor for negative changes and if so, that the physician was notified. The DON will visually observe all ulcer wounds at least weekly to monitor for negative changes. The DON and/or designee(s), through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. The QA committee will review findings and makes changes as needed. During an interviews on 05/13/16 with facilities' nurses LVN #3 at 9:48 am, LVN #1 at 9:55 am , LVN #4 at 10:05 am, LVN #5 at 10:09 am, LVN #6 at 10:52, ADON at 10:15 am, and DON at 10:22 am, indicated they observed pressure ulcer presentation, which included turning residents every two hours, elevating heels on pillows, and using cushions as directed in bed or in wheelchair. In addition these staff was in-serviced to report immediately negative changes to physician and/or nurse practitioner, which included new wounds, decline of current wounds, or wounds that do not improve over a two week period. This plan included a Monitoring Sheet to be noted by DON, which would include residents considered high risk for pressure ulcers. This report which would be noted at least five times per week, to ensure these residents were repositioned, and their wounds were assessed for changes. If changes were noted this report would include notifying physician. During in interviews on 05/13/16 with Certified Nurse Aides, #2 at 9:47 AM, #3 at 10:28 AM, #4 at 10:30 AM, #5 at 10:52 AM, indicated they received training to ensure residents were repositioned every two hours, and their feet were floated as needed to prevent further decline of pressure ulcers. Observation on 05/13/16 for of residents #3 at 9:48 am, #5 at 9:54 am, and #8 at 9:51 am indicated they were lying in their beds or sitting in their recliners, while their feet and/or ankles were floated with pillows, which prevent rubbing against mattress or recliner's foot rest. Review of the facility's Roster/Sample Matrix - Form CMS 802 (Resident Census and Conditions of Residents) dated 05/11/16, confirmed a census of 57. Review of this form revealed facility had 8 residents that were hi-risk pressure ulcers (stage 2 - 4). However, this report did not match hand written sheet provided by facility on 05/12/16, and included the following residents: Review of this sheet dated 05/12/16 indicated there were 10 residents with wounds. 4 of these 10 residents had pressure ulcers on their coccyx (resident #1 had unstageable ulcer, resident #7 had stage 4, nonsample resident had one stage 3, and nonsample resident had one stage 2). Further review of these sheet indicated 7 of these 10 residents had wounds to their feet and/or ankles (resident 1 had one stage 1 to right foot, resident 8 had one stage 2 to left heel, resident 4 had one stage 2 to right ankle, resident 3 had one stage 2 to left inner heel and one stage 3 to left outer heel, resident 5 had one stage 2 to right ankle, nonsample resident had one unstageable to right ankle, and resident 1 one unstageable to right and to left heel.)

Based on observation, record review and interviews, it was determined the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infections, and prevent new sores from developing for 4 of 10 residents (Resident #1, #3, #5, and #8) as evidence by: Resident #1's had three non-stageable pressure sores, which declined into one large pressure sore measuring 14 x 10 cm; however, her physician was not notified for 5 days (05/07/16 to 05/11/16). Residents #3, and #5 and #8, who had pressure ulcer on their feet and/or ankles, did not ensure these ulcers werer floated to prevent rubbing against mattress and/or recliner's footrest as indicated on their current care plans and weekly skin assessments. These failures resulted in identification of an Immediate Jeopardy (IJ) on 5/12/16. While the IJ was removed on 05/13/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. This deficient practice affected 4 residents #1, #3, #5 and #8, and had the potential to place 6 residents at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, pain, possible amputation and death. The evidence is as follows: Review of resident #1's current Admission Record documented an initial admitted [DATE] and a re-admitted [DATE], and this [AGE] year old resident's [DIAGNOSES REDACTED]. Review of resident #1's current Admission Minimum Data Set (MDS) resident assessment dated [DATE], documented Brief Interview For Mental Status (BIMS) cognitive assessment score of 9, (Moderate cognitive loss = 8-12). In addition this MDS indicated resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting use, personal hygiene, locomotion on and off the unit and could not walk; resident was totally dependent on staff for bathing; resident used a wheelchair; resident was occasionally incontinent of bladder and frequently incontinent of bowel, and resident was at risk for pressure ulcers having 1 non-stageable - deep tissue injury (present at admission). Review of resident #1's current Quarterly MDS dated [DATE] indicated a decline in her status as follows: she was unable to complete the BIMS cognitive assessment, which was due to being severely impaired in cognitive skills for daily decision making. Resident was totally dependent on staff for activities of daily living skills (ADLs), and always incontinent of bladder and bowel. This MDS indicated resident #1 had 4 unstageable- Slough and/or Eschar unhealed pressure ulcers and 1 unstageable deep tissue injury (upon readmission) with the dimensions of the largest surface area being 5.5 cm x 4.5 cm, the most severe tissue type for any of the pressure ulcers being slough. Review of resident #1's active Care Plan dated 4/06/16 documented that resident #1 had deep tissue pressure ulcer to coccyx: Intervention - Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, and report declines to the MD (physician). Review of resident #1's Physician Telephone Orders documented the following: On 4/20/16: d/c previous tx (treatment) to bilateral buttocks cleanse wound to bilateral buttocks, pat dry, apply santyl to wound bed, cover and secure. On 5/11/16: stat (immediately) CBC, CMP dx- wound, and notify FNP #2 for wound consult. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/4/16 documented the following; One unstageable pressure ulcer was on her left buttocks with a size of 2.4 x 2.1 cm (centimeter). The wound bed color was listed as red, pink, and yellow; the most severe tissue type present was slough at 25% with a light amount of yellow exudate. One unstageable pressure ulcer was on her left superior (upper) buttocks with a size of 0.7 x 1.0 cm. The wound bed color was yellow; the most severe tissue type was slough at 100% with a light amount of yellow exudate. One unstageable pressure ulcer was on her right buttocks with a size of 6 x 5 cm. The wound bed color was pink, red, and yellow; the most severe tissue type was slough at 50% with a light amount of yellow exudate. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/10/16 (one week later) documented the following: The three pressure ulcers as described on Weekly - Ulcer Assessment - V 3 5/04/16 had developed into the following: One unstageable pressure ulcer on the buttocks with the size as 14 x 10 cm; the wound bed color was pink, red, yellow and black; the most severe tissue type was eschar at 75% with a moderate amount of pink exudate. Observation on 5/11/16 at 2:25 pm for resident #1 revealed she had a large pressure ulcer on her buttocks/coccyx areas. There was about 75 % of the wound bed that was covered with black and tan eschar with yellow slough present. The surrounding edges of the wound bed were [DIAGNOSES REDACTED]tous. The old dressing dated 05/10/16 was removed by LVN #1 on 5/11/16, which revealed a moderate amount of purulent (thick or thin, opaque tan to yellow) drainage on it. Record review of resident #1's medical chart revealed there was no documentation made over the weekend (5/7/16 through 5/8/16) on her declining condition of pressure sores, nor was physician and resident's legal representative notified for 5 days; even though LVN #1, LVN #2 and RN #1 reveal they were aware of resident 1's change in condition, as follows: During an interview on 5/11/16 at 1:25 pm, LVN #1 (Wound Care Nurse) stated that resident #1 pressure ulcer was 3 individual pressure ulcers on Friday 5/6/16. She stated that when she returned to work on Monday 5/9/16 the 3 pressure ulcers had turned into 1 large pressure ulcer. In addition LVN #1 indicated she did not contact the physician on Monday to notify him of resident 1's change in condition, because honestly I just didn't call on it, I just wanted to monitor it, her stuff changes all the time, but now I'm going to call Family Nurse Practioner (FNP) #2 to come and look at it. During an interview on 5/11/16 at 2:11 pm with weekend RN #1 (Wound Care Nurse) said she was shocked when she saw the pressure ulcer on Saturday 5/7/16 compared to the previous weekend. She said it was black on Saturday (5/7/16) when I took the dressing off, the whole area was black, and I've never seen it like that. RN #1 stated she asked LVN #2, who was also the charge nurse (CN), if she had seen resident #1's pressure ulcer, and LVN (CN) #2 replied that she knew what it looked like. RN#1 indicated she if a resident's wound deteriorates on weekends I tell the charge nurse and she will call whoever's on call and tell them. Everyone said they know it's bad, it's changed, obviously everyone knew about it. They said something like she'll (nurse practitioner) be here at the beginning of the week. During an interview on 5/11/16 at 4:20 pm LVN #2 said last weekend (5/7 5/8/16) RN #1 asked her if she had seen resident #1's pressure ulcer and she replied yes, that she had looked at it on Friday (5/07/16) with LVN #1. LVN #2 said RN #1 told her she thought it had gotten worse since the last time she saw it, and LVN #2 agreed. LVN #2 indicated resident #1's pressure ulcer was black on Friday, and that's when LVN #1 wanted me to see it (the pressure ulcer on resident #1's buttock/coccyx area) and if I thought it was getter worse because she thought it was LVN #1 asked LVN #2's opinion on whether she should get a consult with FNP #2, who cares for wounds, and LVN #2 said she agreed with the idea that it needed to be consulted. LVN #2 indicated RN #1 did not ask her to call the physician to report the decline in the pressure ulcer. LVN #2 added that RN #1 usually does not ask her to call the physician. LVN #2 indicated she had not called the doctor on Saturday (5/7/16) about resident #1's worsening condition of the pressure ulcers, because I didn't think about it. During an interview on 5/11/16 at 5:08 pm the ADON was asked if the nurses are supposed to report change in conditions to her and she said yes. She said that she had just found out about the pressure ulcers going from 3 pressure ulcers to 1 large pressure ulcer until today (05/11/16). During an interview on 5/11/16 at 5:25 pm the wound care consultant; FNP #2 was asked if she was informed of resident #1's pressure ulcer, and she replied that she couldn't remember exactly what the nurse had said but that she didn't make it seem urgent. FNP #2 stated that if she is following a wound she wants to know all changes in condition. This FNP #2 indicated she was not informed of the pressure ulcer measurements, and when informed of documented measurements, she replied oh my gosh! No, I didn't know it was that bad. During an interview on 5/11/16 at 5:34 pm Certified Nurse Aide (CNA) #1 was asked if she saw resident #1's pressure ulcer on her buttocks/coccyx this past weekend (5/7/16 - 5/8/16) and she replied I saw it and thought it looked pretty bad. It's gotten bigger and blacker. During an interview on 5/12/16 at 9:15 am FNP #2; the primary care physician's nurse practitioner replied yeah, I can't believe they didn't call me on that (resident 1's pressure ulcer). They call me on everything else. That would've been nice (to be notified about resident #1's change in condition for her pressure ulcers). During an interview on 5/12/16 at 11:15 am the DON was asked if she was contacted this past weekend concerning resident #1's worsening pressure ulcers and she replied no. During an interview on 5/12/16 at 11:30 am the ADON stated that skin issues are a big deal, it's a failure to notify the doctor, plainly black and white. During an interview on 5/12/16 at 11:44 am the Administrator indicated his expectations of the facility's staff, concerning resident #1's pressure ulcers, was that her physician be notified; however, the physician was not notified. During an interview on 5/12/16 at 11:54 am resident #1's primary care physician (and facilities medical director); Physician #1 replied no, I was not notified that resident 1's pressure ulcers had worsen. Physician #1 added that he expected the facility's staff to notify him of this change and he said yeah, I'd expect them to call FNP #1 or Physician #2 if the pressure ulcer had gotten worse. Physician #1 said the wound care has been as issue and a problem (for this facility), and an area that needs improvement. Review of resident #3's current Admission Record indicated she was an [AGE] year old female, who was admitted into this facility on 07/02/12. This report included her [DIAGNOSES REDACTED]. Review of resident #3's Care Plan dated 03/08/16 indicated he pressure ulcer onhis left heel and his pressure ulcer to his left inner heel would be floated with the use of pillows. Observation of resident #3 on 05/12/16 at 10:00 am indicated she was wearing blue (Podus) boots on her feet; however, the boot's straps that went across the top of the foot were loose and dangling due to straps not adhering onto velcro. On 05/13 16 at 9:48 am resident #3's left heel was lying/rubbing directly on her mattress, and she had no pillows to float her heel. Review of resident #5's current Admission Record indicated he was a [AGE] year old male, who was admitted into this facility on 12/17/16 and readmitted on [DATE]. This report included resident #5's [DIAGNOSES REDACTED]. Review of resident 5's Care Plan dated 03/16/16 indicated his right ankle deep tissue injury pressure ulcer, would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #5's Weekly-Ulcer Assessment - V3 dated 05/10/16 indicated he had pressure ulcer - deep tissue injury to his right ankle. This ulcer measured 1.2 centimeters in length, by 0.6 centimeters in width, and unable to determine depth, wound color was black, had eschar - black, brown or tan adhere to the wound bed at 100 percent of approximate amount of necrosis. The intervention for this ulcer was noted as turn ever two hours, [MEDICATION NAME] daily, pillows to float heels, and pillow boots while out of bed. Observation of resident #5 on 05/11/16 at 12:27 pm and on 05/12/16 at 10:05 am indicated his ulcer on his right ankle was lying/rubbing directly on his mattress. Review of resident 8's current Admissions Record indicated she was a [AGE] year old female, who was admitted into this facility on 04/02/09. This report included resident 8's [DIAGNOSES REDACTED]. Review of resident #8's Care Plan dated 05/11/16 indicated her left unstageable pressure ulcer to her left heel would be addressed by assessing/record/monitor wound healing at least weekly (Weekly-Ulcer Assessement). Review of resident #8's Weekly Ulcer assessment dated [DATE] indicated she had a pressure ulcer - deep tissue injury that measured 4 centimeter in length, 3 in width, unable to determine depth, wound bed moist, and skin intact over blister. This report indicated resident #8's pressure ulcer should be provided with pillows to float heels and Podus boot, when out of bed. Observation of resident #8 on 05/12/16 indicated on 05/12/16 at 10:08 am, and on 05/13 16 at 9:51 am indicated she was lying on her recliner with her heels directly touching the recliner's footrest, and she had no pillows to float her heels. During an interview with CNA #3 on 05/13/16 at 10:26 am indicated she assisted resident #8 to her recliner, and she failed to place a pillow under resident #8, in an attempt to float her feet. During an interview with CNA #1 on 05/12/16 at 10:25 am indicated she knows residents with pressure ulcers on their feet and/or ankles should have these feet floating; however, this is not always possible due to needing help on the floor. During an interview with Family Nurse Practioner #1 on 05/12/16 at 10:14 am indicted residents at risk for pressure ulcers, and/or have wounds on feet/ankles, should have these areas floated. During an interview with Physician #1 (Medical Director) on 05/12/16 at 12:03 pm indicated he expect his staff to float resident's feet as much as possible, when they have wounds to feet and/or ankles. Record review of the facilities' policy and procedure dated 2/13/2007 and titled Notifying the Physician of Significant Change in Status documented the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The resident's family member or legal guardian should be notified of significant change in resident's status, unless the resident has specified otherwise. Record review of the facilities' policy and procedure dated 4/2016 and titled Pressure Injury: Prevention, Assessment and Treatment documents the following procedures: The treatment nurse/designee will: Notify the physician of pressure sore and obtain an order to implement the appropriate treatment etc. Nursing Action/Rationale: Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet ant treatment completed (i.e., Stage I through Stage IV). Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages; Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be unstageable. Staging definitions are per guidelines of the national Pressure Injury Advisory Panel February 2016 definitions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed etc. Review of the facility's policy and procedure for Abuse/Neglect dated 01/08/03 included the Definition of Neglect as: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101 (81). On 5/12/16 at 12:57 pm an Immediate Jeopardy (IJ) was identified, and the Administrator, Regional Compliance Registered Nurse, Vice President of Clinical Services, Director Of Nurses, Assistant Director of Nurses was informed of this IJ due to the above failures. On 5/13/16 at 12:25 pm the Administrator, Corporate Registered Nurse, Area Director, Director Of Nurses, Assistant Director of Nurses were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern, due to facility monitoring Plan of Removal. On 5/13/16 at 12:25 the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy included the following: Problem: Notification of physician or nurse practitioner of decline in wound. Interventions included in Plan Of Removal were as follows: The physician for resident 1's was notified of the change in condition related to her coccyx wound on 5/11/16 at 1:20 pm. New orders were received and implemented. All resident pressure ulcers were assessed on 5/12/16 by the DON for potential decline in wound status. No other wounds were assessed as declined in status The following in-services were initiated by the DON, ADON and Regional Nurse on 5/12/16: Any staff member not present at in-service on 5/12/16, will not be allowed to assume their duties until in-serviced. On 5/12/16 residents at a high risk to develop pressure ulcers were identified. Those residents with current pressure ulcers and those considered high risk according to the last completed Braden scale (score or 10 or less) were determined High Risk to develop pressure ulcers. Licensed nurses received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Licensed nurses will immediately reporting negative changes in skin condition to the physician or nurse practitioner i.e. a new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two week time period should be reported immediately to the physician or nurse practitioner Non-licensed nursing staff received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Non-licensed nursing staff are to report changes in a resident's skin condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to immediately report verbally the change to the nurse. The Medical Director was notified of the immediate jeopardy situation on 5/12/16 at 2:55 pm. Monitoring will be conducted by DON and /or designee, who will monitor those residents considered high risk for pressure ulcers at least 5 times per week to ensure that they are being turned and repositioned timely. The DON will monitor all wound assessments each week to monitor for negative changes and if so, that the physician was notified. The DON will visually observe all ulcer wounds at least weekly to monitor for negative changes. The DON and/or designee(s), through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. The QA committee will review findings and makes changes as needed. During an interviews on 05/13/16 with facilities' nurses LVN #3 at 9:48 am, LVN #1 at 9:55 am , LVN #4 at 10:05 am, LVN #5 at 10:09 am, LVN #6 at 10:52, ADON at 10:15 am, and DON at 10:22 am, indicated they observed pressure ulcer presentation, which included turning residents every two hours, elevating heels on pillows, and using cushions as directed in bed or in wheelchair. In addition these staff was in-serviced to report immediately negative changes to physician and/or nurse practitioner, which included new wounds, decline of current wounds, or wounds that do not improve over a two week period. This plan included a Monitoring Sheet to be noted by DON, which would include residents considered high risk for pressure ulcers. This report which would be noted at least five times per week, to ensure these residents were repositioned, and their wounds were assessed for changes. If changes were noted this report would include notifying physician. During in interviews on 05/13/16 with Certified Nurse Aides, #2 at 9:47 AM, #3 at 10:28 AM, #4 at 10:30 AM, #5 at 10:52 AM, indicated they received training to ensure residents were repositioned every two hours, and their feet were floated as needed to prevent further decline of pressure ulcers. Observation on 05/13/16 for of residents #3 at 9:48 am, #5 at 9:54 am, and #8 at 9:51 am indicated they were lying in their beds or sitting in their recliners, while their feet and/or ankles were floated with pillows, which prevent rubbing against mattress or recliner's foot rest. Review of the facility's Roster/Sample Matrix - Form CMS 802 (Resident Census and Conditions of Residents) dated 05/11/16, confirmed a census of 57. Review of this form revealed facility had 8 residents that were hi-risk pressure ulcers (stage 2 - 4). However, this report did not match hand written sheet provided by facility on 05/12/16, and included the following residents: Review of this sheet dated 05/12/16 indicated there were 10 residents with wounds. 4 of these 10 residents had pressure ulcers on their coccyx (resident #1 had unstageable ulcer, resident #7 had stage 4, nonsample resident had one stage 3, and nonsample resident had one stage 2). Further review of these sheet indicated 7 of these 10 residents had wounds to their feet and/or ankles (resident 1 had one stage 1 to right foot, resident 8 had one stage 2 to left heel, resident 4 had one stage 2 to right ankle, resident 3 had one stage 2 to left inner heel and one stage 3 to left outer heel, resident 5 had one stage 2 to right ankle, nonsample resident had one unstageable to right ankle, and resident 1 one unstageable to right and to left heel.)

Based on observation, interview, and record review, it was determined the facility failed to consult the physician and/or notify the resident's legal representative for changes in condition for 1 of 10 sampled residents (Resident #1) reviewed for changes in condition. Resident #1's had three non-stageable pressure sores, which declined into one large pressure sore measuring 14 x 10 cm; however, her physician was not notified for 5 days (05/07/16 to 05/11/16). These failures resulted in identification of an Immediate Jeopardy (IJ) on 5/12/16. While the IJ was removed on 05/13/16, the facility remained out of compliance at a potential for more than minimal harm with scope identified as a pattern. This deficient practice affected 1 (resident #1), and had the potential to place 9 residents at risk for identified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, pain, possible amputation and death. The evidence is as follows: Review of resident #1's current Admission Record documented an initial admitted [DATE] and a re-admitted [DATE], and this [AGE] year old resident's [DIAGNOSES REDACTED]. Review of resident #1's current Admission Minimum Data Set (MDS) resident assessment dated [DATE], documented Brief Interview For Mental Status (BIMS) cognitive assessment score of 9, (Moderate cognitive loss = 8-12). In addition this MDS indicated resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting use, personal hygiene, locomotion on and off the unit and could not walk; resident was totally dependent on staff for bathing; resident used a wheelchair; resident was occasionally incontinent of bladder and frequently incontinent of bowel, and resident was at risk for pressure ulcers having 1 non-stageable - deep tissue injury (present at admission). Review of resident #1's current Quarterly MDS dated [DATE] indicated a decline in her status as follows: she was unable to complete the BIMS cognitive assessment, which was due to being severely impaired in cognitive skills for daily decision making. Resident was totally dependent on staff for activities of daily living skills (ADLs), and always incontinent of bladder and bowel. This MDS indicated resident #1 had 4 unstageable- Slough and/or Eschar unhealed pressure ulcers and 1 unstageable deep tissue injury (upon readmission) with the dimensions of the largest surface area being 5.5 cm x 4.5 cm, the most severe tissue type for any of the pressure ulcers being slough. Review of resident #1's active Care Plan dated 4/06/16 documented that resident #1 had deep tissue pressure ulcer to coccyx: Intervention - Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, and report declines to the MD (physician). Review of resident #1's Physician Telephone Orders documented the following: On 4/20/16: d/c previous tx (treatment) to bilateral buttocks cleanse wound to bilateral buttocks, pat dry, apply santyl to wound bed, cover and secure. On 5/11/16: stat (immediately) CBC, CMP dx- wound, and notify FNP #2 for wound consult. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/4/16 documented the following; One unstageable pressure ulcer was on her left buttocks with a size of 2.4 x 2.1 cm (centimeter). The wound bed color was listed as red, pink, and yellow; the most severe tissue type present was slough at 25% with a light amount of yellow exudate. One unstageable pressure ulcer was on her left superior (upper) buttocks with a size of 0.7 x 1.0 cm. The wound bed color was yellow; the most severe tissue type was slough at 100% with a light amount of yellow exudate. One unstageable pressure ulcer was on her right buttocks with a size of 6 x 5 cm. The wound bed color was pink, red, and yellow; the most severe tissue type was slough at 50% with a light amount of yellow exudate. Record review of resident #1's Weekly - Ulcer Assessment - V 3 dated 5/10/16 (one week later) documented the following: The three pressure ulcers as described on Weekly - Ulcer Assessment - V 3 5/04/16 had developed into the following: One unstageable pressure ulcer on the buttocks with the size as 14 x 10 cm; the wound bed color was pink, red, yellow and black; the most severe tissue type was eschar at 75% with a moderate amount of pink exudate. Observation on 5/11/16 at 2:25 pm for resident #1 revealed she had a large pressure ulcer on her buttocks/coccyx areas. There was about 75 % of the wound bed that was covered with black and tan eschar with yellow slough present. The surrounding edges of the wound bed were [DIAGNOSES REDACTED]tous. The old dressing dated 05/10/16 was removed by LVN #1 on 5/11/16, which revealed a moderate amount of purulent (thick or thin, opaque tan to yellow) drainage on it. Record review of resident #1's medical chart revealed there was no documentation made over the weekend (5/7/16 through 5/8/16) on her declining condition of pressure sores, nor was physician and resident's legal representative notified for 5 days; even though LVN #1, LVN #2 and RN #1 reveal they were aware of resident 1's change in condition, as follows: During an interview on 5/11/16 at 1:25 pm, LVN #1 (Wound Care Nurse) stated that resident #1 pressure ulcer was 3 individual pressure ulcers on Friday 5/6/16. She stated that when she returned to work on Monday 5/9/16 the 3 pressure ulcers had turned into 1 large pressure ulcer. In addition LVN #1 indicated she did not contact the physician on Monday to notify him of resident 1's change in condition, because honestly I just didn't call on it, I just wanted to monitor it, her stuff changes all the time, but now I'm going to call Family Nurse Practioner (FNP) #2 to come and look at it. During an interview on 5/11/16 at 2:11 pm with weekend RN #1 (Wound Care Nurse) said she was shocked when she saw the pressure ulcer on Saturday 5/7/16 compared to the previous weekend. She said it was black on Saturday (5/7/16) when I took the dressing off, the whole area was black, and I've never seen it like that. RN #1 stated she asked LVN #2, who was also the charge nurse (CN), if she had seen resident #1's pressure ulcer, and LVN (CN) #2 replied that she knew what it looked like. RN#1 indicated she if a resident's wound deteriorates on weekends I tell the charge nurse and she will call whoever's on call and tell them. Everyone said they know it's bad, it's changed, obviously everyone knew about it. They said something like she'll (nurse practitioner) be here at the beginning of the week. During an interview on 5/11/16 at 4:20 pm LVN #2 said last weekend (5/7 5/8/16) RN #1 asked her if she had seen resident #1's pressure ulcer and she replied yes, that she had looked at it on Friday (5/07/16) with LVN #1. LVN #2 said RN #1 told her she thought it had gotten worse since the last time she saw it, and LVN #2 agreed. LVN #2 indicated resident #1's pressure ulcer was black on Friday, and that's when LVN #1 wanted me to see it (the pressure ulcer on resident #1's buttock/coccyx area) and if I thought it was getter worse because she thought it was LVN #1 asked LVN #2's opinion on whether she should get a consult with FNP #2, who cares for wounds, and LVN #2 said she agreed with the idea that it needed to be consulted. LVN #2 indicated RN #1 did not ask her to call the physician to report the decline in the pressure ulcer. LVN #2 added that RN #1 usually does not ask her to call the physician. LVN #2 indicated she had not called the doctor on Saturday (5/7/16) about resident #1's worsening condition of the pressure ulcers, because I didn't think about it. During an interview on 5/11/16 at 5:08 pm the ADON was asked if the nurses are supposed to report change in conditions to her and she said yes. She said that she had just found out about the pressure ulcers going from 3 pressure ulcers to 1 large pressure ulcer until today (05/11/16). During an interview on 5/11/16 at 5:25 pm the wound care consultant; FNP #2 was asked if she was informed of resident #1's pressure ulcer, and she replied that she couldn't remember exactly what the nurse had said but that she didn't make it seem urgent. FNP #2 stated that if she is following a wound she wants to know all changes in condition. This FNP #2 indicated she was not informed of the pressure ulcer measurements, and when informed of documented measurements, she replied oh my gosh! No, I didn't know it was that bad. During an interview on 5/11/16 at 5:34 pm Certified Nurse Aide (CNA) #1 was asked if she saw resident #1's pressure ulcer on her buttocks/coccyx this past weekend (5/7/16 - 5/8/16) and she replied I saw it and thought it looked pretty bad. It's gotten bigger and blacker. During an interview on 5/12/16 at 9:15 am FNP #2; the primary care physician's nurse practitioner replied yeah, I can't believe they didn't call me on that (resident 1's pressure ulcer). They call me on everything else. That would've been nice (to be notified about resident #1's change in condition for her pressure ulcers). During an interview on 5/12/16 at 11:15 am the DON was asked if she was contacted this past weekend concerning resident #1's worsening pressure ulcers and she replied no. During an interview on 5/12/16 at 11:30 am the ADON stated that skin issues are a big deal, it's a failure to notify the doctor, plainly black and white. During an interview on 5/12/16 at 11:44 am the Administrator indicated his expectations of the facility's staff, concerning resident #1's pressure ulcers, was that her physician be notified; however, the physician was not notified. During an interview on 5/12/16 at 11:54 am resident #1's primary care physician (and facilities medical director); Physician #1 replied no, I was not notified that resident 1's pressure ulcers had worsen. Physician #1 added that he expected the facility's staff to notify him of this change and he said yeah, I'd expect them to call FNP #1 or Physician #2 if the pressure ulcer had gotten worse. Physician #1 said the wound care has been as issue and a problem (for this facility), and an area that needs improvement. Record review of the facilities' policy and procedure dated 2/13/2007 and titled Notifying the Physician of Significant Change in Status documented the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The resident's family member or legal guardian should be notified of significant change in resident's status, unless the resident has specified otherwise. Record review of the facilities' policy and procedure dated 4/2016 and titled Pressure Injury: Prevention, Assessment and Treatment documents the following procedures: The treatment nurse/designee will: Notify the physician of pressure sore and obtain an order to implement the appropriate treatment etc. Nursing Action/Rationale: Treatment Nurse/Designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet ant treatment completed (i.e., Stage I through Stage IV). Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages; Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be unstageable. Staging definitions are per guidelines of the national Pressure Injury Advisory Panel February 2016 definitions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed etc. Review of the facility's policy and procedure for Abuse/Neglect dated 01/08/03 included the Definition of Neglect as: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Neglect as defined in 40 TAC 19.101 (81). On 5/12/16 at 12:57 pm an Immediate Jeopardy (IJ) was identified, and the Administrator, Regional Compliance Registered Nurse, Vice President of Clinical Services, Director Of Nurses, Assistant Director of Nurses was informed of this IJ due to the above failures. On 5/13/16 at 12:25 pm the Administrator, Corporate Registered Nurse, Area Director, Director Of Nurses, Assistant Director of Nurses were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern, due to facility monitoring Plan of Removal. On 5/13/16 at 12:25 the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy included the following: Problem: Notification of physician or nurse practitioner of decline in wound. Interventions included in Plan Of Removal were as follows: The physician for resident 1's was notified of the change in condition related to her coccyx wound on 5/11/16 at 1:20 pm. New orders were received and implemented. All resident pressure ulcers were assessed on 5/12/16 by the DON for potential decline in wound status. No other wounds were assessed as declined in status The following in-services were initiated by the DON, ADON and Regional Nurse on 5/12/16: Any staff member not present at in-service on 5/12/16, will not be allowed to assume their duties until in-serviced. On 5/12/16 residents at a high risk to develop pressure ulcers were identified. Those residents with current pressure ulcers and those considered high risk according to the last completed Braden scale (score or 10 or less) were determined High Risk to develop pressure ulcers. Licensed nurses received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Licensed nurses will immediately reporting negative changes in skin condition to the physician or nurse practitioner i.e. a new wound or decline of a current wound. In addition, a wound that is not progressing in a positive manner in a two week time period should be reported immediately to the physician or nurse practitioner Non-licensed nursing staff received Pressure ulcer prevention to included turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. Non-licensed nursing staff are to report changes in a resident's skin condition to a nurse immediately using Stop and Watch. After entering the change in the point of care, the non-licensed staff member is to immediately report verbally the change to the nurse. The Medical Director was notified of the immediate jeopardy situation on 5/12/16 at 2:55 pm. Monitoring will be conducted by DON and /or designee, who will monitor those residents considered high risk for pressure ulcers at least 5 times per week to ensure that they are being turned and repositioned timely. The DON will monitor all wound assessments each week to monitor for negative changes and if so, that the physician was notified. The DON will visually observe all ulcer wounds at least weekly to monitor for negative changes. The DON and/or designee(s), through daily rounds 5 times per week ensure that residents are being turned and repositioned timely. The QA committee will review findings and makes changes as needed. During an interviews on 05/13/16 with facilities' nurses LVN #3 at 9:48 am, LVN #1 at 9:55 am , LVN #4 at 10:05 am, LVN #5 at 10:09 am, LVN #6 at 10:52, ADON at 10:15 am, and DON at 10:22 am, indicated they observed pressure ulcer presentation, which included turning residents every two hours, elevating heels on pillows, and using cushions as directed in bed or in wheelchair. In addition these staff was in-serviced to report immediately negative changes to physician and/or nurse practitioner, which included new wounds, decline of current wounds, or wounds that do not improve over a two week period. This plan included a Monitoring Sheet to be noted by DON, which would include residents considered high risk for pressure ulcers. This report which would be noted at least five times per week, to ensure these residents were repositioned, and their wounds were assessed for changes. If changes were noted this report would include notifying physician. During in interviews on 05/13/16 with Certified Nurse Aides, #2 at 9:47 AM, #3 at 10:28 AM, #4 at 10:30 AM, #5 at 10:52 AM, indicated they received training to ensure residents were repositioned every two hours, and their feet were floated as needed to prevent further decline of pressure ulcers. Review of the facility's Roster/Sample Matrix - Form CMS 802 (Resident Census and Conditions of Residents) dated 05/11/16, confirmed a census of 57. Review of this form revealed facility had 8 residents that were hi-risk pressure ulcers (stage 2 - 4). However, this report did not match hand written sheet provided by facility on 05/12/16, and included the following residents: Review of this sheet dated 05/12/16 indicated there were 10 residents with wounds. 4 of these 10 residents had pressure ulcers on their coccyx (resident #1 had unstageable ulcer, resident #7 had stage 4, nonsample resident had one stage 3, and nonsample resident had one stage 2). Further review of these sheet indicated 7 of these 10 residents had wounds to their feet and/or ankles (resident 1 had one stage 1 to right foot, resident 8 had one stage 2 to left heel, resident 4 had one stage 2 to right ankle, resident 3 had one stage 2 to left inner heel and one stage 3 to left outer heel, resident 5 had one stage 2 to right ankle, nonsample resident had one unstageable to right ankle, and resident 1 one unstageable to right and to left heel.)