Every finding on record at Spindletop Hill Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 26.67%, based on 8 errors out of 31 opportunities, which involved 3 of 5 residents (Resident #41 Resident #48, Resident #6) and 3 of 4 staff (MA I, MA F, LVN N) observed during medication administration reviewed for pharmacy services.1.The facility failed to ensure MA I administered Resident #41's ordered dose of ferrous sulfate 326 mg. She administered ferrous sulfate 325 mg oral tablet. 2.The facility failed to ensure MA F administered Resident #48's ordered dose of ferrous sulfate 324 mg oral tablet. She administered ferrous sulfate 325 mg oral tablet. 3.The facility failed to ensure MA F administered Resident #48's ordered dose of magnesium oxide oral tablet 250 mg. She administered magnesium oxide 240 mg oral tablet. 4.The facility failed to ensure MA F administered Resident #48's ordered dose of vitamin c 1000mg oral tablet, instead, she administered one vitamin c 500mg tablet. 5.The facility failed to ensure MA F administered Resident #48's ordered dose of folic acid oral tablet 1 mg instead she administered folic acid 400 mcg oral. 6.The facility failed to ensure MA F administered Resident #48's ordered dose of methocarbamol oral tablet 1000 mg instead she administered one methocarbamol 500 mg oral tablet. 7.The facility failed to ensure LVN N administered Resident #6's ordered dose of miralax oral powder 17 gm/scoop (polyethylene glycol 3350), and instead, administered another resident's MiraLAX oral powder 17 gm/scoop (polyethylene glycol 3350) through her g-tube. 8. The facility failed to ensure LVN N administered Resident #6's ordered water flush at the start and end of the medication administration. These failures could place residents at risk for receiving inaccurate medication dosage leading to an altered therapeutic response. Findings included: 1.Record review of Resident #41's Face Sheet, dated 08/05/2026, indicated a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), muscle wasting, constipation, hypertension (high blood pressure), mixed hyperlipidemia (high cholesterol). Record review of Resident #41's Quarterly MDS assessment, dated 02/22/2026 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating she had severely impaired cognition. Record review of Resident #41's undated Care Plan, indicated interventions give medications as ordered by the physician. Record review of Resident #41's medication administration record (mar) indicated ferrous sulfate oral tablet (ferrous sulfate) give 326 mg by mouth one time a day. An observation on 08/03/2026 at 9:46 a.m. indicated MA I performed hand hygiene, prepared and administered iron 325mg (ferrous sulfate)- 1 tablet to Resident #41. During an interview on 08/03/2026 at 10:22 a.m., with MA I, she said when a medication did not match the order, she was trained to inform her charge nurse and follow the instructions she gave. She said she did not notice the mg did not match because she was nervous. She said she is responsible for ensuring the dosage is correct before administering it to residents. 2.- 6. Record review of Resident #48's Face Sheet, dated 08/05/2026, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of osteomyelitis (an infection in a bone), muscle wasting, anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues.) Record review of Resident #48's Quarterly MDS, dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. Record review of Resident #48's order summary dated 08/05/2026 indicated the following orders:ferrous gluconate oral tablet 324 (37.5 fe) mg (ferrous gluconate)magnesium oxide oral tablet 250 mg (magnesium oxide)vitamin c oral tablet (ascorbic acid) give 1000 mgfolic acid oral tablet (folic acid) give 1000 mcgmethocarbamol oral tablet 1000 mg During an observation on 08/04/2026 at 10:45 a.m. indicated MA F performed hand hygiene, prepared and administered the following medications to Resident #48. ferrous gluconate oral tablet 325 mg (ferrous gluconate)- 1 tabletmagnesium oxide oral tablet 240 mg (magnesium oxide)- 1 tablet vitamin c oral tablet (ascorbic acid) give 1000 mg- 1 (500 mg) tabletfolic acid oral tablet (folic acid) give 1000 mcg- 1 (400mcg) tabletmethocarbamol oral tablet 1000 mg- 1 (500 mg) tablet During an interview on 08/05/2026 at 10:42 a.m., with MA F she said she did not notice the mg did not match for the folic acid. She said she had been trained on medication administration. She said she was responsible for ensuring the dosage was correct before administering it to residents. She said the potential risk to the residents was receiving the wrong dosage of medication and causing harm. 7. - 8. Record review of Resident #6's Face Sheet, dated 08/05/2026, indicated a [AGE] year-old female who admitted to the facility on with diagnoses of cerebral infarction (stroke), dysphasia (a condition that affects the ability to produce and understand spoken language), abdominal pain (stomach pain). Record review of Resident #6's Quarterly MDS, dated [DATE] indicated the Brief Interview for Mental Status (BIMS) was unable to be completed due to her impaired cognition. Record review of Resident #6's undated care plan indicated Give medications as ordered. Monitor for side effects, effectiveness. Record review of Resident #6's order summary dated 08/05/2026 indicated the following orders:-miralax oral powder 17 GM/scoop (polyethylene glycol 3350) (give 1 scoop via g-tube) -npo diet npo texture, npo (nothing by mouth) consistencyenteral feed order every shift flush feeding tube with 50 ccs of water before and after medication administration. During an observation on 08/05/2026 at 8:50 a.m. indicated LVN N performed hand hygiene and prepared miralax oral powder 17 GM/scoop (polyethylene glycol 3350) (give 1 scoop via g-tube) for Resident #6. by mixing 1 scoop with 15ml of water. LVN N used another resident's bottle of MiraLAX. Resident #6 did not have her own bottle of MiraLAX oral powder on the medication cart. During the observation, LVN N performed hand hygiene, applied PPE, and entered Resident #6's room. LVN N disconnected Resident #6's tube feeding, checked residual with g-tube syringe (5 ml residual noted). She began medication administration without flushing g-tube with 50 ccs of water as stated in order. During an interview on 08/05/2026 at 11:00 a.m., with LVN N, she said she had not flushed Resident #6's g-tube before administering her medications because she was nervous, she said she usually did. She said she did not notice the names did not match on the miralax bottle. She said she was nervous and overlooked it. She said the potential risk to the resident was her getting the wrong medication and potentially causing harm. During an interview on 08/05/2026 at 3:00 p.m., with the DON, she said it was her expectation for staff, that administer medications, to follow facility's policy and correctly administer medications safely. She said that had not administered medications correctly would be re-trained on medication administration. The DON said the potential risk to the residents was not receiving the correct medication or dosage. She said staff (MA's and Nurses had been re-trained and in-serviced on medication administration since the last survey. During an interview on 08/05/2026 at 3:10 p.m., with the Administrator, he said his expectation was for staff to follow the facility's medication policy and to ask questions for clarification.

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 2 of 6 residents (Residents #4 and #76) observed for infection control.1. The facility failed to ensure the Wound Care Nurse performed hand hygiene between glove changes when she provided wound care to Resident #4.2. The facility failed to implement EBP for Resident #76 during incontinent care on 08/04/2026. This failure could place residents and staff at risk for cross-contamination and development of infections.Findings included: 1. Record review of Resident #4's admission record dated 08/05/2026 indicated she was a [AGE] year-old-female admitted [DATE] and readmitted [DATE] with diagnoses of diabetes mellitus (a chronic condition where blood sugar levels stay too high), end stage renal disease (kidney s can no longer clean blood or remove extra fluid and patients need dialysis to survive), dependence on renal dialysis (a person's kidneys have failed and they rely on a machine to filter waste and extra fluid from their blood to stay alive), and cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review of Resident #4's quarterly MDS assessment, dated 05/04/2026, indicated a BIMS score of 9, indicated moderately impaired cognition, diagnoses of end stage renal disease, diabetes mellitus, and dependence on renal dialysis. The assessment indicated a risk of pressure ulcers, pressure reducing device for bed, and application of nonsurgical dressings. Record review of Resident #4's care plan, with a target date of 10/05/2026 indicated Resident #4 had alteration in skin integrity, a sacral abscess to sacrum, history of refusing wound care and had interventions included apply treatment as orders and follow enhanced barrier precautions. Record review of physician's orders for Resident #4, dated 08/03/2026, indicated cleanse abscess to sacrum with wound cleanser, pat dry, apply betadine, cover with gauge island 3 times weekly and as needed with a start date of 07/28/2026 and enhanced barrier precautions with a start dated of 01/21/2026. During an interview on 08/03/2026 at 10:50 a.m., Resident #4 was sitting up in a wheelchair she said she had sore on her bottom that was being treated by staff. She said they were doing a good job treating her. During an observation and interview on 08/05/2026 at 9:40 a.m., the Wound Care Nurse cleaned a bedside table, applied wax paper and set up her supplies. She entered the room with her supplies, closed the door then washed her hands applied a gown and applied gloves. Resident #4's soiled dressing had been removed previously. The Wound Care Nurse cleaned the wound and removed her gloves but did not perform hand hygiene and applied new gloves. She patted the wound dry with gauze and removed gloves but did not perform hand hygiene and applied new gloves. She performed wound care and applied the new dressing and removed her gloves but did not perform hand hygiene and applied new gloves. The Wound Care Nurse pulled Resident #4's pants up and adjusted her in bed. She removed her trash and disposed of it. After leaving the resident's room the Wound Care Nurse said she should have cleaned her hands between glove changes and did not. She said she got nervous. The Wound Care Nurse said she was educated on proper wound care and was aware she should have cleaned her hands after removing her gloves and before applying new gloves. She said the resident risk of not cleaning her hands between glove changes was a potential spread of infection. 2. Record review of Resident # 76's admission record dated 08/03/2026 indicated she was a [AGE] year old female, initially admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dysphagia (difficulty swallowing), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube status. Record review of Resident #76's quarterly MDS assessment, dated 07/09/2026, indicated she was severely impaired cognitively. She rarely/never made herself understood and rarely/never understood others. She was dependent on facility staff and/or maximum assistance for self-care and mobility tasks. Record review of Resident #76's care plan, revised 08/16/2024 indicated Resident #76 had the need for Enhanced Barrier Precautions due to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube with interventions place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Record review of physician's orders for Resident #76, dated 08/19/2024, indicated EBP Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR. (residents with wounds or indwelling medical devices) every shift. During an observation on 08/04/2026 at 2:30 p.m., outside of Resident #76's room there was an EBP signage. There was an over-door organizer on Resident #76's door with PPE (gloves, gowns, goggles,) available. Resident #76 was lying in bed; she did not respond appropriately to interview questions. During an observation on 08/04/2026 at 2:58 p.m., CNA C and CNA D provided perineal/incontinent care to Resident #76. CNA C and CNA D, during direct contact with Resident #76, did not wear gowns while providing perineal/incontinent care. During an interview on 08/04/2026 at 3:15 p.m., CNA C and CNA D said they failed to follow the EBP because they forgot to wear a gown during Resident #76's perineal/incontinent care. Both said they were trained in EBP and should have applied gowns prior to entering the room to perform care. They said Resident #76 was on EBP because she hads a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube. They said that not wearing a gown during the perineal/incontinent care could spread infection or cause cross contamination. During an interview on 08/04/2026 at 3:45 p.m., the ICP said she expected the facility staff and vendors to follow the EBP policy when providing direct care to residents identified as requiring EBP which included residents with chronic wounds, indwelling devices, and MDROs. She said Resident #76 was on EBP because she had a gastronomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube for her continuous feedings requiring precautions and staff and vendors should be wearing PPE when providing direct care/incontinent care. The ICP said she provided facility staff training on infection control measures and EBP routinely, at a minimum of quarterly, and as needed. The ICP said not following the EBP as ordered could lead to spread of infection, transfer of bacteria, putting both staff and residents at risk. She said all staff should follow all infection control procedures. During an interview on 08/05/2026 at 3:50 p.m., the DON said she expected facility staff to apply PPE when providing direct resident care for residents with EBP ordered. She said Resident #76 was on EBP because she had a gastrostomy tube (indwelling medical devices - an opening into the stomach from the abdominal wall, made surgically for the introduction of food) requiring precautions and staff should be wearing the proper PPE while providing direct care to her. She said EBP should be followed by staff and vendors with direct care provided to residents with MDROs, wounds, and indwelling devices. The DON said the risk of failing to perform EBP could lead to spread of MDROs, infections to other residents or even staff. The DON said the Wound Care Nurse was responsible for wound care in the facility when she was there and was educated on proper completion of wound care. She said the Wound Care Nurse should have washed her hands or used ABH gel after changing her gloves each time. She was overwhelmed. She said the potential resident risk of not performing hand hygiene between glove changes was a potential for infection. The DON said her expectation was all nurses follow all infection control policies. During an interview on 08/05/2026 at 4:15 p.m., the Administrator said his expectations were that all staff adhere to the EBP policy, orders and signage when providing high- contact care for residents requiring EBP (residents with MDROs, chronic and pressure wounds, and indwelling devices). He said not following EBP as required could cause spread of infection or cross contamination. The Administrator said the Wound Care Nurse was educated on proper wound care and responsible for completing wound care on the residents in the facility. He said she was nervous. The Administrator said the resident risk of not cleaning her hands between glove changes was potential for infection. He said his expectation was all staff follow infection control policy and procedures. Record review of a facility policy titled, Hand Hygiene, dated 10/24/2022, indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic had rub, also known as alcohol-based hand rub (ABHR). a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of facility policy titled, Enhanced Barrier Precautions, dated 12/30/2025, indicated the following: . Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.2. Initiation of enhanced barrier precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following i. Wounds (e.g., chronic wounds such as pressure ulcers diabetic foot ulcers unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of enhanced barrier precautions: a. Make gowns and gloves available immediately here or outside of the residence room. Note: face protection may also be needed if performing activities with risk of splashes or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the residence room. 4. High contact resident care activities include.d. Providing hygiene.f. changing briefs or assisting with toileting .

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the status of the residents for 2 of 18 (Resident #2 and Resident #48) residents reviewed for accuracy of assessment. 1. The facility failed to accurately complete the MDS assessment to indicate Resident #2's PASRR status was positive. 2. The facility failed to accurately complete the MDS assessment to indicated Resident #48 did not receive insulin injections. These failures could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of Resident #2's admission record indicated a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis of major depressive order (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), stoke, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #2's annual MDS assessment, dated 03/13/2026, indicated a BIMS score of 10 indicating Resident #2 was moderately impaired cognitively. The MDS Section A1500: Preadmission Screening and Resident Review (PASRR) Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The MDS was coded 0 indicating No conditions related to ID/DD Status. Record review of Residents #2's care plan updated on 07/08/2026 indicated she received antipsychotic medications for major depressive disorder with monitoring and reporting interventions. No care plan identified for Resident #2 having PASRR positive status for mental illness and interventions in place. Record review of Resident's #2's PASRR Level 1 Screening dated 07/24/2025 indicated Resident #2 was PASRR positive for a mental illness. Record review of Resident's #2's PASRR Comprehensive Service Plan form dated 08/27/2025 indicated Resident #2 was PASRR positive for MI and received MI specialized services. Record review of Resident's #2's PASRR Quarterly Comprehensive Service Plan form dated 04/15/2026 indicated Resident #2 continued to be PASRR positive for MI and continues to receive MI specialized services. During an interview on 08/05/2026 at 11:00 am, Resident #2 and Resident #2's family members said Resident #2 was PASRR positive since facility admission, attended quarterly PASRR meetings, and she receives MI specialized services. 2. Record review of Resident #48's admission record dated 06/20/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Osteomyelitis (bone infection), hypertension (when your blood pressure is consistently too high over time), and GERD (when stomach acid flows back up into the esophagus). The admission record did not reveal a diagnosis of diabetes disorder. Record review of Resident #48's MDS assessment completed on 06/23/2026 indicated the resident received insulin injections. Record review of Resident #48's care plan completed on 06/20/2026 indicated no mention of diabetes disorder or that the resident received insulin. Record review of Resident #48's MAR dated June 2026 indicated no insulin orders. Record review of Resident #48's Physician orders dated July 2026 indicated no insulin orders. During an Interview on 08/04/2026 at 1:45 p.m., Resident #48 stated she has no history of diabetes, nor has she ever taken insulin before. Resident #48 said she only had blood thinner injections in her stomach while in the facility. During an Interview on 08/05/2026 at 11:53 a.m., the MDS Coordinator A (skilled services) said Resident #48's MDS assessment, completed on 06/23/2026, should not have insulin marked under the injections section and it was a data entry error. She said she should have put a zero in the insulin injection section. She said the only injections Resident #45 received were anticoagulant injections. She said Resident #2 was PASRR positive, receiving PASRR services, and the annual MDS assessment for 03/13/2026 was incorrect. She said she completed skilled care MDS's, and completed Resident #2's annual MDS dated [DATE] because she was receiving skilled care at the time. She said the Regional MDS Coordinator reviewed the MDS for accuracy and completion. She said she had been doing MDS assessments for over 30 years and received MDS training quarterly from corporate staff. She said inaccurate assessments had low risk of harm, and could lead to residents not receiving needed services. She said she followed the most recent RAI Manual for guidance for completing the MDSs. She said she would modify Resident #45 and #2 incorrect MDS's to reflect the correct information. During an interview on 08/05/2026 at 12:05 p.m., the MDS Coordinator B (long-term care) said she was responsible for completion of the long-term care residents' MDSs, and Resident #2 was a long-term care resident and received PASRR services, and she should have communicated that Resident #2 was PASRR positive to MDS Coordinator A to accurately complete the annual MDS, dated [DATE]. She said the Regional MDS Coordinator reviewed all the MDSs for accuracy and completion. She said she received MDS training quarterly from the corporate MDS Coordinator staff. She said inaccurate assessments had a low risk of harm and could lead to residents not receiving needed services. She said she followed the most recent RAI Manual for guidance for completing the MDSs. During an interview on 08/05/2026 at 12:48 p.m., the DON said the MDS Coordinators were responsible for all MDS assessments in the facility with the Regional MDS Coordinator reviewing the MDS for accuracy and completion. The DON said she expected her MDS coordinators to be efficient and accurate when submitting MDS forms. The DON said the resident risk of an MDS marked incorrectly was the MDS may not reflect the accurate residents care needed. The DON said they used the RAI Manual for guidance for completing the MDSs. During an interview on 08/05/2026 at 2:15 p.m., the Administrator said the MDS Coordinator was responsible for all MDSs in the facility and were trained in the completion of MDSs. He said the Regional MDS Coordinator completed random MDS audits for accuracy. The Administrator said the resident risk of an MDS not marked correctly was the MDS may not be an accurate reflection of the resident and the resident's care. He said his expectation was all MDSs be correct and accurate. The Administrator said they did not have a policy regarding MDS completion, the facility utilized the RAI Manual for guidance for completing the MDSs. Record review of the facility's policy titled, Documentation, indicated the following in part. Goal: 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 indicated the following: .A1500: Preadmission Screening and Resident Review (PASRR). Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. N0300: Injections Coding instructions Record the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that the resident received any type of medication, antigen, vaccine, etc., by injection. Insulin injections are counted in this item as well as in Item N0350. N0350: Insulin Coding Instructions: Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. Enter in Item N0350B, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that the physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders. SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood, or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of four (Resident #80) residents reviewed for abuse and neglect. The facility failed to report an allegation of abuse within 2 hours to HHSC of learning about alleged abuse that involved Resident #80 allegedly during the week of July 27th, 2026. This failure could place residents at risk of not receiving timely investigation into allegations of abuse and neglect, continued abuse, fear, and retaliation.The findings included: Record review of Resident #80's face sheet dated 08/03/2026 indicated a [AGE] year-old female was admitted to the facility on [DATE]. Resident #80 had diagnoses of cerebral infraction (stroke), lack of coordination, and anxiety disorder. Record review of Resident #80's Quarterly MDS assessment dated [DATE] indicated she made herself understood and others could understand her. She had a BIMS score of 15/15 indicating she was cognitively intact. Record review of Resident 80's undated care plan indicated the resident has a behavior problem with an intervention of intervene as necessary to protect the rights and safety of others. Approach/ speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of the TULIP case detailed an allegation involving Resident #80 was learned about on 08/03/2026 at 1:00 p.m., indicated it was not reported to HHSC until 08/03/2026 at 5:04 p.m. Record review of CNA P's timesheet indicated she was had not worked since 08/02/2026. Record review of the Provider Investigation Report dated 08/03/2026 indicated Resident #80 allegedly felt bullied by CNA P sometime last week, she could not recall. She alleged it occurred around 6:30 p.m., (smoke break). An observation and interview on 08/03/2026 at 12:00 p.m., indicated Resident #80 was lying in bed watching tv. There were no bruises, markings noted on Resident #80. She said the way CNA P had talked to her made her feel like she was bullied. Resident #80 said she could not recall what CNA P had said to her nor the setting they were in when it happened. She was said she had recalled the alleged incident happened on 08/02/2026. She said she had not told anyone because she was waiting to get out of bed. During an interview on 08/03/2026 at 1:00 p.m., the Administrator indicated he initiated his investigation of the allegation at 1:00 p.m. He said he should have reported the allegation within 2 hours. The Administrator said he re-read the provider letter on reporting abuse and read that alleged abuse was to be reported within two hours. He said he was responsible for reporting to HHSC within 2 hours. He said CNA P was suspended until the investigation was complete. He said CNA P did not have a history of abuse allegations. During an interview on 08/05/2026 at 3:00 p.m., with CNA P, she said she had never been Resident #80's assigned CNA. She said she was the assigned staff member that took the smokers outside to smoke. She said after the smoke break was over Resident #80 could not push her wheelchair inside by herself, so she helped push her wheelchair. She said Resident #80 accused her of trying to push her out of her wheelchair. She said she told the resident that she was trying to help her wheelchair over the hump. Record review of facility's policy titled Abuse, Neglect, and Exploitation dated: 07/11/2025. Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 18 residents (Resident #2) reviewed for comprehensive resident centered care plans. The facility failed to ensure Resident #2's comprehensive care plan was reviewed and revised with having PASRR positive status for mental illness. This failure could place residents at risk of not receiving the care and services to meet their needs.Record review of Resident #2's admission record indicated a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis of major depressive order (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), stoke, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #2's annual MDS assessment, dated 03/13/2026, indicated a BIMS score of 10 indicating Resident #2 was moderately impaired cognitively. The MDS Section A1500: Preadmission Screening and Resident Review (PASRR) Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The MDS was coded 0 indicating No conditions related to ID/DD Status. Record review of Residents #2's care plan updated on 07/08/2026 indicated she received antipsychotic medications for major depressive disorder with monitoring and reporting interventions. No care plan identified for Resident #2 having PASRR positive status for mental illness and interventions in place. Record review of Resident's #2's PASRR Level 1 Screening dated 07/24/2025 indicated Resident #2 was PASRR positive for a mental illness. Record review of Resident's #2's PASRR Comprehensive Service Plan form dated 08/27/2025 indicated Resident #2 was PASRR positive for MI and received MI specialized services. Record review of Resident's #2's PASRR Quarterly Comprehensive Service Plan form dated 04/15/2026 indicated Resident #2 continued to be PASRR positive for MI and continues to receive MI specialized services. During an interview on 08/05/2026 at 11:00 am, Resident #2 and Resident #2's family members said Resident #2 was PASRR positive since facility admission, attended quarterly PASRR meetings and she receives MI specialized services. During an interview on 08/05/2026 at 11:53 a.m., (the skilled services) MDS Coordinator A said Resident #2 was PASRR positive and received PASRR services. She said Resident #2's care plan should indicate that she was PASRR positive and include appropriate interventions. She said Resident #2's care plan should have been revised when Resident #2 became PASRR positive or when the facility discovered the care plan was not correct. She said the annual MDS and comprehensive care plan was not accurate, and Resident #2 should have been identified as PASRR positive. She said if a care plan was not reviewed and updated with changes, it could affect resident care. During an interview on 08/05/2026 at 12:05 p.m., the long-term care MDS coordinator B said Resident #2 was PASRR positive and received PASRR services. She said Resident #2's care plan should indicate that she is PASRR positive with appropriate interventions. She said not having an accurate care plan could affect resident care needs. During an interview on 08/05/2026 at 3:50 p.m., the DON said the MDS Coordinators were responsible for the revision of the resident's care plan at the time of the assessment. The DON said the inaccurate care plans should have been identified and revised during the IDT care plan meeting. She said inaccurate care plans could result in affecting resident care needs being met. The DON said Resident #2's care plan should reflect that she was PASRR positive. She said the expectation was for all residents' care plans to be completed accurately. During an interview on 08/05/2026 at 4:00 p.m., the Administrator said comprehensive care plans should be reviewed and revised with significant changes, quarterly, annually, and as needed with resident care changes. He said the MDS Coordinators and IDT should be reviewing the care plan and making sure all the care need areas were addressed. He said not having an accurate care plan could affect resident care needs, and he expected each resident's comprehensive care to be reviewed, revised and accurate. Record review of the facility's policy titled, Comprehensive Care Plans dated 10/24/2022 indicated the following: . Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines:. 3.The comprehensive care plan will describe, at a minimum, the following:. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (Memory Care and Station and Hall 100 medication aide medication cart) reviewed for medication storage. 1. The facility failed to ensure medication was not on the floor of the Memory Care unit in front of the memory care medication cart on 8/4/2026 at 1:25 p.m. 2. The facility failed to ensure the Hall 100 medication cart was locked without keys in the keyhole and supervised. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication. Findings include: 1. During an observation and interview on 08/4/2026 at 1:25 p.m., LVN E in the memory care unit was observed checking meal tickets. LVN E observed a small white round pill (with a 49 impressed on one side of the pill) on the floor in front of the memory care medication cart. LVN E picked up the pill and did a search on her phone to identify the pill as an anti-itch medication. LVN E said only one resident in the memory care unit has an anti-itch medication. LVN E compared and identified the round white pill found on the floor to be an anti-itch medication of Hydroxyzine 25 mg. LVN E said she had just administered a resident an anti-itch medication prior to lunch, but she verified the medication was in the cup and that the resident swallowed the administered meds. LVN E said she was unsure where the pill on the floor came from, but she placed it in the biohazard box for destruction. Observed 12 memory care unit residents sitting in wheelchairs or chairs eating lunch. Observed 2 memory care unit residents independently ambulatory and no residents observed near the medication cart or pill found on the floor. During an interview on 08/04/2026 at 1:30 p.m., LVN E stated it was her responsibility to make sure all medications were stored and locked in the medication cart. LVN E said she was unsure where the anti-itch pill found on the floor came from, but she should make sure medications are secure and not on the floor around the medication cart prior, during and after administering medications. LVN E said if it was from the anti-itch medication she administered, she had just administered the medication prior to lunch, so it had not been unsecure for more than 15-20 minutes. LVN E said only 2 of the residents on memory care had the physical mobility and dexterity to bend down and pick up a small pill from the floor and with those 2 it would be difficult and facility staff alertness would intervene. LVN E said the negative outcome was that another resident could have picked up the medication and ingested it causing drowsiness. LVN E said she was trained in medication storage, use of medication carts, and to keep medications locked up when not in use. 2. During an observation and interview on 08/05/2026 from 9:40 a.m. to 9:43 a.m., indicated MA F's medication cart was noted to be unsecured with the keys inside of the key lock and unsupervised on Hall 100. MA F was in a resident's room when that medication cart was seen unattended. The medication cart was front facing with the drawers facing the hallway with the lock mechanism out (indicating it was unlocked). Inside the medication cart Drawer #1 were OTC (over the counter) aspirin, vitamins, minerals and eye drops. Drawer #2 had a locked compartment with several controlled substances, and multiple resident's individual medication bubble-blister packets. During an interview with MA F, she said she was assigned the Hall 100 medication aide medication cart, and it should had been locked. She said she should not have left the cart keys inside the lock. She said the potential risk was someone taking medication off her cart. She said she had been trained on ensuring the medication cart was secured and locked when not in use. During an interview on 08/05/2026 at 3:55 p.m., the DON said the MAs and nurses were responsible for keeping the medication carts locked and the medications secure. The DON said medications should not be left unattended on the medication cart or on the floor near the medication cart. The DON said an adverse outcome could be a resident or other staff member could obtain the medication off the cart/nearby floor and cause missing medication or unauthorized access or use of the medication. During an interview on 08/05/2026 at 4:20 p.m., the Administrator said he expected the staff to be compliant with the policies regarding proper medication storage. The Administrator said medications should never be left on top of a medication cart or on the floor near cart unattended because from a safety perspective, someone could come along and take it. Record review of facility policy titled, Medication Administration, dated 10/01/2019, indicated the following: .Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. 2. Administration.P. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained at all times for all resident information (e.g., MAR) by closing the MAR book/covering the MAR sheet or computer screen when not in use. R. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment.The facility did not ensure the back center burner on the gas stove ignited when the knob was turned. This failure could place the residents at risk of not having safe operating equipment. Findings included:During an observation and interview on 08/03/2026 at 8:50 a.m., with [NAME] J the stove was checked, 1 of the 6 burners the back center burner did not light when turned on. She said it had not been lighting for about 1 to 2 months. [NAME] J said the cooks were responsible for notifying the DM when equipment did not work. She said there was no resident risk just may take longer to prepare meals. She said she rarely used the back middle burner; she mostly used the ovens and steamer and outer edge burners to prepare food. She denied gas odors. No gas odors on all sides of the stove or anywhere in the kitchen were observed and no hissing sound of gas from the stove observed. During an interview on 08/03/2026 at 9:45 a.m., the Regional Director of Dietary Services said the cooks were responsible for notifying the DM or a manager when equipment did not work and the DM or manager would notify the Maintenance Director so it would be repaired immediately and document the equipment concern in the electronic Maintenance reporting system. She said it was potentially a miscommunication between dietary and maintenance departments. All dietary staff were educated to notify the DM with any equipment not working properly. She said there was no resident risk of the stove burner not working it could possibly slow meal service. She said her expectation was repairs within 24 hours. She said the burner was taken out of service until repaired and there was no smell of gas in the kitchen. The Regional Director of Dietary Services immediately notified the Maintenance Director that the stove burner was not working. During an interview on 08/03/2026 at 10:00 a.m., the DM said the cooks were responsible for notifying her if a burner or any equipment was not working properly. She would notify the Maintenance Director and put the concern in the electronic Maintenance reporting system. She said she worked Monday 07/27/2026 and the back center burner was not lit since 07/20/2026. She lit the pilot light on Monday 07/27/2026 and thought the pilot light had just went out. She said all dietary staff were educated to notify her if any dietary equipment was not working properly. The DM said the potential risk was that meal service may be slower than normal. She said there were no fumes or gas odor in the kitchen when she worked. She said her expectation was all staff would notify her immediately when any dietary equipment was not working properly. During an interview on 08/03/2026 at 10:59 a.m., the Maintenance Director said he was not aware of any problem with the stove until this morning (08/05/2026). He said the cooks were responsible for notifying the DM, the DM would notify him and add it into the electronic reporting Maintenance system. The Maintenance Director said he would check the equipment and repair it, order parts or call a professional to repair it. He said he cleaned the pilot light, but it was still not working, and he called the vendor and ordered a part to repair it. He said there was no resident risk. He could light the pilot light if needed until repaired.During an observation and interview on 08/05/2026 at 8:50 a.m., [NAME] K had been at the facility since March 2026. It was observed the stove burners were checked, the back middle burner did not light immediately. [NAME] K said the cooks were responsible for notifying the DM if equipment was not working properly and she was educated to inform the DM immediately when equipment was not working properly and the DM notified the Maintenance Director and he repaired it. She said she was unsure if she splashed water from eggs this morning and put out the pilot. [NAME] K said the resident risk of a stove burner not lighting was food may not be sent out to the residents timely. She said it worked 3 days ago (08/02/2026) when she last worked. She denied any gas smell near the stove or in the kitchen. No gas smells were observed in the kitchen or on any side of the stove. During an interview on 08/05/2026 at 9:00 a.m., the Administrator said the cooks were responsible for notifying the DM if any dietary equipment was not working properly. The DM would notify the Maintenance Director, and he would repair it if possible or order it to be repaired by professionals. He said the dietary staff were all educated to notify the DM if any equipment was not working properly. The Administrator said the resident risk was potentially would take a little longer to prepare meals. He said his expectation was that all equipment be fixed as soon as possible. He said today was the first time he was made aware the stove had a burner not working and the Maintenance Director had checked it and ordered a part to repair it. Record review of in-service dated 08/04/2026 titled, Process for employee . the electronic Maintenance reporting system input for repair services indicated, The electronic reporting Maintenance system in kiosk is located near the employee break rooms. The electronic Maintenance system is also available on all nursing carts and nursing stations and the director's computers have access to the computer application, where the electronic reporting Maintenance system is located. orientation on the proper way to communicate repairs. Record review of Logbook documentation dated 04/08/2026 indicated kitchen rounds stove and oven clean and equipment well- maintained.Record review of an undated facility policy titled, Building Management indicated, . Inspections; Daily, Weekly and Monthly. Expect complete, accurately and on-time. All staff should utilize the electronic reporting Maintenance system .Equipment repairs must be documented with a work order associated with the asset. Expect 100% Completion.

Based on interviews and record review, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 1 of 23 (MA F) staff reviewed for licensure and training requirements. The facility failed to ensure that MA F had completed the mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff.Record review of personnel records for MA F indicated rehire date of 01/02/2024. Review of the facility's training log, undated, showed no evidence of QAPI training for MA F. Review of the training log for the previous 12 months (08/06/2025 to 08/05/2026) provided by human resources and nursing department indicated no evidence that MA F completed QAPI training.During an interview on 08/05/2026 at 2:15 p.m., HR G said annual required training was computer generated quarterly and staff were provided reoccurring emails regarding required completion and/or the delinquent courses. HR G said the annual training completion was reported to the appropriate department heads each morning Monday through Friday during stand-up meetings. HR G said percentages of completion were reported not delinquent staff. HR G said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including QAPI in the last quarter of the year. HR G said she should have monitored the employees that were not completing the training timely and reported the delinquent staff to the appropriate department heads for appropriate disciplinary actions. HR G said not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/05/2026 at 3:15 p.m. with MA F was unsuccessful, no return call to voicemail and text message.During a group interview on 08/05/2026 at 3:51 p.m., HR H (via phone), DON and the Administrator said the HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. HR H said they did not have a policy regarding annual QAPI training. HR H said facility staff were assigned computer generated training quarterly. HR H said depending on their assigned responsibilities, determined which trainings were assigned. HR H said the facility HR G had access to the computer-generated training completion and delinquent staff. The DON and the Administrator said it was the responsibility of the employees to complete their training on time. The DON and the Administrator said the department heads were responsible for ensuring staff completed the assigned training. The DON and the Administrator said the annual training completion should be monitored closer and delinquent staff should be held accountable like removed from schedule until training completed. The DON stated residents could be at risk for poor quality of care by staff not completing their training.A policy addressing annual employee training was requested from the Administrator, HR G, HR H, and DON on 08/05/2026 at 2:15 p.m. and again on 08/05/2026 at 3:51 p.m. but was not provided prior to exit.

Based on interviews and record review, the facility failed to provide required Ethics training for 1 of 23 (MA F) staff reviewed for licensure and training. The facility failed to ensure that MA F completed the mandatory Ethics training. This failure could place residents at risk of being cared for by untrained staff.Record review of personnel record for MA F indicated rehire date of 01/02/2024. Record review of the training log for the previous 12 months (08/06/2025 to 08/05/2026) provided by human resources and nursing department indicated no evidence that the MA F completed ethics training. During an interview on 08/05/2026 at 2:15 p.m., HR G said annual required training was computer generated quarterly and staff were provided reoccurring emails regarding required completion and/or the delinquent courses. HR G said the annual training completion was reported to the appropriate department heads each morning Monday through Friday during stand-up meetings. HR G said percentages of completion were reported not delinquent staff. HR G said employees are assigned the training quarterly and it was the employee's responsibility to complete training timely. HR G said she should have monitored the employees that were not completing the training timely and reported the delinquent staff to the appropriate department heads for appropriate disciplinary actions. HR G said not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/05/2026 at 3:15 p.m. with MA F was unsuccessful, no return call to voicemail and text message. During a group interview on 08/05/2026 at 3:51 p.m., HR H (via phone), DON and the Administrator said HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. HR H said they did not have a policy regarding annual Ethics training. HR H said facility staff were assigned computer generated training quarterly including ethics in the last quarter of the year. HR H said depending on their assigned responsibilities, determined which trainings were assigned. HR H said the facility HR G had access to the computer-generated training completion and delinquent staff. DON and the Administrator said it was the responsibility of the employees to complete their training on time. DON and the Administrator said the department heads were responsible for ensuring staff completed the assigned training. DON and the Administrator said the annual training completion should be monitored closer and delinquent staff should be held accountable like removed from schedule until training completed. DON stated residents could be at risk for poor quality of care by staff not completing their training. A policy addressing annual employee training was requested from the Administrator, HR G, HR H, and DON on 08/05/2026 at 2:15 p.m. and again on 08/05/2026 at 3:51 p.m. but was not provided prior to exit.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 2 of 6 (Resident #16 and Resident #17) residents reviewed for quality of life in that: 1. Resident #16 had noticeable long strands of facial hair on her chin that she wanted staff to shave for her.2. Resident #17 had noticeable thick long strands of facial hair on her upper lip and chin that she wanted staff to shave for her. This failure could affect residents who need assistance with grooming facial hair and could result in low self-esteem and embarrassment. The Findings included: 1. Record review of Resident #16's face sheet dated August 3, 2026, indicated she was admitted on [DATE]. Resident #16 had diagnoses of multiple sclerosis (a chronic condition where the immune system mistakenly attacks the protective covering of nerve cells), lack of coordination, need for assistance with personal care, muscle wasting, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), and blindness right eye. Record review of Resident #16's Quarterly MDS assessment dated [DATE], indicated she made herself understood, she understood others, and had a BIMS (Brief Interview for Mental Status) score of 15/15 (cognition intact). She had severely impaired vision, required assistance from staff for personal hygiene, had right eye blindness, and required assistance with personal care. Record review of Resident #16's undated Care Plan indicated The resident has an ADL Self Care Performance Deficit related to impaired balance, limited mobility, blind, MS (multiple scoliosis) .Intervention: Personal Hygiene: the resident requires (limited assistance) by (1) staff with personal hygiene and oral care. During an observation on 08/03/2026 at 09:10 a.m., Resident #16 's face had long facial hair on chin area. During an observation on 08/04/2026 at 1:00 p.m. Resident 16's face had long facial hair on her chin area. During an observation on 08/05/2026 at 3:00 p.m. Resident 16's face had long facial hair on her chin area. During an interview on 08/03/2026 at 09:12 a.m. with Resident #16, she said she wanted the hair on her chin to be shaved. Resident #16 said she was aware of her facial hair. Resident #16 said she had depended on staff to shave her because she could not see well. She said staff used to shave her once a week regularly then had stopped. Resident #16 said she would have liked staff to have shaved her regularly to keep her chin hair from being noticeable. She said she would go to bible study on Tuesdays and Sundays, and she would have liked to be shaved so she would look presentable. 2. Record review of Resident #17's face sheet dated August 3, 2026, indicated she was re-admitted to the facility on [DATE]. Resident #17 had diagnoses of cerebral infraction (stroke), Hemiplegia (complete loss of strength or paralysis (inability to move) on one side of the body) and Hemiparesis (weakness on one side of the body), need for assistance with personal care, muscle wasting, lack of coordination, absence of the right and left leg above the knee. Record review of Resident #17's Quarterly MDS assessment dated [DATE], indicated she sometimes made herself understood, and usually understood others. She had a BIMS score of 04/15 (severely cognitively impaired). She had impaired vision, and required maximum assistance from staff with personal hygiene. Record review of Resident #17's undated Care Plan indicated The resident has an ADL Self Care Performance Deficit related to Hemiplegia, impaired balance, limited mobility, musculoskeletal (muscles, bones, joints, ligaments, tendons, and connective tissues, supporting movement, posture) impairment, stroke. Intervention: Personal Hygiene: the resident requires (maximum assistance) by (1) staff with personal hygiene and oral care. During an observation on 08/03/2026 at 09:25 a.m., Resident #17 's face had thick and long facial hair above her upper lip and chin area. During an observation on 08/04/2026 at 1:10 p.m. Resident 17's face had thick and long facial hair above her upper lip and chin area. During an observation on 08/05/2026 at 3:12 p.m. Resident 17's face had thick and long facial hair above her upper lip on her chin area. During an interview on 08/03/2026 at 10:14 a.m. with Resident #17, she answered yes when asked if she wanted her facial hair shaved. She could not say the last time staff shaved her. During an interview on 08/05/2026 at 2:15 p.m. with CNA M, he said Resident #16 and Resident #17 had long facial hair. CNA M said he had not shaved Resident #16 and Resident #17 for a while. He said both Residents #16 and #17 were dependent on staff to shave their facial hair. He said residents should be shaved if they want. He said not regularly shaving the residents could potentially result in the residents developing low self- esteem. He said CNAs and nurses were responsible for ADL care.During an interview on 08/032026 at 3:25 p.m. with LVN L, she said Resident #16 and Resident #17 required assistance from staff to shave their facial hair. LVN L said the CNAs and nurses were responsible for providing personal hygiene, that included shaving to residents that required assistance. She said staff needed to offer residents (male or female) hair removal, if residents wanted it. LVN L said personal hygiene was important because residents had the right to have their own grooming preferences. During an interview on 08/05/2026 at 4:11 p.m. with the DON, she said Resident #16 and Resident #17 did not have a history of refusing staff to shave them. She said if the residents refused care, it should be documented. She said the potential risk to the residents was a decrease in their self-esteem. She said the CNAs and the nurses were responsible for shaving residents. She said her expectation was for staff to address any of the residents' needs and to shave them during showers. During an interview on 08/05/2026 at 4:20 p.m., with the Administrator, he said his expectation was for staff to follow the facility's policy and meet residents' needs by shaving their facial hair. He said the CNAs and the nurses were responsible for shaving residents. The Administrator said the risk to the residents not receiving appropriate ADL care was low esteem. Record review of facility's policy titled: Activities of Daily Living (ADLs), dated 05/26/2023, indicated Policy:The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:I . Bathing, dressing, grooming and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene4. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred.

Based on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for 1 of 8 residents (Resident #1) reviewed for abuse, neglect and misappropriation. The facility failed to thoroughly investigate and conduct relevant interviews after Resident #1 alleged on 06/24/26 that CNA A stole her money. This failure could place residents at risk of not having allegations of abuse, neglect, exploitation, or misappropriation investigated properly to prevent re-occurrence. Findings included: Record review of Resident #1's face sheet, dated 07/29/26, indicated a 75- year- old female who was admitted to the facility on [DATE]. Her diagnosis included severe bilateral glaucoma (serious eye condition characterized by significant damage to the optic nerve in both eyes, often leading to vision loss). Record review of Resident #1's quarterly MDS assessment, dated 07/01/26, indicated she was able to make herself understood and understood others. She had severely impaired vision. She was cognitively intact with a BIMS-15. Record review of Resident #1's care plan, dated 06/24/26, indicated Resident #1 was at risk of potential psychosocial well-being problem related to missing money. She was angry that someone would take her money without permission. Interventions included a provided lock box and a key. Record review of the facility schedule, dated 06/23/26 at 10:00 p.m. through 06/24/26 at 6:00 a.m., indicated CNA B and LVN E were assigned to work with Resident #1. Record review of the facility investigation, dated 07/01/26, and completed by the Administrator, indicated the incident occurred on 06/23/26 at 11:15 p.m. and was reported to HHSC on 06/24/26 at 5:02 p.m. The AP was identified and confirmed as CNA A. There were no identified witnesses. The allegation was noted on 06/24/26 as Resident #1 stated someone had stolen her money and she thought it was the aide. The Administrator asked when she thought it was stolen and she stated last night. The Administrator asked who and she stated that girl. The Administrator asked who that girl was, and she stated the one who gave her the bath. CNA A was suspended during the investigation. CNA A denied the allegation. The facility investigation did not include interviews and/or statements from the night staff assigned to Resident #1 from 10:00 p.m. on 06/23/26 through 6:00 a.m. on 06/24/26. The facility investigation did not include interviews or statements of other night staff from 10:00 p.m. on 06/23/26 through 6:00 a.m. on 06/24/26. The facility investigation identified Resident #1 was missing $205. The facility investigation concluded the allegation was unconfirmed. During an interview on 07/28/26 at 11:00 a.m., the Administrator said he was the abuse coordinator and responsible for conducting thorough investigations in the facility. He said Resident #1 reported she was missing money on 06/24/26. He said Resident #1 asked CNA A to put her purse/fanny pack on the seat of the walker. He said it was in the doorway of the shower area and was in view during the shower. He said Resident #1 identified CNA A as the AP. He said CNA A was immediately suspended pending the outcome of the investigation and the police were notified. He said it was determined Resident #1's money was missing, but he could not identify who stole the money. During an interview on 07/28/26 at 12:15 p.m., Resident #1 said she was blind and could not see her money. She said other staff and Resident #2 (her roommate) helped her count her money. She said she had more than $200 before she went into the shower on 06/23/26. She said she believed CNA A took her money. She said CNA A assisted her with her bath/shower. She said CNA A put her purse with her money on the seat of her walker and then moved the walker out of the shower area. She said after her shower, CNA A put her purse on the overbed table and assisted her backto bed. She said the next morning, on 06/24/26, she discovered she was missing a wallet with more than $200. She said she now had a lock box and a key for her money. She said she kept the [NAME] a lanyard around her neck. During an interview on 07/28/26 at 12:20 p.m., Resident #2 (Resident #1's roommate) said she did not see anyone take any money or Resident #1's wallet. During an interview on 07/28/26 at 12:23 p.m., CNA A said she assisted Resident #1 to the shower on 06/23/26. She said she put Resident #1's purse on the seat of her walker and pushed the walker out of the shower area and into the doorway of the shower room. She said the walker and purse were not out of Resident #1's sight during the entire shower. She said after she completed Resident #1's shower, she assisted Resident #1 to dress and then assisted her back into bed. She said she handed Resident #1 her purse and Resident #1 put the purse around her neck as she usually did. She said she did not see Resident #1's money or wallet. She denied taking Resident #1's money. She said she was suspended and interviewed during the facility investigation. During an interview on 7/28/26 at 2:45 p.m., LVN E said Resident #1 reported her money was missing on 06/24/26. She said she reported it to the Administrator immediately. She said Resident #1 said her purse was on the overbed table when she was put in bed and that was not the usual place Resident #1 kept her purse or money. She said Resident #1 usually kept her purse/fanny pack around her neck at all times. During an interview on 07/28/26 at 2:57 p.m., CNA C said Resident #1 told her on 06/24/26 she was missing her money. She said she reported Resident #1's missing money to LVN E immediately. She said Resident #1 asked for her purse/fanny pack from the overbed table. She said it was unusual because Resident #1 always had her purse/fanny pack around her neck, even when she was sleeping. She said she handed the purse/fanny pack to Resident #1 and Resident #1 asked for her wallet She said she opened the purse/fanny pack and handed her a wallet. She said Resident #1 opened the wallet and felt the bills and asked if it was all $1's. CNA C said she told Resident #1 it was only $1's in her wallet and she put it back and thought she had another wallet. I helped her search her bed for another wallet and we did not find another wallet. She said her money was missing. She said she reported the missing money to LVN E immediately. During an interview on 07/29/26 at 9:05 a.m., LVN D said she worked from 10:00 p.m. on 06/23/26 through 06/24/26 at 6:00 a.m. She said she did not know of Resident #1's missing money. She said she did not recall where Resident #1's purse/fanny pack was at the time of the alleged incident. She said she was not interviewed regarding Resident #1's missing money. During an interview on 07/29/26 at 9:23 a.m., the Administrator said he usually interviewed other staff and got interviews that said they knew something or they knew nothing if that was the case. He said this time, he did not. He said he asked a few other staff if they knew anything and they did not know anything, but he did not get any statements. He said he tried to get ahold of CNA B, but she did not respond. He said he did not interview LVN D or get her statement. He said residents were at risk of continued misappropriation if investigations were not thorough. During an interview on 07/29/26 at 11:00 a.m., the SW said Resident #1 kept her money in 1 one of 2 two wallets. She said Resident #1 usually kept her wallets in her purse/fanny pack around her neck or under her pillow. She said Resident #1 guarded her money at all times. She said she assisted to search Resident #1's room for the missing wallet and couldn't find the missing wallet or the money. Attempted interview on 07/23/26 at 1:38 p.m. with CNA B (worked from 10:00 p.m. on 06/23/26 through 06/24/26) was unsuccessful. A voicemail message was left. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 07/11/25 indicated . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .6. Providing complete and thorough documentation of the investigation.

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's humidifier was not empty.2. The facility failed to ensure the nasal cannula and humidifier were replaced weekly.3. The facility failed to ensure Resident #1's oxygen maintenance requirements for regular replacement of nasal cannulas and humidifiers were documented in Resident #1's orders or care plan. These failures could place residents at risk for dry nasal passages or infection.Findings include: 1. Record review of Resident #1's face sheet, dated 11/06/2025, indicated Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), dementia (decline in cognitive functioning), and COPD (chronic obstructive pulmonary disease; inflammation and narrowing of the airways leading to breathing difficulties). Record review of Resident #1's Quarterly MDS assessment, dated 10/15/2025, indicated he was understood by others and was able to understand others. Resident #1 had a BIMS score of 03, which indicated he had severe cognitive impairment. Resident #1 received oxygen while a resident in the facility. Record review of Resident #1's Order Summary Report, dated 11/06/2025, indicated may have oxygen at 4 liters per nasal cannula every shift with a start date of 07/11/2025, and check oxygen saturation frequency every shift for hypoxia (inadequate oxygen supply) with a start date of 7/11/2025. There were no other orders related to oxygen administration. Record review of Resident #1's care plan, with a date initiated of 08/20/2025, indicated he had COPD (chronic obstructive pulmonary disease; inflammation and narrowing of the airways leading to breathing difficulties) and should avoid lying flat due to shortness of breath. The goal was for the resident to display optimal breathing patterns daily through the review date. There were no interventions related to regular replacement of the nasal cannula or the humidifier. During an observation and interview on 11/06/2025 at 10:22 AM, revealed Resident #1 was in his bed, and he had oxygen via nasal canula on and running. The nasal cannula and the humidifier were dated 10/26/25. The humidifier was completely empty. Resident #1 was not aware the humidifier was empty and did not know when it was changed or how frequently. He stated he had no issues related to the humidifier being empty and had no complaints regarding oxygen administration. During an interview on 11/06/25 at 12:28 p.m., LVN A stated nasal cannulas were to be changed on the night shift weekly and the humidifiers were to be changed weekly and/or when they were empty. LVN A stated it was the night nurse's responsibility to change the nasal cannulas and the humidifiers weekly, but any nurse could replace them. LVN A stated the failure to replace nasal cannulas and humidifiers could cause infection and failure to replace humidifiers when they were empty could restrict moisture in the tubing and cause the resident to dry up. During an interview on 11/06/25 at 12:37 p.m., ADON B stated nasal cannulas were to be changed weekly and the humidifiers were to be changed weekly and/or when they were empty. ADON B stated it was all the nurses' responsibility to ensure the nasal cannulas were changed weekly and the humidifiers when they were empty. ADON B stated the failure to replace nasal cannulas and humidifiers could be infection and the failure to replace humidifiers when they were empty was it could cause the nasal area to be dry or bleed. During an interview on 11/06/25 at 1:53 p.m., the DON said the nursing staff were responsible for changing the nasal cannulas and the humidifiers every seven days or as needed. She stated, the humidifiers should be dated within 7 day look back. If any humidifiers were empty, they should refill it and date it. The DON stated these failures could cause infection or dry nasal passages. A more specific policy related to oxygen administration was requested multiple times on 11/06/25, the DON stated she did not have another policy to provide except for Oral Inhalation Administration, which also did not provide any related oxygen administration requirements. Record review of the facility's policy titled, Oxygen Safety, revised January 26th, 2024, indicated no related oxygen administration requirements were included in this policy.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication errors. On 07/24/25 LVN A administered 8 units of insulin outside of parameters (hold for BG less than 100). LVN B noted a change of condition for Resident #1 on 07/24/25. She was unable to rouse, clammy, and lethargic and only responded to painful stimuli. Resident #1 was admitted to hospital for hypoglycemia. The facility did not identify this significant medication error. An IJ was identified on 07/29/25. The IJ template was provided to the facility on [DATE] at 1:18 p.m. While the IJ was removed on 07/30/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures could place residents at risk of not receiving the intended therapeutic benefit of the medications, worsening or exacerbation of chronic medical conditions, hospitalization, and death.Findings included: Record review of Resident #1's face sheet dated 07/30/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke) and Type II diabetes (the body becomes resistant to insulin or when the pancreas fails to produce insulin). Record review of Resident #1's quarterly MDS dated [DATE] indicated she was rarely able to make herself understood, sometimes understood others, and had severe impaired cognitive skills for daily decision making. Resident #1 received insulin injection for 6 of 7 days. Record review of Resident #1's care plan dated 02/17/25 (revised 07/29/25) indicated Resident #1 had diabetes. On 07/24/25 Resident #1 responded to painful stimuli only, blood sugar was 46 and she was sent to ER and admitted . Interventions dated 02/17/25 included check glucose before meals and call if above 350 and diabetes medications as ordered by physician. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any ss/sx of hypoglycemia. Record review of Resident #1's physician orders dated 06/24/25 indicated Insulin Aspart Injection Solution (fast acting insulin) 100 unit/ml inject 8 units subcutaneously with meals for DM2. Hold for BG <100. Record review of Resident #1's MAR dated 07/24/25 at 5:00 p.m. indicated LVN A administered 8 units of Insulin Aspart Injection Solution. The MAR indicated hold for BG less than 100. LVN A noted Resident #1's BG was 99. Record review of Resident #1's progress nurse note dated 07/24/25 at 7:37 p.m., completed by LVN B indicated Resident #1 responded to painful stimuli only, blood sugar 46 and has worsened. Physician and RP notified. Record review of Change of Condition Form dated 07/25/25 at 12:00 a.m., completed by LVN B indicated LVN B noticed Resident #1 appeared sleeping during medication pass. Resident #1 was unable to maintain proper body posture. Blood sugar was 46. Administered Baqsimi (dry nasal spray used to treat severe hypoglycemia). in left nostril and called emergency services. Physician and RP notified. Resident #1 was transferred to hospital. Record review of Resident #1's progress nurse note dated 07/25/25 at 9:15 a.m., completed by LVN H, indicated Resident #1 was admitted to the hospital and her admitting diagnosis was hypoglycemia (low blood sugar-level). Record review of Resident #1's hospital records dated 07/25/25 indicated Resident #1 presented to the emergency department via EMS with complaints of hypoglycemia. Staff reported Resident #1 had a glucose of 99 and facility administered 8 units of insulin causing Resident #1 glucose to drop to 25. EMS administered 250 ml of D10 (dextrose/sugar), raised glucose to 169. Resident remained responsive to painful stimuli only. Record review of Resident #1's hospital records dated 07/26/25 Blood glucose earlier this a.m. was 58. Continue to monitor glucose and hold diabetic medications and insulin. Record review of Resident #1's hospital records dated 07/27/25 indicated hypoglycemia was resolved. Discharge plan for tomorrow. Record review of Resident #1's progress nurse noted dated 07/28/25 at 5:37 p.m., completed by LVN J indicated Resident #1 was readmitted to the facility in stable condition. During an interview on 07/29/25 at 10:50 a.m., the DON said she was not aware LVN A administrated Resident #1's insulin outside of parameters on 07/24/25. She said she was aware the physician was notified of Resident #1's change of condition and transport to hospital for evaluation and treatment. She said she reviewed Resident #1's clinical record for a change of condition but did not investigate the possible reasons for hypoglycemia. She said it was her expectation LVN A would have held Resident #1's insulin on 07/24/25 due to the BG being out of parameters. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 11:18 p.m., LVN A said she must have made a mistake on 07/24/25 when she administered Resident #1's insulin outside of parameters. She said she did not recall if Resident #1 ate her supper meal. She could not recall if she gave Resident #1 a supplement. She said she did not recall if staff reported a change of condition. She said she left the facility at 6:00 p.m. on 07/24/25 after working a 4 hour shift. She said she was not aware Resident #1 had a change of condition, became unresponsive, or was sent to the hospital for evaluation and treatment for hypoglycemia. She said she was aware of the proper medication administration procedures. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 1:27 p.m., the DON said she did not know why LVN A administered insulin outside of parameters on 07/24/25 was missed as a med error. She said she missed that LVN A documented Resident #1's BG at 99 and the parameters indicated to hold if BG was less than 100. She said it was an oversight. During an interview on 07/29/25 at 2:28 p.m., CNA C said Resident #1 was sleeping in her wheelchair after the supper meal. She said Resident #1 would not wake up so she could transfer her to bed. She said she called for LVN B to come and assist. She said LVN B could not wake Resident #1 and called for another nurse and ambulance. She said she was trained on recognizing the signs of diabetes and hypoglycemia and figured something was wrong with Resident #1 when she could not wake her up to get ready for bed. During an interview on 07/29/25 at 3:30 p.m., CNA D said Resident #1 was awake when she gave her supper tray on 07/24/25. She said Resident #1 did not eat her supper meal. She said she advised LVN A Resident #1 did not eat her meal. She said she believed LVN A gave Resident #1 a supplement. She said she moved Resident #1 closer to her room to get ready for bed. She said CNA C was getting Resident #1 ready for bed and couldn't wake her up. I thought she was deep sleeping because she was snoring loud. She said CNA C and LVN B could not wake Resident #1 so they called for the crash cart and EMS. She said Resident #1 was sent to the hospital because her BG had dropped. She said she was trained to call for the nurse immediately if a resident was unresponsive or the residents were not at their normal. During an observation on 07/29/25 at 3:37 p.m., Resident #1 was lying in bed. She pulled the blanket over her face and did not respond to questions from the surveyor. During an interview on 07/29/25 at 5:05 p.m., LVN B said she arrived for her shift on 07/24/25 at 6:00 p.m. She said LVN A did not report Resident #1 was not at her normal baseline. LVN A did not report Resident #1 did not eat her supper meal. She said CNA C reported she could not wake Resident #1 to get her ready for bed. She said Resident #1 did not respond to anything, not even painful stimuli. She said she called for another nurse and the crash cart just in case it was needed and EMS. She said she tested Resident #1's BG and it was 46. She said EMS arrived and tested Resident #1's BG and the result was 25. She said EMS transported Resident #1 to the hospital for evaluation and treatment. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. During an observation on 07/30/25 at 2:00 p.m., Resident #1 was sitting in her wheelchair in the common area watching TV. She did not respond to questions from the surveyor. She displayed no signs of anxiety or agitation. During an interview on 07/30/25 at 9:33 a.m. NP D said she was aware Resident #1 was transferred to hospital on [DATE] for change of condition. She said if Resident #1's BG was 99, LVN A should have held the insulin due to the BG being out of parameters. She said Resident #1's BG usually ran high. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. Review of the facility's Medication Administration policy dated 10/24/22, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. An Immediate Jeopardy/Immediate Threat was identified on 07/29/25 at 1:05 p.m. The Administrator and the DON were notified of the Immediate Jeopardy and provided the IJ template on 07/29/25 at 1:18 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's POR was approved on 07/30/25 at 11:15 a.m. and indicated: Actions for Resident Involved: On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for Hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the Director of nursing with the physician and Aspart was discontinued. Identify residents who could be affected: On 7/29/2025, the Director of Nursing and/or designee completed 100% audit of all residents with current insulin orders to ensure Insulin is given within ordered parameters in the last 30 days. Any insulin administered outside of ordered parameters will be addressed with physician, Responsible party notified, resident assessment and medication error report completed if error is identified. Any unclear or missing insulin parameters will be clarified with the Attending physician and order changes as needed. 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. Identified residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. No new order for residents that were identified as insulin administered outside of parameters. Action Taken/ System Change: On 7/29/25, the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on Medication review and reconciliations to ensure that resident is free of significant medication errors, insulin parameters are followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education includes this process: New physicians order will be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. The Medication Administration Record will also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. On 7/29/25, All license nurses and Medication Aides were immediately re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of parameters. All license nurses were re-educated by the Director of Nursing/Designee on Insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition will have medication administration record reviewed to ensure orders were followed and notify physician if errors were identified. Licensed Nurses will review medication record after medication administration to ensure insulin parameters are followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error is identified. A post-test will be completed to ensure comprehension of knowledge of the education provided . If 100% is not achieved, re-education will be completed and re-tested prior to taking an assignment. Licensed Nurses and Medication Aides not in the facility on 7/29/25 and/ or on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. Beginning 7/29/25 and ongoing, newly hired licensed nurses and Certified Medication Aides will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. Beginning 7/29/25 and ongoing Medication administration audit report and Medication error incidents will be reviewed during the morning clinical meeting to ensure identification of medication errors and that physician is notified if error is identified. Monitoring Beginning 7/29/25 and going forward, DON/Designee will monitor compliance with medication administration policy through review of medication administration record to ensure insulin parameters are followed as ordered and medication pass observations. Beginning 7/29/25 and going forward, the DON/Designee will monitor compliance with the weekday morning review of new medication orders, insulin medication administration record, medication error incidents and change in conditions to ensure medications are administered as ordered and identify medications errors if any and referred to physician timely. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the Incident reports and medication administration report during clinical meetings. On 7/29/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. The Surveyor monitored the POR on 07/30/25 by: During observation on 07/30/25 from 1:20 p.m. through 3:54 p.m., LVN F, LVN G, and LVN H checked Residents #2, #3, and #4 BG and administered insulin as required. During interviews on 07/30/25 from 1:20 p.m. through 4:30 p.m., DON, ADON, LVN B, LVN F, LVN G, LVN H, LVN J, CMA K, CMA L, CMA M. MDS LVN N, LVN O, and LVN P who represented all shifts, (6:00 a.m.-6:00 p.m., 6:00 p.m. -6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. - 10:00 p.m., 8:00 a.m. - 5:00 p.m.) indicated they were aware to complete medication review and reconciliations to ensure that residents were free of significant medication errors, that insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. They were aware new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware the Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware insulin administration included parameters and blood glucose monitoring. The indicated residents who experienced change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were identified. Nursing staff indicated they would review medication record after medication administration to ensure insulin parameters were followed as ordered and to notify DON/Designee if a medication error was identified. During an interview on 07/30/25 at 3:30 p.m., the Administrator said he would be attending the morning clinical meeting to ensure the Director of Nursing and/or designee reviewed the incident reports and medication administration report during clinical meetings and all errors were addressed as required. He said he expected the nursing staff to administer medications per the facility policy and protocols. Record review of Resident #1's clinical chart indicated On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the DON with the physician and Aspart (fast acting insulin) was discontinued. Record review of the facility audit of residents with current insulin orders 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. The residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. There were no new orders for the identified residents that were identified as insulin administered outside of parameters. Record review of in-services dated 07/29/25 indicated the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on medication review and reconciliations to ensure that residents were free of significant medication errors, insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education included new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. The Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. Record review of in-service dated 07/29/25 indicated licensed nurses and Medication Aides were re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of Parameters. All license nurses were re-educated by the Director of Nursing/Designee on insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were identified. Licensed Nurses would review medication record after medication administration to ensure insulin parameters were followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error was identified. Record review of an in-service post-tests dated 07/29/25 indicated all tested nursing staff and medication aides achieved 100%. The Administrator and DON were notified on 07/30/25 at 4:35 p.m., the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure Resident #2's BG parameters were updated accurately on the electronic physician orders and MAR as of 07/02/25. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #2's face sheet dated 07/29/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Type II diabetes and dementia. Record review of Resident #2's annual MDS dated [DATE] indicated she was usually able to make herself understood and understood others. She had severe cognitive impairment (BIMS-3). Record review of Resident #2's care plan dated 11/20/20 indicated she had Type II diabetes. Interventions included diabetes medications as ordered by a doctor. Monitor/document for side effects and effectiveness. Record review of Resident #2's physician orders dated 07/02/25 indicated -Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. Record review of Resident #2's physician orders dated 07/29/25 indicated -Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. Record review of Resident #2's MAR dated 07/02/25 through 07/29/25 indicatedNovolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200.The insulin was held if BG was less than 100. Record review of Resident #2's MAR dated 07/29/25 from 5:00 p.m. through 07/30/25 indicated Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 100.The insulin was held if BG was less than 100. Record review of Resident #2's nurse progress note dated 07/02/25 at 9:32 a.m., completed by LVN H indicated new orders from NP D Novolog 6 units with meals. Hold if BG less than 100. During an interview on 07/30/25 at 9:00 a.m. the DON said LVN H made a typo error in the Resident #2's electronic record when she was updating the physician orders and it was not noticed. She said NP D was notified on 07/29/25 and she was waiting for confirmation for the new order to hold Resident #2's insulin if her NG was less than 100. During an interview on 07/30/25 at 9:33 a.m., NP D she reviewed Resident #2's physician orders and MARs on 07/02/25. She said it was a typo error for Resident #2's Novolog to be held for BS less than 200. She said insulin was generally held if BG was lower than 100. She said she reviewed Resident #2's BG parameters for the previous months and said it should have been 100 and not 200. She said she ordered it changed to hold insulin if BG was less than 100 on 07/02/25. She said there was no negative outcome. During an interview on 07/30/25 at 1:52 p.m., LVN H said she put the new orders from NP H on 07/02/25 in the electronic for Resident #2's Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. She said it was an error at 200 that was supposed to be corrected to read 100. She said it was generally good nursing judgment to hold insulin if BG was less than 100. She said she did not notice the hold if less than 200 on the orders or the MAR when she checked Resident #2's BG or when she administered the insulin. She said she always held the insulin if the BG was less than 100. Record review of the facility's policy Documentation in Medical Record dated 10/24/22 indicated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.6% based on 3 errors out of 39 opportunities, which involved 3 of 6 residents (Residents #42, #71 and #90) and 2 of 4 staff observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA P did not administer Tylenol 325 mg instead of Tylenol 500 mg to Resident #45's on 06/10/25 as ordered by the physician. 2. The facility failed to ensure LVN K did not administer Saccharomyes boulardii (Probiotic) 500 mg instead of Probiotic 250 mg to Resident #71 on 06/10/25 as ordered by the physician. 3. The facility failed to hold Resident #90's Metoprolol medication due to low heart rate. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications. Findings include: 1. Record review of Resident #45's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol) and cerebral infarction (blood flow to brain is blocked). Record review of Resident #45's Quarterly MDS assessment, dated 05/01/25, reflected a BIMS score of 12, which indicated Resident #45's cognition was intact. Record Review of Resident #45's physician orders, dated 06/11/25, reflected an order for Tylenol extra strength 500mg twice a day for pain. Record review of Resident #45's medication administration record, dated 06/11/25, reflected Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for Pain at 9:00 a.m. and 9: p.m The medication was signed out as given by MA P on 06/10/25 at 9: a.m. During an observation on 06/10/25 at 6:45 a.m., revealed MA P administered the following medications to Resident #45 : - Acidopgilus 75 million, 2 capsules - Tylenol 325 mg, 1 tablet - Carvedilol 3.125 mg, 1 tablet - Eliquis 5 mg, 1 tablet - Famotidine 20 mg, 1 tablet - Gabapentin 400 mg, 1 capsule - Lisinopril 20 mg, 1 tablet - Furosemide 20 mg, 1 tablet She did not administer - Tylenol 500 mg, 1 tablet. During an interview on 06/10/25 at 12:50 p.m., MA P stated the current order in the chart for Resident #45 indicated Tylenol Extra Strength Tablet 500 MG was to be given. MA P searched the medication cart to reveal there was no Tylenol Extra Strength Tablet 500 MG on her cart. She stated she misread the dosage and gave the 325 mg instead. She stated she was not sure how she missed it. Stated she just got nervous. MA P said medications were administered from doctor's order and following the 6 Rights of Medication Administration. MA P said residents could have worsening of their health condition. 2. Record review of Resident #71's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included dysphagia (difficulty swallowing), history of cerebral infarction (stroke), tracheostomy (tube in windpipe to provide an airway) and gastrostomy (opening to the stomach to deliver nutrients, fluids and medications). Record review of Resident #71 's annual MDS assessment, dated 03/05/2025, reflected no BIMS was conducted, short-term/long-term memory problems and severely impaired cognitive skills for daily decision making. Record review of Resident #71's physician orders, dated 06/11/25, reflected an order for Saccharomyces boulardii Oral Capsule (Saccharomyces boulardii). Give 250 mg 1 packet via gastrostomy tube one time a day for ANTIDIARRHEA. Record review of Resident #71's medication administration record, dated 06/11/25, reflected Saccharomyces boulardii Oral Packet 250 MG (Saccharomyces boulardii), Give 1 capsule via gastrostomy tube daily for ANTIDIARRHEA at 8:00 a.m. The medication was signed out as given by LVN K on 06/10/25 at 8: a.m. During an observation on 06/10/25 at 7:54 a.m., LVN K administered the following medications to Resident #71 via gastrostomy: - Amlodipine 5 mg 1 tablet - Levetiracetam 100 mg/ml 5ml - Pantoprazole oral suspension 40mg 1 packet - Probiotic saccharomyces boulardii 500mg 1 capsule - Vitamin C 500mg 1 tablet She did not administer Probiotic saccharomyces boulardii 250mg 1 capsule. During an observation on 06/10/25 at 07:54 a.m., revealed LVN K administered medications to Resident #71. LVN K crushed 2 of the medications (Amlodipine and Vitamin C) and mixed them each with 10 ml of water in separate clear 30 ml medication cups. LVN K then opened Probiotic saccharomyces boulardii 500mg 1 capsule and mixed it in 10 ml of water and administered it thru Resident #71's gastrostomy tube. During an interview on 06/10/25 at 09:45 AM, LVN K said prior to administering medications nursing staff must check the medication against the order to verify accuracy. LVN K said she gave the 500mg Probiotic saccharomyces boulardii instead of the 250 mg because none was on the medication cart. LVN K said risk of not giving medications as ordered could have a negative effect on the resident where they may not get better or have prolonged illness. 3. Record review of Resident #90's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #90 had diagnoses which included dysphagis (difficulty swallowing), hypertension (high blood pressure) and atrial fibrillation (irregular rapid heart rate). Record review of Resident #90 's annual MDS assessment, dated 05/07/25, reflected a BIMS score of 10, which indicated Resident #90's cognition was moderately impaired. Record review of Resident #90's physician orders, dated 06/11/25, reflected an order for Metoprolol Tartrate Tablet, Give 12.5 mg by mouth two times a day for hypertension hold for systolic blood pressure less than 110 or heart rate less than 60. Record Review of Resident #90's MAR/TAR dated 06/11/25 indicated that Metoprolol 25mg ½ tablet at 8:00 a.m. The medication was signed out as given by MA P on 06/10/25 at 8: a.m During an observation on 06/10/25 at 7:00 a.m., obtained Resident #90's blood pressure according to physician orders. Resident #90's blood pressure was systolic 130 with diastolic 71 and his heart rate was 52. MA P then proceeded to administer the following medications to Resident #90: - Vitamin C 500 mg 1 tablet - Metoprolol 25mg ½ tablet (12.5 mg) - Amiodarone 200mg 1 tablet During an interview on 06/10/25 at 12:40 p.m., MA P acknowledged the current order in the chart for Resident #90 indicated Metoprolol Tartrate Tablet Give 12.5 mg by mouth two times a day for hypertension and hold for systolic blood pressure less than 110 or heart rate less than 60 was not to be given. MA P said she only saw the blood pressure parameter and not the heart rate. MA P said the potential for adverse effects was the heart rate dropping too low. During an interview on 07/25/24 at 03:27 PM, the DON said a pharmacy consultant comes in monthly and reviews medication administration and reports any errors and also provides training to the staff. The DON said she expects the staff to follow the orders as written and the order for Resident #90's Metoprolol should have been held, Resident #45 and #71 were given the wrong dosage of medication. The DON said she expected her nurses to pass medications and do basic medication functions like following the 5 Rights of Medication Administration and notify the Physician for anything out of the ordinary. The DON said the risk to residents would beheart rate dropping and not receiving the correct therapeutic dosages of medications. Record review of the facility policy titled, Medication Administration, dated 10/24/22, read in part: .8. Obtain and record vital signs, when applicable are per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .10. Review MAR to identify medication to be administered.11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident's name, medication name, form, dose, route, and time

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #60) reviewed for narcotic medication. The facility failed to ensure Resident #60's Lorazepam Medication was accounted for. This failure could place residents at risk for not receiving prescribed medication and drug diversion. Findings include: Record review of Resident #60's, face sheet, dated 06/11/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #60 had diagnoses which included: anxiety (feeling of uneasiness), insomnia (difficulty falling asleep) and mood disturbance (disruptions in a person's emotional state). Record review of Resident #60's admission MDS, dated [DATE], indicated a BIMS of 05, which indicated severe cognitive impairment. Record review of Resident #60's physician orders, dated 06/10/25, indicated an active order for Lorazepam Oral tablet 1 mg, Give 1 tablet by mouth every four hours as needed for anxiety. Further review of Resident #60's Physician orders for 04/2025 indicated no order for Lorazepam (medication used to treat anxiety). Record review of Resident #60's Individual Control Drug Record Narcotic Count sheet for the Lorazepam Oral tablet 1 mg indicated the facility received the medication from the pharmacy on 03/31/25 and the quantity received was 30 tablets. The record indicated the following on: -04/01/25, at 8:00 p.m. MA P administered 1 tablet leaving 29 tablets -04/02/25 at 8:00 p.m. MA F administered 1 tablet leaving 28 tablets -04/07/25 at 8:00 p.m. LVN E administered 1 tablet leaving 27 tablets with a line drawn through LVN E's name and error written beside her name -04/09/25 at 8:00 p.m. MA P administered 1 tablet leaving 26 tablets -04/14/25 at 4:00 p.m. MA F administered 1 tablet leaving 25 tablets -04/15/25 at 6:00 p.m. MA F administered 1 tablet leaving 24 tablets -04/16/25 at 6:00 p.m. MA F administered 1 tablet leaving 23 tablets -04/22/25 at 6:00 p.m. MA G administered 1 tablet leaving 22 tablets For a total of eight tablets being administered without an active physician order, and the count indicated 22 remained out of 30. Record review of Resident's #60's Medication Administration Record for the month of 04/2025 indicated no order for Lorazepam and no indication that Lorazepam was administered to Resident #60 for the month of 04/2025. Observation of a random narcotic count with LVN K on 06/10/25 at 1:30 p.m. indicated Resident #60's Lorazepam 1 mg, Narcotic Count Sheet indicated there were 22 tablets of Lorazepam 1 mg, Further observation indicated a line drawn through LVN E's name and error written beside her name for 04/07/25, 8:00 p.m. During an interview on 06/10/25 at 1:30 p.m., LVN K said she had not given Resident #60 any Lorazepam and noticed the scratch thru name, but the narcotic count was correct, so she thought nothing of it. She said per the facility protocol if the narcotic count was off, staff must stay at the facility, the DON must be notified to re-count the narcotics and attempt to locate the narcotics. The staff involved in any missing narcotics would be required to take a drug test. She said the risk to residents could be drug diversion if meds were not accounted for or signed out as administered on the medication administration record. During an interview on 06/11/2025 at 9:30 a.m., the ADON said she was not aware of Resident #60 not having an order for Lorazepam for the month of April 2025. She said she monitored administration of narcotics by doing random counts of the medication cart and she would look at the narcotic record sheets for any mistakes. The ADON said medication carts were to be counted at shift change. She said she expected staff to count the medication carts, make sure medication orders were there before administering and to document correctly, notify the DON and herself immediately if there was a problem, staff were to remain at the facility until administrative staff arrived. The ADON stated no medications were to be given without a physician's order, because residents could receive the wrong dose of medications. During an interview on 06/11/2025 at 10:30 a.m., MA C said she never administered the medication to Resident #60 because she didn't have and order and she drew a line thru her name but did not administer the medication. She said if she would have seen it on the medication administration record she would have given it. MA C said she did not notify her nurse Resident #60 didn't have an active order because she didn't give the Lorazepam. MA C said giving medication without a physician order put them at risk of taking medications they didn't need. During an interview on 06/11/2025 at 12:18 p.m., MA F said medications carts were supposed to be counted at the time of shift change. She said staff were to count all narcotic pills in the medication carts one staff to check the paper record and the other staff to check the medication to ensure they matched. She said the facility in-serviced all nurses and medication aides on counting all narcotic medication in the medication carts and how to document on the medication administration record. She was not sure why she did not document in the eMAR for Resident #60 to show she received the Narcotic she logged out on the individual narcotic record. MA F said she knew better than to administer Resident #60 Lorazepam without it being on the medication administration record. MA F said because Resident #60's Lorazepam blister card was on her cart she thought there was already an order for the medication on the eMAR but she did not sign it out. MA F said administering medication without an doctor's order could mean giving residents medication they could be allergic too. MA F said next time she would report it to her ADON or DON. During an attempted interview on 06/11/25 at 12:25 p.m., MA G did not answer the phone call, or reply to the voice message that was sent to her regarding the investigation. During an attempted interview on 06/11/25 at 12:30 p.m., LVN E did not answer the phone call, or reply to the voice message that was sent to her regarding the investigation. During an interview on 6/11/25 at 2:00 p.m., the DON said she was not aware of any concerns with Narcotics not being given or any documentation discrepancies until state surveyor intervention. The DON explained her expectation was for anyone administering to sign out on the individual narcotic record and then immediately sign the eMAR after the resident took the medication. The DON said she expected the nurses to do follow-up documentation after the narcotic was given to document effectiveness in the nurse's progress notes. The DON said the ADON was responsible for monitoring the pain management of residents and the narcotic logs looking for discrepancies such as scratch outs, frequency of person giving Narcotics. The DON said administer medications and not signing off on the medication administration record put the resident at risk of double dosing and taking something they didn't need. Record review of the facility's policy titled Medication Administration, dated 10/24/22, read in part: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection so . 11. Document administered medications as they are passed medications not given are logged with an initial and circled in the proper time slot. 12. The medication administration record will be used when passing medications

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 of 20 residents (Resident #41) reviewed for unnecessary medication. The facility failed to monitor Resident #41 for side effects of the antidepressant medication, Duloxetine (used to treat depression). These failures could place the residents at risk for adverse consequences and decline in health. Findings include: Record review of Resident #41's face sheet, dated 06/09/25, indicated Resident #41 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #41 had diagnoses which included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (disorder of persistently depressed mood or loss of interest in activities causing significant impairment in daily life) and anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #41's significant change in status MDS assessment, dated 03/29/25, with a BIMS score of 6, which indicated severely impaired cognition with diagnoses which included bipolar disorder, depression and anxiety. The assessment indicated she received antidepressant medication for the last 7 days. Record review of Resident #41's MAR, dated 06/10/25, indicated Resident #41 received duloxetine 30 mg daily for bipolar disease with a start date of 04/21/25. Record review of Resident #41's physician orders, dated 06/11/25, indicated Resident #41 was prescribed duloxetine 30 mg daily for bipolar disease with a start date of 04/21/25. The orders did not address monitoring the antidepressant medication for side effects. Record review of Resident #41's care plan, with a target date of 06/25/25, indicated Resident #41 was prescribed the antidepressant medication duloxetine with interventions which included administer antidepressant medication as ordered by physician and monitor, document side effects and effectiveness every shift. Record review of Resident #41's electronic medical record, from 05/01/25 to 06/11/25, for Resident #41 did not indicate the nurses' documented monitoring of side effects of the antidepressant medication, duloxetine daily with medication administration. During an observation and interview on 06/11/25 at 8:45 a.m., Resident #41 was lying in bed and nodded in agreement that she received needed medication, received antidepressant medication but was unsure if was monitored for side effects. During an interview on 06/11/25 at 8:46 a.m., LVN B said she was providing care for Resident #41 today, but CMA C gave Resident #41's duloxetine. She said it should be monitored for side effects and documented and was not in the documentation. LVN B said the nurses were responsible for ensuring side effect monitoring was added to the computer system and the ADON was the back up. She said she was in-serviced on and was aware antidepressant medication should be monitored for side effects. She said Resident #41's was overlooked. LVN B said the resident risk was the staff could miss behaviors or side effects if not monitored. During an interview on 06/11/25 at 8:50 a.m., CMA C said Resident #41 should be monitored for side effects for the duloxetine with the medication administrator but was not. She said she was responsible for providing medication to Resident #41 today and her duloxetine should be monitored for side effects but was not. She said the nurses were responsible for adding side effect monitoring to the computer system and the ADONs and DON were the back up to double check. She said Resident #41's side effect monitoring was overlooked. CMA C said she was educated on monitoring antidepressant medication for side effects. She said she gave Resident #41 medication which included duloxetine on 06/06/25, but had not given the duloxetine yet today. CMA C said the resident risk of a resident given an antidepressant medication and not monitored for side effects was the resident could get worse and more depressed. During an interview on 06/11/25 at 9:14 a.m., the DON said Resident #41's antidepressant medication should have been monitored for side effects when the medication was given to the resident. She said LVN A added it after state surveyor intervention. The DON said the nursing who admitted the resident was responsible for addition of side effect monitoring into the computer system and the ADONs were the back up. She said LVN D admitted resident #41 and was responsible, and ADON A was the back up. She said the ADON's ran daily reports to check for new medications, consents and side effect monitoring and did monthly monitoring charts for accuracy of orders. She said Resident #41 was overlooked. The DON said the resident risk was possible not capturing adverse reactions and not immediate intervention to a reaction. She said the side effect monitoring queued the nurses with specific side effects to monitor. The DON said her expectation was daily monitoring of psychotropic medication (drugs that affect mental processes and behaviors and often used to treat mental illness) and any noted side effect and addressed immediately. During an interview on 06/11/25 at 9:23 a.m., ADON A said the nurse who admitted the resident or wrote the order for the psychotropic medication was responsible for addition of the side effect monitoring into the computer system and the ADON was responsible for the resident's Hall she was admitted and for double checking for monitoring. She said she was responsible for hall 200 and memory care residents. ADON A said she was responsible for ensuring Resident #41's monitoring was added for her antidepressant medication. She said the antidepressant monitoring dropped off when the resident readmitted on [DATE] and was not added back into the computer system. She said she ran reports daily to ensure all new medication was reviewed and had monitoring as needed. ADON A said all the nurses were educated on monitoring antidepressant medication for side effects. She said the resident risk of an antidepressant medication not monitored for side effects was staff may not be aware of the specific side effects to monitor for, a side effect could go unnoticed, and the resident may not receive needed interventions for side effects. During an interview on 06/11/25 at 9:47 a.m., LVN D said she readmitted Resident #41 from the hospital on [DATE]. She said the ADON and DON were responsible to ensure all antidepressant medication was monitored for side effects. LVN D said she was educated on side effect monitoring and aware all antidepressant medication should be monitored. She said she did not know how to add side effect monitoring into the computer system but would find out immediately. LVN D said the resident risk was without a specific list of side effects to be monitored a resident could have side effects the nurse could be unaware and may not address the side effect. During an interview on 06/11/25 at 10:00 a.m., the Administrator said the charge nurses were responsible for entering the side effect monitoring into the computer system for psychotropic medication and the ADON and DON were responsible for double checking to ensure side effects were monitored. All the nurses were educated on monitoring psychotropic medication for side effects. He said Resident #41's was overlooked. The Administrator said the resident risk of an antidepressant medication not monitored for side effects was it could possibly affect other medication or cause side effects that may not be treated if staff were unaware of them. The Administrator said his expectation was all psychotropic medication was monitored as required. Record review of the facility's, undated, policy titled, Psychoactive Medication Management Program indicated, . 3. Implement the behavior monitoring / side effects monitoring in PCC on the MAR for psychoactive medications with the target behaviors or not behaviors observed.

Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 5 medication carts (Station 2 Nurse Cart) reviewed for medication storage. The facility failed to ensure Station 2 Nurse Cart did not contain loose pills This failure could place residents at risk of adverse reactions to medications, misappropriation of medications and injury. Findings include: In an observation and interview on 06/10/25 at 12:45 p.m., revealed inventory of the Hall A & B Nurse Cart with LVN S had 16 loose pills. LVN S said nursing staff were expected to check their carts daily as used for inappropriately labeled medication or lose pills. She said all medications were expected to be packaged in the original pharmacy packaging containing all the required pharmacy labels or in the OTC stock bottles to ensure patient safety. She said if mistakenly administered, loose pills could place residents at risk of disastrous side effects since their identification was unknown so they must be crushed and discarded in the sharp's container. In an interview on 06/10/25 at 2:40 p.m., the DON said nursing staff were expected to check their carts daily for loose pills and inappropriately labeled medications. The ADON said all medications should be stored in their original containers. She said loose pills could place residents at risk of adverse reactions, infection from contamination or uncontrolled health conditions. Record review of the facility's policy Administering Medications, revised 10/01/19, read in part: .10. the licensed nurse or medication aide should maintain a clean top surface on the medication cart while passing medications and clean and replenish the medication cart after each use equipment and supplies relating to medication administration are clean and orderly

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 24 hours to the State Agency after Family Member B alleged Resident #1 was neglected on 04/10/25. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 04/16/25 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included diabetes (high blood sugar levels), metabolic encephalopathy (brain dysfunctions due to problems with metabolism), aphasia (disorder that affects communication), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing), and gastrostomy (artificial external opening into the stomach). Record review of a grievance dated 04/10/25 indicated Resident #1's Family Member B alleged neglect due to Resident #1's change of condition. Record review of the facility's undated print-out from TULIP indicated there was no date or time available to confirm the date of the facility's report submission. Record review of the facility's TULIP account indicated there was no report of neglect dated 04/10/25, 04/11/25, 04/12/25, 04/13/25, or 04/14/25. During an interview on 04/16/25 at 9:37 a.m., the DON said the Administrator was the abuse coordinator. She said she was notified by LVN A at approximately 7:15 p.m. on 04/10/25 of the allegation of staff neglect for not suctioning Resident #1. The Administrator made the report in TULIP on 04/10/25 at 7:23 p.m. She said when the facility attempted to obtain the intake number for the 5-day report, HHSC indicated there was no report. She said the facility was advised to re-report the allegation on 04/15/25. The DON said the facility addressed the allegation of neglect with a resolved grievance dated for 04/10/25 that indicated Resident #1 did not have a tracheostomy (a surgically created hole, also called a stoma, in the windpipe) and there were no orders for suctioning. During an interview on 04/16/25 at 2:22 pm. the Administrator said he completed the report of neglect for Resident #1 in TULIP, printed out the pages of the report from TULIP, and then submitted the report on 04/10/25. He said he printed out the pages of the report prior to submitting because after submitting the report, it was not possible to print. He said he waited at the facility until late on 04/10/25 to receive an intake number but did not receive. It. He said he became aware the report did not get submitted on 04/10/25 as required when the facility was completing the 5 day report for submission. He said the facility was informed there was no report or intake number and the facility would have to re-report. He said the facility made a second report of the allegation of neglect for Resident #1 on 04/15/25. He said he did not check with HHSC after 04/10/25 to ensure the first report was received. During an interview on 04/16/25 at 2:39 p.m., LVN A said said she received a call from Family Member B on 04/10/25 (after 6:00 p.m.). She said Family Member B alleged neglect and she immediately notified the DON per facility policy. Record review of the facility's Abuse, neglect and Exploitation policy dated 08/15/22 indicated .Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to thoroughly investigate and have evidence that all alleged violations were thoroughly investigated and/or prevent further potential abuse for 2 of 2 residents (Residents #1 and #2) reviewed for allegations of abuse or neglect. The facility failed to conduct a thorough investigation when Resident #1 alleged CNA A wanted to be intimate approximately in October 2024. The facility failed to conduct a thorough investigation when an unknown staff alleged CNA B caused Resident #2 injury during care November 26, 2024. An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. While the IJ was removed on 02/07/25 at 3:15 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 02/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE], and her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) affecting left non-dominant side, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, had moderate impaired cognition (BIMS 11), had verbal behaviors directed at others (behavior of this type occurred 4-6 days but less than daily). Record review of Resident #1's care plan dated 06/19/24 indicated Resident #1 made false allegations against staff stating, I will get y'all fired and makes false allegations to get things she needs. Interventions included administer medications as ordered, anticipate, and meet Resident #1's needs, provide opportunity for positive interactions, and monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of TULIP on 02/04/25 indicated there was no facility investigation report for Resident #1's allegation of sexual abuse. 2. Record review of Resident #2's face sheet dated 02/05/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that covers and protects the brain) with loss of consciousness, bipolar disorder (mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, was cognitively intact (BIMS-13), and had no behaviors. Record review of Resident #2's x-ray dated 12/05/24 indicated chronic left femur fracture. Record review of Resident #2's progress note dated 11/27/24, at 12:26 p.m., completed by the DON indicated the DON and Administrator C spoke with Resident #2 on 11/26/24 (specific time not documented). Resident #2 indicated CNA B performed incontinent care and he heard a pop. He said it occurred about 1 week ago. CNA B said she was not assigned to Resident #2. Resident #2 was moved to his current room [ROOM NUMBER]/12/24 and CNA B was not assigned to that room. CNA B stated she and CNA J gave him a shower on Monday (date not documented) with no complaints and CNA B did not hear a pop. Resident #1 stated nothing had happened intentionally. Record review of TULIP on 02/04/25 indicated there was no facility investigation report for Resident #2's allegation of harm. During an interview on 02/04/25 at 11:36 a.m., Resident #2 said CNA B was providing care and he heard a pop. He said CNA B broke his leg, but it was not on purpose. He said CNA B was not mean or rough during care. He said CNA B did not do it on purpose. He said he had pain before and after he heard the pop. He said he received pain medication for his pain. During confidential interview on 02/04/25 at 3:19 p.m., the surveyor was informed Resident #2 said CNA B broke his leg. The surveyor was also informed ADON A said the allegation of harm was investigated and it was not intentional but Resident #2 repeated she broke my leg but not on purpose. CNA B was not suspended, and Resident #2 did not want her providing his care. During an interview on 02/04/25 at 4:00 p.m., ADON A said Resident #2 alleged CNA B broke his leg. She said she told Administrator C about Resident #2's allegation that CNA B broke his leg. She said Resident #2 said he did not want CNA B providing his care. She said she thought the allegation was reported to HHS by Administrator C. She said she heard of the allegation of sexual abuse from Resident #1 against CNA A during a morning meeting. She could not recall the date of the meeting. She said Resident #1 was moved to a different hall and room. She said the allegation of sexual abuse was reportable to HHS. She said CNA A was suspended due to Resident #1's allegations. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/04/25 at 4:25 p.m., the DON said an allegation of abuse was not reported to HHS regarding CNA B because Resident #2 said she was not mean or rough and did not mind if CNA B took care of him. She said Resident #1 said she did not like CNA A from a previous facility. She said Resident #1 said CNA A wanted her to put on lipstick and put it on his privates. She said she did not report the allegations because Resident #1 said it happened at another facility. She said CNA A continued to work at the facility until he was terminated on 11/14/24 for insubordination and threatening behavior towards other staff. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/05/25 at 9:24 a.m., CNA B said she and CNA J had bathed Resident #2 in bed as he usually was bathed. She said it was a few days before the DON asked her if Resident #2 complained of pain and she told the DON Resident #2 did not complain of pain. She said she heard Resident #2 said he heard a pop but had told the DON she and CNA J had not done anything, that it had just happened. She said she would have reported immediately to the charge nurse if Resident #2 had complained of pain or if she had heard a pop during care. She said she was never suspended or informed there was an investigation related to Resident #2's injury. During an interview on 02/05/25 at 1:54 p.m., the SW said Resident #1 reported CNA wanted her to give him oral sex. She said she did not recall what day or time Resident #1 made the allegation. She said she did not document Resident #1's allegation. She said she did not report the allegation to the administrator, DON, or HHS because Resident #1's behaviors included telling lies on staff to get them fired. She said she was trained on abuse, abuse prevention, and reporting allegations. She said she was aware all allegations were reportable to the administrator immediately and to HHS within two hours. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 7:35 a.m., the DON said she could not recall who reported CNA B provided care to Resdient #2 and hurt his leg. She said she could not recall the exact words the reporter used or what day the allegation was reported. She said Resident #2 was interviewed on 11/26/24 and he said there was no intentional abuse. She said Resident #2 said he heard a pop during care. She said Resident #2 was diagnosed with a chronic fracture to his femur on 12/05/24. During an interview on 02/06/25 at 10:20 a.m., Administrator C said he had been employed with the facility for a few days in November 2024, when a staff (he could not recall who the staff was) had reported CNA B had provided care to Resident #2 and caused Resident #2 harm. He said he was not familiar with the residents and asked the DON to accompany him to interview Resident #2. He said Resident #2 said CNA B provided care and he heard a pop. He said Resident #2 did not alleged abuse and denied CNA B had cause him harm intentionally. He said he was aware all allegations of abuse were reportable with two hours to HHS. He said he should have reported the allegation of harm as abuse, suspended CNA B and investigated. During an interview on 02/06/25 at 10:55 a.m., LVN J said Resident #1 had reported a male staff had done something to her. She said she could not recall the exact date. She said it was at the end of September 2024 or beginning of October 2024. She said interim Administrator D was dealing with the allegation and it was the reason Resident #1's room was moved to a different hall. LVN J said she was making rounds (she could not recall the date or time) when Resident #2 reported his leg hurt because someone had dropped him. She said she reported the allegation to interim Administrator D. She said she believed the complaint was being addressed. During an interview on 02/06/25 at 12:45 p.m., interim Administrator D said he was not aware of Resident #1's allegation of sexual abuse against CNA A. He said if he were made aware, CNA A would have been immediately suspended and he would have reported to HHS within 2 hours as required. He said he could not recall an allegation Resident #2 reported of a staff breaking his leg during care. During an interview on 02/06/25 at 4:18 p.m., CNA A said he was suspended for a day due to allegations of sexual abuse. He said he could not recall the day he was suspended. He said he could not recall which staff advised him of the suspension. He said Resident #1 was moved to a different hall and he was advised to not go in her room or provide her care. He denied the allegation he told Resident #1 to suck his dick. He said Resident #1 had a behavior of telling lies on staff to get them fired when she did not like the staff. During interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A told her he wanted her to suck his dick. She said she told interim Administrator D, the DON, and the SW. She said she moved to another room on another hall. She said it was not right for CNA A to tell her he wanted her to suck his dick. She said she moved from the facility and was happier in the new facility. During an interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A wanted her to suck his dick. She said CNA A kept asking her to be intimate. She said he should not have been asking her for sex. She said she told the facility manager about CNA A asking her to have oral sex, but she could not recall his name. She said she could not remember the date she reported the allegation. She said she also reported the allegation to the SW but could not remember her name or when she reported the allegation to the SW. She said she was moved to another room on a different hall. She said she later moved to a different facility and was happy and safe at the new facility. Record review of CNA A's employee file indicated there was no suspension August through October 2024 related to the allegations of sexual abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: .1. Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) withing specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.5. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur 6. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation This was determined to be an Immediate Jeopardy (IJ) on 02/06/25. The facility's Administrator, the VPO, and the RCS were notified. The Administrator was provided with the IJ template on 02/06/25 at 11:48 a.m. The following POR was accepted on 02/06/25 at 7:43 p.m.: Done for those affected: Resident #1 was discharged from the facility on 10/24/2024. An Allegation of Abuse was reported to HHSC for Resident #1 on 2/05/2025. On 2/5/2025, the Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/5/2025, Resident #2 was interviewed regarding abuse and neglect with no reports and/ or allegations of being abused and/ or neglected. On 2/6/2025, Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted. An allegation of abuse was reported to HHSC for Resident #2 on 2/6/2025. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2. Identify residents who could be affected: Beginning 2/05/2025, the Administrator and/ or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified. Date of completion was 2/06/2025. Beginning 2/05/2025, head to toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/ or evidence of abuse, neglect and mistreatment with no concerns identified. Date of completion was 2/06/2025. Beginning 2/05/2025, the Administrator and/ or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted. Date of completion was 2/06/2025. On 2/06/2025, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/ or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified. Date of completion was 2/06/2025. On 2/06/2025, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Date of completion was 2/06/2025. On 2/06/2025, the Administrator and/or Designee reviewed resident grievances in the last 30 days to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified. Date of completion was 2/06/2025. Systemic Process: On 02/06/2025, the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Beginning 02/05/2025, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Effective 2/05/2025, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. To monitor, the Administrator and/ or designee and Director of Nursing/ designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday - Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head to toe assessments were completed and provided. The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided. Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. The facility has the [facility] Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/ concerns will be reported to the Administrator/ Abuse Coordinator immediately. Monitoring: An AdHoc QAPI was conducted on 2/06/2025, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 610 - thoroughly investigate allegations of sexual and physical abuse and implement interventions to prevent the potential for further abuse from occurring while the investigation was in progress and develop the above Action Plan. The surveyors monitored the POR on 02/07/25 as followed: During an interview on 02/07/25 at 11:30 a.m., Resident #2 indicated he was not abused and felt safe in the facility. He said he would report all abuse to the charge nurse and the Administrator. During interviews on 02/07/25 from 8:30 a.m. - 2:30 p.m. Administrator C, 2 ADONs (ADON F and ADON G), 11 CNAs (CNA B, CNA H, CNA J, CNA U, CNA V, CNA W, CNA Y, CNA AA, CNA DD, CNA EE), 5 LVNs ( LVN K, LVN M, LVN N, LVN P, LVN BB), 1 ( LVN/treatment nurse Q), 3 MA (MA L, MA R, MA MM), 1 dietary staff (DM X), 1 housekeeping staff (HSK GG ), 2 activities staff (Activity Director HH and Activity aide JJ , 2 nurse aides (NA S, NA T) and 1 Physical Therapists (PT NN), who represented all shifts (6:00 a.m. -6:00 p.m., 6:00 p.m. - 6:00 a.m., 6:00 a.m. -2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m.) said they were in-serviced and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, emotional abuse, and sexual abuse. They were aware of the importance of reporting alleged abuse immediately. They knew where the corporate compliance hotline number was posted and when to contact, as necessary. During interviews on 02/07/25 from 8:00 a.m. - 2:30 p.m. with alert and oriented (Residents #2, #5, #6, #7, #8, #9, #10, #11, #12) indicated they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. They would report abuse or neglect to the administrator or the DON. During an interview on 02/07/25 at 7:35 a.m., the DON said she was given one-on-one in-service with the VPO and the RCS regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse were reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 02/07/25 at 2:30 p.m., Administrator C said said he was in-serviced one-on-one with the VPO and the RCS regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 75% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record review of Resident #1's closed clinical chart indicated she was discharged from the facility on 10/24/2024. Record review of CNA A's personnel file indicated he was terminated on 11/14/24 for insubordination and threatening behavior. Record review of TULIP on 02/07/25 indicated an allegation of abuse was reported to HHSC for Resident #1 on 2/05/25. Record review of the the SW's personnel record indicated she was suspended as of 02/05/25, pending investigation outcome related to the allegation of sexual abuse for Resident #1. Record review of the DON's personnel file indicated she was suspended on 02/06/25 pending investigation outcome related to the allegation of sexual abuse for Resident #1. The DON resigned from the facility effective 02/07/25. Record review of TULIP 02/07/25 indicated an allegation of Resident Neglect was reported to HHSC for Resident #2 on 02/06/25. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending the investigation outcome related to the allegation of abuse for Resident #2. Record review of Administrator C's personnel file on 02/07/25 indicated he was suspended on 02/06/25, pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, CNA B was suspended pending investigation outcome related to the allegation of neglect for Resident #2. Record review of head to toe assessments completed by the facility on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment indicated no concerns were identified. Record review of resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension indicated no concerns were identified. Record review of incident/accidents from 01/06/25 -02/06/25 indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review of grievances from 01/06/25-02/06/25, indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review dated 02/06/25, indicated the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Record review dated 02/05/25, 02/06/25 and 02/07/25 indicated 75% of facility staff were re-educated by the Administrator, the DON and/or designee on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Record review of morning meeting minutes, the 24-hour report, and resident incidents dated 02/07/25 indicated there were no additional concerns identified related to abuse or neglect. Record review of monitoring sheets dated 02/07/25 indicated there were no concerns reported by [facility] Ambassadors . Administrator C, the VPO, and the RCS were informed the Immediate Jeopardy was removed on 02/07/25 at 3:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator or HHSC and failed to ensure that all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or neglect resulting in serious bodily injury, to the State Survey Agency, 2 of 2 residents (Residents #1 and #2) reviewed for reporting allegations of abuse or neglect. 1. The SW did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted to be intimate with her. The DON did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted her to put on her new lipstick and and put it on him (Resident #1 looked toward her private area) 2. Administrator C and the DON did not report an allegation of abuse or neglect to HHSC after they were informed Resident #2 indicated CNA B injured his leg during care in November 2024 . An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. While the IJ was removed on 02/07/25 at 3:15 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 02/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE], and her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) affecting left non-dominant side, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, had moderate impaired cognition (BIMS 11), and had verbal behaviors directed at others (behavior of this type occurred 4-6 days but less than daily). Record review of Resident #1's care plan dated 06/19/24 indicated Resident #1 made false allegations against staff stating, I will get y'all fired and makes false allegations to get things she needs. Interventions included administer medications as ordered, anticipate, and meet Resident #1's needs, provide opportunity for positive interactions, and monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of TULIP on 02/04/25 indicated there was no facility report for Resident #1's allegation of sexual abuse. 2. Record review of Resident #2 face sheet dated 02/05/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that covers and protects the brain) with loss of consciousness, bipolar disorder (mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, was cognitively intact (BIMS-13), and had no behaviors. Record review of Resident #2's x-ray dated 12/05/24 indicated chronic left femur fracture. Record review of Resident #2's progress note dated 11/27/24, at 12:26 p.m., completed by the DON indicated the DON and Administrator C spoke with Resident #2 on 11/26/24 (specific time not documented). Resident #2 indicated CNA B performed incontinent care and he heard a pop. He said it occurred about 1 week ago. CNA B said she was not assigned to Resident #2. Resident #2 was moved to his current room [ROOM NUMBER]/12/24 and CNA B was not assigned to that room. CNA B stated she and CNA J gave him a shower on Monday (date not documented) with no complaints and CNA B did not hear a pop. Resident #2 stated nothing had happened intentionally. Record review of TULIP on 02/04/25 indicated there was no facility report for Resident #2's allegation of harm. During an interview on 02/04/25 at 11:36 a.m., Resident #2 said CNA B was providing care and he heard a pop. He said CNA B broke his leg, but it was not on purpose. He said CNA B was not mean or rough during care. He said CNA B did not do it on purpose. He said he had pain before and after he heard the pop. He said he received pain medication for his pain. During an interview on 02/04/25 at 1:46 p.m., previous Administrator E said she was no longer employed at the facility by mid-August 2024. She said she was not made aware of any allegations of sexual abuse made by Resident #1 against CNA A. During confidential interview on 02/04/25 at 3:19 p.m., the surveyor was informed Resident #2 said CNA B broke his leg. The surveyor was also informed ADON A said the allegation of harm was investigated and it was not intentional but Resident #2 repeated she broke my leg but not on purpose. CNA B was not suspended, and Resident #2 did not want her providing his care. During an interview on 02/04/25 at 4:00 p.m., ADON A said Resident #2 alleged CNA B broke his leg. She said she told Administrator C about Resident #2's allegation that CNA B broke his leg. She said Resident #2 said he did not want CNA B providing his care. She said she thought the allegation was reported to HHS by Administrator C. She said she heard of the allegation of sexual abuse from Resident #1 against CNA A during a morning meeting. She could not recall the date of the meeting. She said Resident #1 was moved to a different hall and room. She said the allegation of sexual abuse was reportable to HHS . She said CNA A was suspended due to Resident #1's allegations. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/04/25 at 4:25 p.m., the DON said an allegation of abuse was not reported to HHS regarding CNA B because Resident #2 said she was not mean or rough and did not mind if CNA B took care of him. She said Resident #1 said she did not like CNA A from a previous facility. She said Resident #1 said CNA A wanted her to put on lipstick and put it on his privates. She said she did not report the allegations because Resident #1 said it happened at another facility. She said CNA A continued to work at the facility until he was terminated on 11/14/24 for insubordination and threatening behavior towards other staff. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/05/25 at 9:24 a.m., CNA B said she and CNA J had bathed Resident #2 in bed as he usually was bathed. She said it was a few days before the DON asked her if Resident #2 complained of pain and she told the DON Resident #2 did not complain of pain. She said she heard Resident #2 said he heard a pop but had told the DON she and CNA J had not done anything, that it had just happened. She said she would have reported immediately to the charge nurse if Resident #2 had complained of pain or if she had heard a pop during care. She said she was never suspended or informed there was an investigation related to Resident #2's injury. During an interview on 02/05/25 at 1:54 p.m., the SW said Resident #1 reported CNA A wanted her to give him oral sex. She said she did not recall what day or time Resident #1 made the allegation. She said she did not document Resident #1's allegation. She said she did not report the allegation to the administrator, DON, or HHS because Resident #1's behaviors included telling lies on staff to get them fired. She said she was trained on abuse, abuse prevention, and reporting allegations. She said she was aware all allegations were reportable to the administrator immediately and to HHS within two hours. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 7:35 a.m., the DON said she could not recall who reported CNA B provided care to Resident #2 and hurt his leg. She said she could not recall the exact words the reporter used or what day the allegation was reported. She said Resident #2 was interviewed on 11/26/24 and he said there was no intentional abuse. She said Resident #2 said he heard a pop during care. She said Resident #2 was diagnosed with a chronic fracture to his femur on 12/05/24. During an interview on 02/06/25 at 10:20 a.m., Administrator C said he had been employed with the facility for a few days in November 2024, when a staff (he could not recall who the staff was) had reported CNA B had provided care to Resident #2 and caused Resident #2 harm. He said he was not familiar with the residents and asked the DON to accompany him to interview Resident #2. He said Resident #2 said CNA B provided care and he heard a pop. He said Resident #2 did not alleged abuse and denied CNA B had cause him harm intentionally. He said he was aware all allegations of abuse were reportable with two hours to HHS. He said he should have reported the allegation of harm as abuse, suspended CNA B and investigated. He said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 10:55 a.m., LVN J said Resident #1 had reported a male staff had done something to her. She said she could not recall the exact date. She said it was at the end of September 2024 or beginning of October 2024. She said interim Administrator D was dealing with the allegation and it was the reason Resident #1's room was moved to a different hall. LVN J said she was making rounds (she could not recall the date or time) when Resident #2 reported his leg hurt because someone had dropped him. She said she reported the allegation to interim Administrator D. She said she believed the complaint was being addressed. During an interview on 02/06/25 at 12:45 p.m., interim Administrator D said he was not aware of Resident #1's allegation of sexual abuse against CNA A. He said if he were made aware, CNA A would have been immediately suspended and he would have reported to HHS within 2 hours as required. He said he could not recall an allegation Resident #2 reported of a staff breaking his leg during care or being dropped. During an interview on 02/06/25 at 4:18 p.m., CNA A said he was suspended for a day due to allegations of sexual abuse. He said he could not recall the day he was suspended. He said he could not recall which staff advised him of the suspension. He said Resident #1 was moved to a different hall and he was advised to not go in her room or provide her care. He denied the allegation he told Resident #1 to suck his dick. He said Resident #1 had a behavior of telling lies on staff to get them fired when she did not like the staff. During an interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A wanted her to suck his dick. She said CNA A kept asking her to be intimate. She said he should not have been asking her for sex. She said she told the facility manager about CNA A asking her to have oral sex, but she could not recall his name. She said she could not remember the date she reported the allegation. She said she also reported the allegation to the SW but could not remember her name or when she reported the allegation to the SW. She said she was moved to another room on a different hall. She said she later moved to a different facility and was happy and safe at the new facility. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: .1. Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) withing specified timeframes: a. Immediately, but not later than2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. This was determined to be an Immediate Jeopardy (IJ) on 02/06/25. The facility's Administrator, the VPO, and the RCS were notified. The Administrator was provided with the IJ template on 02/06/25 at 11:48 a.m. The following POR was accepted on 02/06/25 at 7:43 p.m.: The Administrator C and DON on 11/26/24 spoke to Resident #2 regarding a negative comment about C.N.A. B causing an injury during care of possible abuse or neglect. Resident #2 later assessed to have a femur fracture. Done for those affected: Resident #1 was discharged from the facility on 10/24/2024. An Allegation of Abuse was reported to HHSC for Resident #1 on 2/05/2025. On 2/5/2025, the LBSW Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/5/2025, Resident #2 was interviewed regarding abuse and neglect with no reports and/ or allegations of being abused and/ or neglected. On 2/6/2025, Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted. An allegation of abuse was reported to HHSC for Resident #2 on 2/6/2025. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2. Identify residents who could be affected: Beginning 2/05/2025, the Administrator and/ or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified. Date of completion is 2/06/2025. Beginning 2/05/2025, head-to-toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/ or evidence of abuse, neglect and mistreatment with no concerns identified. Date of completion was 2/06/2025. Beginning 2/05/2025, the Administrator and/ or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted. Date of completion was 2/06/2025. On 2/06/2025, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/ or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified. Date of completion is 2/06/2025. On 2/06/2025, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Date of completion is 2/06/2025. On 2/06/2025, the Administrator and/or Designee reviewed resident grievances in the last 30 days to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified. Date of Completion: 02/06/2025. Systemic Process: On 02/06/2025, the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Beginning 02/05/2025, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Date of Completion: 02/06/2025. Effective 2/05/2025, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday-Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head-to-toe assessments were completed and provided. The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided. Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. The facility has the [facility] Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/ concerns will be reported to the Administrator/ Abuse Coordinator immediately. Monitoring: An AdHoc QAPI was conducted on 2/06/2025, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 609 - Immediate reporting of allegations of abuse, neglect, and exploitation and misappropriation of resident property and develop the above Action Plan. The surveyors monitored the POR on 02/07/25 as followed: During an interview on 02/07/25 at 11:30 a.m., Resident #2 indicated he was not abused and felt safe in the facility. He said he would report all abuse to the charge nurse and the Administrator. During interviews on 02/07/25 from 8:30 a.m. - 2:30 p.m. Administrator C, 2 ADONs (ADON F and ADON G), 11 CNAs (CNA B, CNA H, CNA J, CNA U, CNA V, CNA W, CNA Y, CNA AA, CNA DD, CNA EE), 5 LVNs ( LVN K, LVN M, LVN N, LVN P, LVN BB), 1 ( LVN/treatment nurse Q), 3 MA (MA L, MA R, MA MM), 1 dietary staff (DM X), 1 housekeeping staff (HSK GG ), 2 activities staff (Activity Director HH and Activity aide JJ , 2 nurse aides (NA S, NA T) and 1 Physical Therapists (PT NN), who represented all shifts (6:00 a.m. -6:00 p.m., 6:00 p.m. - 6:00 a.m., 6:00 a.m. -2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m.) said they were in-serviced and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, emotional abuse, and sexual abuse. They were aware of the importance of reporting alleged abuse immediately. They knew where the corporate compliance hotline number was posted and when to contact, as necessary. Interviews conducted on 02/07/25 from 8:00 a.m. - 2:30 p.m. with 9 residents who were alert and oriented (Residents #2, #5, #6, #7, #8, #9, #10, #11, #12) indicated they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. They would report abuse or neglect to the administrator or the DON. During an interview on 02/07/25 at 7:35 a.m., the DON said she was given one-on-one in-service with the VPO and the RCS regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse were reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 02/07/25 at 2:30 p.m., Administrator C said said he was in-serviced one-on-one with the VPO and the RCS regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 75% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record review of Resident #1's closed clinical chart indicated she was discharged from the facility on 10/24/24. Record review of CNA A's personnel file on 02/07/25 indicated he was terminated on 11/14/24 for insubordination and threatening behavior. Record review of TULIP on 02/07/25 indicated an allegation of abuse was reported to HHSC for Resident #1 on 2/05/25. Record review of the the SW's personnel record on 02/07/25 indicated she was suspended as of 02/05/25, pending investigation outcome related to the allegation of sexual abuse for Resident #1. She was terminated on 02/07/25 for failure to report an allegation of sexual abuse. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending investigation outcome related to the allegation of sexual abuse for Resident #1. The DON resigned from the facility effective 02/07/25. Record review of TULIP 02/07/25 indicated an allegation of Resident Neglect was reported to HHSC for Resident #2 on 02/06/25. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending the investigation outcome related to the allegation of abuse for Resident #2. Record review of Administrator C's personnel file on 02/07/25 indicated he was suspended on 02/06/25, pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, CNA B was suspended pending investigation outcome related to the allegation of neglect for Resident #2. Record review of head-to-toe assessments completed by the facility on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment indicated no concerns were identified. Record review of resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension indicated no concerns were identified. Record review of incident/accidents from 01/06/25 -02/06/25 indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review of grievances from 01/06/25-02/06/25, indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review dated 02/06/25, indicated the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Record review dated 02/05/25, 02/06/25 and 02/07/25 indicated 75% of facility staff were re-educated by the Administrator, the DON and/or designee on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Record review of morning meeting minutes, the 24-hour report, and resident incidents dated 02/07/25 indicated there were no additional concerns identified related to abuse or neglect. Record review dated 02/07/25 indicated there were no concerns reported by [facility] Ambassadors. Administrator C, the VPO, and the RCS were informed the Immediate Jeopardy was removed on 02/07/25 at 3:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure all alleged violations involving abuse or mistreatment were reported to the to the administrator of the facility and other State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 18 (Resident #1) residents reviewed for abuse and neglect. LVN A heard two episodes of what sounded like slapping sounds from Resident #1's room while CNA B was providing care on 06/29/23 at approximately 9:00 p.m. and did not immediately report the alleged abuse to the administrator. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of an MDS dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understands others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, char, wheelchair), and totally dependent of 1 person for toilet use. Record review of care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the Resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/13/23 at 11:15 a.m., the DON said the Administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/ or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This was effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 18 residents (Resident #1) reviewed for abuse. 1. The facility failed to ensure LVN A intervened and investigated when she heard two episodes of what sounded like slapping sounds while CNA B provided care to Resident #1 on 06/29/23. 2. LVN A did not remove CNA B from providing care to other residents leaving them at risk for abuse. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understood others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, chair, wheelchair), and totally dependent of 1 person for toilet use. Record review of Resident #1's care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. Record review Resident #1's progress note dated 06/30/23 at 9:30 a.m., completed by the DON, indicated there was an allegation of abuse involving Resident #1. CNA B was separated from resident via suspension pending outcome of investigation. All proper authorities were contacted. City Police department took Resident #1's statement. RP was notified of the incident. Record review of the facility investigation dated 07/07/23 indicated on 06/09/23 at approximately 9:00 p.m. LVN A was passing evening medications between rooms [ROOM NUMBERS]. CNA B was seen taking Resident #1 to her room and then she closed the door. Approximately two or three minutes later, LVN A indicated she heard five sounds like hand against skin, like spanking, then silence, no sounds followed, no one called out or other indications of concern. LVN A then finished administering medications. Approximately one minute later as she returned to her cart, she heard the same sound again like hand against skin. She then saw CNA B exit Resident #1's room. When CNA B exited Resident #1's room, she told LVN A Resident #1 was acting out. LVN A asked CNA B what she meant, and she said, Oh she's flopping around and won't let me change her, when I was trying to put her to bed. She then stated, I had to get with her. LVN A went to Resident #1's room to check on Resident #1. Resident #1 was lying in bed and LVN A leaned over and asked Are you about to go to sleep? Resident #1 was pouting. When asked what happened, Resident #1 responded pop. LVN A asked, Are you saying pop? Resident #1 nodded her head yes. LVN A asked Resident #1 who popped her. Resident #1 began looking at the door. LVN A closed the door and assured Resident #1 she was not in trouble and asked again Who popped you? Resident #1 responded girl. LVN A assessed Resident #1 and found no injuries. CNA B did not provide further care and left the facility. LVN A attempted to notify the DON. The DON received the information on the morning of 06/30/23. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the Administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened, and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/14/23 at 9:09 a.m., CNA B said she did the normal things to get Resident #1 ready for bed. She said she changed her brief and dressed her. She said Resident #1 turned over and watched TV. CNA B denied saying I had to get with her (Resident #1) to LVN A. She said she then took care of Resident #1's roommate, put the used briefs in a bag, and left the room. She said LVN A was at her cart and asked what was wrong. She said she replied she had to do it all by herself. She said she did it all by herself because everyone else was busy. She said she asked everyone one else for help. She said everyone else said they were busy. She said Resident #1 and her roommate were the last residents she provided care for, and she left the facility at approximately 10:00 p.m. on 06/29/23. CNA B said she had been working in the facility since March 2023 and was trained on abuse, neglect, and reporting. She said if LVN A heard sounds like slaps coming from Resident #1's room then she should have checked what was going on. She said she never slapped Resident #1. During an interview on 07/13/23 at 11:15 a.m., the DON said the Administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said CNA B was suspended on 06/30/23 pending the facility's investigation. She said the police were notified and were conducting their own investigation. The Administrator said CNA B was terminated on 07/05/23. She said facility staff were retrained on abuse, neglect, and reporting. She said she held an ad-hoc QAPI meeting on 06/30/23. She said the medical director was made aware of the incident and the QAPI meeting by phone. She said the facility had not completed all staff re-training on abuse, neglect, and reporting. She said she had not implemented a formal monitoring system to monitor the effectiveness of the retraining for abuse, neglect, and reporting. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. During an interview on 07/17/23 at 4:45 p.m., the SW said she interviewed Resident #1 regarding the allegation of abuse from staff. She said Resident #1 was not upset or angry except when CNA B's name was mentioned. She said Resident #1 was able to distinguish between named staff and only got upset when she mentioned CNA B. During an interview on 07/17/23 at 3:17 p.m., DP D said LVN A told him she heard two separate incidents of slapping sounds coming from Resident #1's room. He said she (LVN A) said she did not intervene or investigate the slapping sounds. He said his report had gone to the DA for consideration of possible charges of elder abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/ or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 18 Residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A reported immediately to the Administrator or DON or immediately sent CNA B home after hearing what sounded like slapping noises while CNA B provided care for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of an MDS dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understands others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, char, wheelchair), and totally dependent of 1 person for toilet use. Record review of care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. Record review of progress note dated 06/30/23 at 9:30 a.m., completed by the DON, indicated there was an allegation of abuse involving Resident #1. CNA B was separated from Resident via suspension pending outcome of investigation. All proper authorities were contacted. City Police department took Resident #1's statement. RP was notified of the incident. Record review of the facility investigation dated 07/07/23 indicated on 06/09/23 at approximately 9:00 p.m. LVN A was passing evening medications between rooms [ROOM NUMBERS]. CNA B was seen taking Resident #1 to her room and then she closed the door. Approximately two or three minutes later, LVN A indicated she heard five sounds like hand against skin, like spanking, then silence, no sounds followed, no one called out or other indications of concern. LVN A then finished administering medications. Approximately one minute later as she returned to her cart, she heard the same sound again like hand against skin. She then saw CNA B exit Resident #1's room. When CNA B exited Resident #1's room, she told LVN A Resident #1 was acting out. LVN A asked CNA B what she meant, and she said, Oh she's flopping around and won't let me change her, when I was trying to put her to bed. She then stated, I had to get with her. LVN A went to Resident #1's room to check on Resident #1. Resident #1 was lying in bed and LVN A leaned over and asked Are you about to go to sleep? Resident #1 was pouting. When asked what happened, Resident #1 responded pop. LVN A asked, Are you saying pop? Resident #1 nodded her head yes. LVN A asked Resident #1 who popped her. Resident #1 began looking at the door. LVN A closed the door and assured Resident #1 she was not in trouble and asked again Who popped you? Resident #1 responded girl. LVN A assessed Resident #1 and found no injuries. CNA B did not provide further care and left the facility. LVN A attempted to notify the DON. The DON received the information on the morning of 06/30/23. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the Resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/14/23 at 9:09 a.m., CNA B said she did the normal things to get Resident #1 ready for bed. She said she changed her brief and dressed her. She said Resident #1 turned over and watched TV. CNA B denied saying I had to get with her (Resident #1) to LVN A. She said she then took care of Resident #1's roommate, put the used briefs in a bag, and left the room. She said LVN A was at her cart and asked what was wrong. She said she replied she had to do it all by herself. She said she did it all by herself because everyone else was busy. She said she asked everyone one else for help. She said everyone else said they were busy. She said Resident #1 and her roommate were the last residents she provided care for, and she left the facility at approximately 10:00 p.m. on 06/29/23. CNA B said she had been working in the facility since March 2023 and was trained on abuse, neglect, and reporting. She said if LVN A heard sounds like slaps coming from Resident #1's room then she should have checked what was going on. She said she never slapped Resident #1. During an interview on 07/13/23 at 11:15 a.m., the DON said the administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said CNA B was suspended on 06/30/23 pending the facility investigation. She said the police were notified and were conducting their own investigation. The Administrator said CNA B was terminated on 07/05/23. She said facility staff were retrained on abuse, neglect, and reporting. She said she held an ad-hoc QAPI meeting on 06/30/23. She said the medical director was made aware of the incident and the QAPI meeting by phone. She said the facility had not completed all staff re-training on abuse, neglect, and reporting. She said she had not implemented a formal monitoring system to monitor the effectiveness of the retraining for abuse, neglect, and reporting. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. During an interview on 07/17/23 at 4:45 p.m., the SW said she interviewed Resident #1 regarding the allegation of abuse from staff. She said Resident #1 was not upset or angry except when CNA B's name was mentioned. She said Resident #1 was able to distinguish between named staff and only got upset when she mentioned CNA B. During an interview on 07/17/23 at 3:17 p.m., DP D said LVN A told him she heard two separate incidents of slapping sounds coming from Resident #1's room. He said she (LVN A) said she did not intervene or investigate the slapping sounds. He said his report had gone to the DA for consideration of possible charges of elder abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable was provided for 2 of 3 residents reviewed for pressure injuries. (Resident #s 3 and 6) The facility did not: * Assess, consult the facility physician (for five days), get a wound care consult as ordered, or provide wound care (for 9 days) for Resident #3's left bunion (joint at the base of the big toe) pressure injury found by the facility consultant podiatrist on 4/28/21. The resident was admitted to the hospital on 5/7/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had an amputation of his great toe on 5/13/21. * Assess, consult the physician, or treat Resident #6's sacral (area at the base of the spinal column) stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible but boned, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) until surveyor intervention on 5/11/21. An Immediate Jeopardy (IJ) situation was identified on 5/12/21. While the IJ was removed on 5/14/21, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-servicing and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and infection. Findings included: 1. A face sheet dated 5/11/21 indicated Resident #3 was a [AGE] year-old male, admitted [DATE], and discharged on [DATE] to a local hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had moderately impaired cognition, made his needs known, and understood others. Resident #3 required supervision from staff for bed mobility, transfers, dressing and personal hygiene. Resident #3 was independent for bathing. He was continent of bowel and bladder. Resident #3 was low risk of developing pressure injuries and had no unhealed pressure injuries. A care plan dated 3/17/21 indicated Resident #3 required limited assistance by one staff for showering Monday, Wednesday, and Friday on the 2-10 shift. The care plan indicated resident #3 required daily skin inspection. Staff were to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. A Braden scale for predicting pressure sore risk dated 4/11/21, indicated Resident #3 was low risk for developing pressure injuries. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 5/6/21 at 2:57 p.m., Resident #3 had an undated dressing on his left foot. The dressing had a compression bandage wrapped around the foot. There was a foul odor from the left foot. The bandage had drainage that seeped through the compression bandage. The resident was alert and said he had some pain in his foot. He said he had some pain medication. There were no documented skin assessments from 3/2/21 until 4/27/21 in the clinical record. During an interview on 5/7/21 at 12:46 p.m., the DON said there had not been a wound care nurse since 4/5/21. She said the facility hired a new wound care nurse who would be starting the next week. A weekly skin assessment dated [DATE], completed by LVN A, indicated Resident #3 had no new skin impairment. A hand-written note from the contract podiatrist regarding Resident #3 dated 4/28/21 indicated Please order wound care consult for evaluation and management of left foot ulcer. Ulcer location - left first metatarsal head (bunion area) are measures: 1.4cm x 1cm x 0.1cm. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 8:20 a.m., the DON said they have a meeting to go over telephone orders from the previous day every morning Monday through Friday. The MDS nurse hooks her computer up to the television and they review the orders. She said the order for Resident #3 somehow got missed. She said she keeps a notebook and keeps notes from the meetings. She said there were no notes regarding Resident #3 or the consult would not have been missed. During an interview on 5/11/21 at 5:33 p.m., LVN A said the contract podiatrist was at the facility on 4/28/21 to trim residents' toenails. She said the podiatrist stopped at the nurse station and handed her a hand-written note for Resident #3 to have a wound care consult. She said she did not look at the wound or assess the wound. She said the podiatrist did not give any wound care orders because she was not the resident's facility physician. She said she did not follow through with the wound care consult or call Resident #3's regular physician/nurse practitioner. She said she did not document in the progress note about the order. She said she did not look at Resident #3's feet when she did the skin assessment on 4/27/21. There was no treatment record for the month of April 2021 for Resident #3. The only documented wound care was on 5/7/21. During an interview on 5/7/21 at 4:45 p.m., NP C said she was first made aware of a wound on Resident #3's foot on 5/3/21 and ordered an x-ray of his foot. She first saw Resident #3's foot on 5/5/21. She said the dressing on his foot had a lot of drainage and had seeped through his sock. She said the resident said the dressing had been on his foot for a few days. NP C said the foot had a foul odor. NP C said Resident #3 had an MRI ordered because his x-ray showed possible [CONDITION(S)]. The MRI was completed on 5/7/21 and showed [CONDITION(S)]. She sent Resident #3 to the emergency room for evaluation due to the results of the MRI. A weekly skin evaluation dated 5/3/21, completed by LVN B, indicated Resident #3 had a new pressure ulcer. The description was for a wound care consult for the left foot ulcer to the left first metatarsal head area with the same wound measurements from the podiatrist on 4/28/21. During an interview on 5/13/21 at 12:55 p.m., LVN B said she did see Resident #3's foot on 5/3/21. She said it was bloody and had gone through his sock. She said she cleaned the wound and put a 4x4 gauze pad and tape over it. She said she did not measure the wound but used the measurements from the order on 4/28/21. LVN B called NP C who ordered an x-ray and arterial doppler. She said the x-ray company did not have an ultrasound technician to do the doppler. She called another company the next day on 5/4/21 and was told to send Resident #3's information to them and they would get him scheduled. LVN B said the NP C made her rounds on 5/5/21. She said NP C got the resident into their office for a visit with a different podiatrist and to have the doppler done. She said she did not do any other dressing changes on Resident #3's foot. LVN B said the DON had an in-service about a week or so earlier. She said the nurses were told they would need to help with doing the skin assessments. She said there was a schedule at the desk. The assessments were split between the 6-2 and 2-10 shift. She said she had not completed any skin assessments. A skin assessment dated [DATE], signed on 5/10/21 and completed by ADON E, indicated Resident #3's wound developed on 5/3/21. The assessment indicated the wound was on the left toe, was vascular and had the same measurements from the previous assessments. The assessment indicated there was a small amount of thin, watery, clear drainage, no odor, and had epithelial tissue (new pink or shiny). The notes/comments section indicated Resident #3's new ulcer was deteriorating, a wound consult was in place, and physician ordered IV antibiotics were in place. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 12:21 p.m., ADON E said she did not look at Resident #3's wound on 5/6/21 when she completed the skin assessment. She did not give a reason why she completed the assessment without looking at the resident. During an interview on 5/6/21 at 2:22 p.m., the DON said Resident #3 had gone to a podiatrist on 5/5/21 because he had a wound on the bottom of his foot. She said she had not seen the wound yet and had planned on doing his skin assessment on 5/6/21. During an interview on 5/6/21 at 12:47 p.m., DPM D said he had seen Resident #3 on 5/5/21. He said he had wanted him to go to the hospital for an MRI and IV antibiotics. He said he suspected Resident #3 had [CONDITION(S)]. He put a dressing on the resident's foot and wrapped it in a compression wrap. He said he stepped out of the exam room for a few minutes and the resident left. He had not given any wound care orders. There were no wound care orders for Resident #3's wound until 5/7/21 after surveyor asked to watch wound care. During an observation and interview on 5/7/21 at 10:23 a.m., Resident #3 had the same dressing from 5/6/21. LVN F removed the dressing from Resident #3's left foot. She said she had not seen the wound until that day. The gauze and gauze roll had yellow, red, and brown drainage. Resident #3's wound had an odor. The wound on the left bunion area was slightly larger than a quarter. The wound was mostly covered in black necrotic tissue. The resident's foot was swollen and warm to touch per LVN F. The resident winced in pain when LVN F lifted his foot. Resident #3 said his leg hurt half way up his shin. He said he did not feel good. He had not eaten his breakfast and did not feel like he was going to eat his lunch. A nurse note dated 5/7/21 at 11:25 a.m. indicated Resident #3 was sent to have an MRI of his left foot. A nurse note dated 5/7/21 at 8:46 a.m. indicated the hospital called to schedule Resident #3's MRI. The earliest appointment was scheduled for 5/13/21 at 8:30 a.m. Resident #3's family member was notified and said she was told by DPM D the MRI needed to be done 5/7/21. A nurse note dated 5/7/21 at 3:50 p.m. indicated Resident #3's MRI results showed [CONDITION(S)] of the left foot. Orders were received from NP C to send Resident #3 to the hospital. Resident #3 told staff he was too tired to go to the hospital and wanted to wait until the next morning. The facility called a family member who convinced the resident to go to the hospital. Physician documentation from the hospital dated 5/7/21 indicated Resident #3 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A discharge summary dated 5/15/21 indicated Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had an amputation of his great toe. 2. A face sheet dated 5/11/21 indicated Resident #6 was admitted [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident #6 had moderately impaired cognition, made her needs known, and usually understood others. Resident #6 required extensive assistance from two staff for bed mobility, transfers and bathing. She was incontinent of bowel and bladder. Resident #6 was at risk of developing pressure injuries and had no unhealed pressure injuries. A care plan dated 3/8/21 indicated Resident #6 required skin inspection daily and to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A skin assessment dated [DATE] completed by the previous treatment nurse indicated Resident #6 had a previous stage III wound on her coccyx (tailbone) had healed. Weekly skin evaluations dated 4/6/21, 4/13/21, 4/20/21, 4/27/21, and 5/4/21 indicated Resident #6 did not have any skin issues including pressure ulcers. A nurse noted dated 4/17/21 at 1:06 p.m., completed by LVN G, indicated Resident #6's family member called the nurse to the room to inquire about a wound on the resident's coccyx area. The nurse told the family member Resident #6 was going to the wound care center and being treated by the wound care nurse. A follow-up nurse note dated 4/17/21 at 1:42 p.m., completed by LVN G, indicated the LVN cleaned Resident #6's wound with wound cleanser, patted it dry, and covered the wound with a dry dressing. There was no assessment of the wound or physician notification documented. A nurse note dated 4/17/21 at 2:48 p.m., completed by LVN G, indicated she observed bruising on Resident #6's left elbow and arm. The nurse notified the NP and was told to monitor the arm. There was no mention of the open area on the resident's coccyx. A Braden Scale for Predicting Pressure Sore Risk dated 4/24/21 indicated Resident #6 was at risk for pressure ulcers. During an interview on 5/11/21 at 12:51 p.m., LVN G said she thought she had called the on-call person for the physician about Resident #6's wound. She said the ADON and administrator were aware of the wound because the resident's family member contacted the administrator. She said she did not measure the wound because she thought an RN had to do the first assessment. She thought she had passed it along to the next shift. She said she was not sure if it was the same wound. During an interview on 5/11/21 at 1:02 p.m., LVN H said she did not recall hearing Resident #6 had a wound on her coccyx in April. She said LVN G was usually already gone when she arrived at work. During an observation and interview on 5/11/21 at 10:06 a.m., Resident #6 had an open area approximately two inches long and 0.5 inches wide on the right buttock in the crease of a previously healed wound. The middle had yellow slough (necrotic tissue). There was no dressing on the wound. CNA I said she found it on 5/10/21. She told LVN J who put some ointment and a bandage on the wound. LVN G said she was not aware Resident #6 had a wound. Resident #6 said nobody had measured anything on her bottom. She denied any pain. During an interview on 5/11/21 at 10:17 a.m., LVN J said he did not call the doctor or nurse practitioner or measure Resident #6's wound on 5/10/21. He said he just got busy. LVN J said Resident #6's wound did not have any yellow slough on 5/10/21. He said he put some Santyl ointment and a dry dressing on the wound. He said he should have documented he found the wound. There were no treatment orders on the treatment sheet for Resident #6's coccyx after 4/17/21 until 5/11/21. During an interview on 5/11/21 at 2:55 p.m., the DON said she was not aware of Resident #6's wound on her coccyx re-opening. She said the treatment nurse used to do all skin assessments when there was a treatment nurse. She said she had an in-service on 4/5/21 for the nurses. The nurses were told to start doing weekly skin assessments. She had the residents divided between the 6-2 and 2-10 shift. She said when a wound was found, the nurse should describe the wound and get measurements. During an interview on 5/10/21 at 4:13 p.m., LVN G said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/10/21 at 4:25 p.m., LVN J said he was aware the nurses were supposed to do weekly skin assessments. He all said he had not completed any assessments since the in-service on 4/5/21. He said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 3:50 p.m., LVN K said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 3:52 p.m., LVN L said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 5:33 p.m., LVN A said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/13/21 at 9:39 a.m., the DON said she had a Quick Reference Guide for skin management so the nurses would have a guide. She said the physician should be notified when a resident has a change in condition including and changes in skin. The undated Quick Reference Guide for skin management indicated it was a guide to assist the center in actions required in the prevention and/or healing of wounds . 3. A Weekly Skin Evaluation must be completed the day of admission (including readmission), at least once every 7 days, any change in skin condition and prior to discharge or transfer of a patient. 4. A Weekly Pressure Ulcer Evaluation must be completed upon any identification of pressure ulcers and updated at least every 7 days and as necessary with significant change . 10. The Director of Nursing or Nurse Manager must observe every Resident/Patient wound weekly. The corporate undated Weekly Skin Assessment Policy indicated The following should be notified of alterations in skin integrity: Nursing Supervisor, Physician, and Resident/Responsible party. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 5/17/21/21 indicated: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss 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. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The administrator was notified on 5/12/21 at 2:34 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 5/12/21. The facility's Plan of Removal was accepted on 5/13/21 at 2:39 p.m. and included: NURSING STAFF, TO INCLUDE LICENSED NURSES, CNAs, CMAs AND NEW HIRES WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. The alleged immediate jeopardy allegations are as follows: Issue: The facility did not obtain the wound care consult for Resident CR#1 (RESIDENT #3). Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse reviewed the orders for residents with wounds to identify residents with orders for a wound care consult. This will be completed by 5/12/2021 - 11:59 PM. The Licensed Nurse reviewed the medical record of residents with orders for a wound care consult to validate that the consult was completed as ordered. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on following physician orders. Reeducation included the process for initiating orders for wound care consults and communicating resident information related to a wound care consultation to the wound care consultant. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Issue: The facility did not conduct weekly skin assessments for Resident CR#1 (RESIDENT #3) from 3/2/21 until 4/27/21. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated nursing staff (Licensed Nurses, CNAs, CMAs) on observing for and reporting resident changes in skin condition. Reeducation included when to observe for skin changes, what to observe for and actions to take, including required documentation when changes are identified. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the weekly skin evaluation process. Reeducation included when and how skin evaluations should be completed and documented, as well as completion of routine weekly skin evaluations as directed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion of resident weekly skin assessments by observing the skin status and reviewing the medical record for five residents weekly for four weeks, then monthly for two months. Issue: There were no wound care orders for Resident CR#1 (RESIDENT #3) from 4/28/21 until 5/7/21. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Licensed Nurse will review orders for residents with wounds to observe for and validate physician notification and the presence of wound care orders. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on actions to take when changes in resident skin conditions are noted and/ or reported. Reeducation included required documentation, to include skin evaluations, obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the Skin and Wound Process. Reeducation included use of the process for wound care treatment options to be discussed with the MD/ NP. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician notification and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Issue: Assessment completed on 5/6/2021 for Resident CR#1 (RESIDENT #3) was based on prior documentation and not based on observation of the wound. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Licensed Nurse reviewed the wound assessments for residents with wounds to identify residents who may not have current and/ or accurate wound assessments. Where applicable, wound assessments were completed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion and accuracy of wound assessments by reviewing documentation for three residents with wounds weekly for four weeks, then monthly for two months. Issue: The facility identified a wound on Resident #6's coccyx on 4/17/2021. There was no assessment of the wound. There was no physician notification of the wound. There was no treatment orders. Resident #6 was reassessed by the Registered Nurse related to wound status on 5/12/2021 with no changes identified in skin status. The Nurse Practitioner was made aware of the resident's wound status by the Registered Nurse with no new orders received. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021 - 11:59PM. The Licensed Nurse reviewed orders for residents with wounds to observe for and validate physician notification and the presence of wound care orders. This will be completed by 5/12/2021 - 11:59PM. The Licensed Nurse reviewed the wound assessments for residents with wounds to identify residents who may not have current and/ or accurate wound assessments. Where applicable, wound assessments were completed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on actions to take when changes in resident skin conditions are noted and/ or reported. Reeducation included required documentation, to include evaluation, obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the Skin and Wound Process. Reeducation included use of the process for wound care treatment options to be discussed with the MD/ NP. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician notification and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing and/ or designee will monitor compliance with completion and accuracy of wound assessments by reviewing documentation for three residents with wounds weekly for four weeks, then monthly for two months. Issue: The floor nurses said they were not doing weekly skin assessments. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021 - 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the weekly skin evaluation process. Reeducation included when and how skin evaluations should be completed and documented, as well as completion of routine weekly skin evaluations as directed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion of resident weekly skin assessments by observing the skin status and reviewing the medical record for five residents weekly for four weeks, then monthly for two months. On 5/12/2021, an adhoc Quality Assurance Performance Improvement Meeting was held with the Administrator, Director of Nursing, Medical Director and two other staff members present to discuss the above plan. On 5/14/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: In-service dated 5/12/21 indicated the ADONs and treatment nurse were re-educated on the facility Skin Management Process. Re-education included documentation associated with the Skin Management Process to include Weekly Pressure Ulcer, Non-Pressure Ulcer and Skin Evaluation Forms. Re-education included notification process to include MD/NP and RP, as well as the DON and time-frames for notification. Attendees were also re-educated on the facility skin Management - PCC Quick Reference Guide related to skin and wound documentation and the Skin and wound Care Guidelines. In-services dated 5/12/21 indicated the DON in-serviced staff on the topics of changes in resident skin condition - actions to take, pain management, skin evaluation process, observing for and reporting resident changes in conditi

Based on observation, interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 2 of 3 residents reviewed for notification of changes. (Residents #3 and #6) After podiatrist saw Resident #3 and indicated a wound consult was needed, the facility failed to schedule the wound consult or consult with Resident #3's physician. The resident was transferred to the ER 9 days later and diagnosed with [CONDITION(S)] (infection of the bone). Resident #3's great toe was amputated while in the hospital. The facility failed to consult physician when Resident #6 developed an open wound on her coccyx. An Immediate Jeopardy (IJ) situation was identified on 5/12/21. While the IJ was removed on 5/14/21, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-servicing and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life. Findings included: 1. A face sheet dated 5/11/21 indicated Resident #3 was a [AGE] year-old male, admitted [DATE], and discharged on [DATE] to a local hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had moderately impaired cognition, made his needs known, and understood others. Resident #3 required supervision from staff for bed mobility, transfers, dressing and personal hygiene. Resident #3 was independent for bathing. He was continent of bowel and bladder. Resident #3 was low risk of developing pressure injuries and had no unhealed pressure injuries. A care plan dated 3/17/21 indicated Resident #3 required limited assistance by one staff for showering Monday, Wednesday, and Friday on the 2-10 shift. The care plan indicated resident #3 required daily skin inspection. Staff were to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. A Braden scale for predicting pressure sore risk dated 4/11/21, indicated Resident #3 was low risk for developing pressure injuries. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 5/6/21 at 2:57 p.m., Resident #3 had an undated dressing on his left foot. The dressing had a compression bandage wrapped around the foot. There was a foul odor from the left foot. The bandage had drainage that seeped through the compression bandage. The resident was alert and said he had some pain in his foot. He said he had some pain medication. There were no documented skin assessments from 3/2/21 until 4/27/21 in the clinical record. During an interview on 5/7/21 at 12:46 p.m., the DON said there had not been a wound care nurse since 4/5/21. She said the facility hired a new wound care nurse who would be starting the next week. A weekly skin assessment dated [DATE], completed by LVN A, indicated Resident #3 had no new skin impairment. A hand-written note from the contract podiatrist regarding Resident #3 dated 4/28/21 indicated Please order wound care consult for evaluation and management of left foot ulcer. Ulcer location - left first metatarsal head (bunion area) are measures: 1.4cm x 1cm x 0.1cm. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 8:20 a.m., the DON said they have a meeting to go over telephone orders from the previous day every morning Monday through Friday. The MDS nurse hooks her computer up to the television and they review the orders. She said the order for Resident #3 somehow got missed. She said she keeps a notebook and keeps notes from the meetings. She said there were no notes regarding Resident #3 or the consult would not have been missed. During an interview on 5/11/21 at 5:33 p.m., LVN A said the contract podiatrist was at the facility on 4/28/21 to trim residents' toenails. She said the podiatrist stopped at the nurse station and handed her a hand-written note for Resident #3 to have a wound care consult. She said she did not look at the wound or assess the wound. She said the podiatrist did not give any wound care orders because she was not the resident's facility physician. She said she did not follow through with the wound care consult or call Resident #3's regular physician/nurse practitioner. She said she did not document in the progress note about the order. She said she did not look at Resident #3's feet when she did the skin assessment on 4/27/21. There was no treatment record for the month of April 2021 for Resident #3. The only documented wound care was on 5/7/21. During an interview on 5/7/21 at 4:45 p.m., NP C said she was first made aware of a wound on Resident #3's foot on 5/3/21 and ordered an x-ray of his foot. She first saw Resident #3's foot on 5/5/21. She said the dressing on his foot had a lot of drainage and had seeped through his sock. She said the resident said the dressing had been on his foot for a few days. NP C said the foot had a foul odor. NP C said Resident #3 had an MRI ordered because his x-ray showed possible [CONDITION(S)]. The MRI was completed on 5/7/21 and showed [CONDITION(S)]. She sent Resident #3 to the emergency room for evaluation due to the results of the MRI. A weekly skin evaluation dated 5/3/21, completed by LVN B, indicated Resident #3 had a new pressure ulcer. The description was for a wound care consult for the left foot ulcer to the left first metatarsal head area with the same wound measurements from the podiatrist on 4/28/21. During an interview on 5/13/21 at 12:55 p.m., LVN B said she did see Resident #3's foot on 5/3/21. She said it was bloody and had gone through his sock. She said she cleaned the wound and put a 4x4 gauze pad and tape over it. She said she did not measure the wound but used the measurements from the order on 4/28/21. LVN B called NP C who ordered an x-ray and arterial doppler. She said the x-ray company did not have an ultrasound technician to do the doppler. She called another company the next day on 5/4/21 and was told to send Resident #3's information to them and they would get him scheduled. LVN B said the NP C made her rounds on 5/5/21. She said NP C got the resident into their office for a visit with a different podiatrist and to have the doppler done. She said she did not do any other dressing changes on Resident #3's foot. LVN B said the DON had an in-service about a week or so earlier. She said the nurses were told they would need to help with doing the skin assessments. She said there was a schedule at the desk. The assessments were split between the 6-2 and 2-10 shift. She said she had not completed any skin assessments. A skin assessment dated [DATE], signed on 5/10/21 and completed by ADON E, indicated Resident #3's wound developed on 5/3/21. The assessment indicated the wound was on the left toe, was vascular and had the same measurements from the previous assessments. The assessment indicated there was a small amount of thin, watery, clear drainage, no odor, and had epithelial tissue (new pink or shiny). The notes/comments section indicated Resident #3's new ulcer was deteriorating, a wound consult was in place, and physician ordered IV antibiotics were in place. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 12:21 p.m., ADON E said she did not look at Resident #3's wound on 5/6/21 when she completed the skin assessment. She did not give a reason why she completed the assessment without looking at the resident. During an interview on 5/6/21 at 2:22 p.m., the DON said Resident #3 had gone to a podiatrist on 5/5/21 because he had a wound on the bottom of his foot. She said she had not seen the wound yet and had planned on doing his skin assessment on 5/6/21. During an interview on 5/6/21 at 12:47 p.m., DPM D said he had seen Resident #3 on 5/5/21. He said he had wanted him to go to the hospital for an MRI and IV antibiotics. He said he suspected Resident #3 had [CONDITION(S)]. He put a dressing on the resident's foot and wrapped it in a compression wrap. He said he stepped out of the exam room for a few minutes and the resident left. He had not given any wound care orders. There were no wound care orders for Resident #3's wound until 5/7/21 after surveyor asked to watch wound care. During an observation and interview on 5/7/21 at 10:23 a.m., Resident #3 had the same dressing from 5/6/21. LVN F removed the dressing from Resident #3's left foot. She said she had not seen the wound until that day. The gauze and gauze roll had yellow, red, and brown drainage. Resident #3's wound had an odor. The wound on the left bunion area was slightly larger than a quarter. The wound was mostly covered in black necrotic tissue. The resident's foot was swollen and warm to touch per LVN F. The resident winced in pain when LVN F lifted his foot. Resident #3 said his leg hurt half way up his shin. He said he did not feel good. He had not eaten his breakfast and did not feel like he was going to eat his lunch. A nurse note dated 5/7/21 at 11:25 a.m. indicated Resident #3 was sent to have an MRI of his left foot. A nurse note dated 5/7/21 at 8:46 a.m. indicated the hospital called to schedule Resident #3's MRI. The earliest appointment was scheduled for 5/13/21 at 8:30 a.m. Resident #3's family member was notified and said she was told by DPM D the MRI needed to be done 5/7/21. A nurse note dated 5/7/21 at 3:50 p.m. indicated Resident #3's MRI results showed [CONDITION(S)] of the left foot. Orders were received from NP C to send Resident #3 to the hospital. Resident #3 told staff he was too tired to go to the hospital and wanted to wait until the next morning. The facility called a family member who convinced the resident to go to the hospital. Physician documentation from the hospital dated 5/7/21 indicated Resident #3 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A discharge summary dated 5/15/21 indicated Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had an amputation of his great toe. 2. A face sheet dated 5/11/21 indicated Resident #6 was admitted [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident #6 had moderately impaired cognition, made her needs known, and usually understood others. Resident #6 required extensive assistance from two staff for bed mobility, transfers and bathing. She was incontinent of bowel and bladder. Resident #6 was at risk of developing pressure injuries and had no unhealed pressure injuries. A care plan dated 3/8/21 indicated Resident #6 required skin inspection daily and to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A skin assessment dated [DATE] completed by the previous treatment nurse indicated Resident #6 had a previous stage III wound on her coccyx (tailbone) had healed. Weekly skin evaluations dated 4/6/21, 4/13/21, 4/20/21, 4/27/21, and 5/4/21 indicated Resident #6 did not have any skin issues including pressure ulcers. A nurse noted dated 4/17/21 at 1:06 p.m., completed by LVN G, indicated Resident #6's family member called the nurse to the room to inquire about a wound on the resident's coccyx area. The nurse told the family member Resident #6 was going to the wound care center and being treated by the wound care nurse. A follow-up nurse note dated 4/17/21 at 1:42 p.m., completed by LVN G, indicated the LVN cleaned Resident #6's wound with wound cleanser, patted it dry, and covered the wound with a dry dressing. There was no assessment of the wound or physician notification documented. A nurse note dated 4/17/21 at 2:48 p.m., completed by LVN G, indicated she observed bruising on Resident #6's left elbow and arm. The nurse notified the NP and was told to monitor the arm. There was no mention of the open area on the resident's coccyx. A Braden Scale for Predicting Pressure Sore Risk dated 4/24/21 indicated Resident #6 was at risk for pressure ulcers. During an interview on 5/11/21 at 12:51 p.m., LVN G said she thought she had called the on-call person for the physician about Resident #6's wound. She said the ADON and administrator were aware of the wound because the resident's family member contacted the administrator. She said she did not measure the wound because she thought an RN had to do the first assessment. She thought she had passed it along to the next shift. She said she was not sure if it was the same wound. During an interview on 5/11/21 at 1:02 p.m., LVN H said she did not recall hearing Resident #6 had a wound on her coccyx in April. She said LVN G was usually already gone when she arrived at work. During an observation and interview on 5/11/21 at 10:06 a.m., Resident #6 had an open area approximately two inches long and 0.5 inches wide on the right buttock in the crease of a previously healed wound. The middle had yellow slough (necrotic tissue). There was no dressing on the wound. CNA I said she found it on 5/10/21. She told LVN J who put some ointment and a bandage on the wound. LVN G said she was not aware Resident #6 had a wound. Resident #6 said nobody had measured anything on her bottom. She denied any pain. During an interview on 5/11/21 at 10:17 a.m., LVN J said he did not call the doctor or nurse practitioner or measure Resident #6's wound on 5/10/21. He said he just got busy. LVN J said Resident #6's wound did not have any yellow slough on 5/10/21. He said he put some Santyl ointment and a dry dressing on the wound. He said he should have documented he found the wound. There were no treatment orders on the treatment sheet for Resident #6's coccyx after 4/17/21 until 5/11/21. During an interview on 5/11/21 at 2:55 p.m., the DON said she was not aware of Resident #6's wound on her coccyx re-opening. She said the treatment nurse used to do all skin assessments when there was a treatment nurse. She said she had an in-service on 4/5/21 for the nurses. The nurses were told to start doing weekly skin assessments. She had the residents divided between the 6-2 and 2-10 shift. She said when a wound was found, the nurse should describe the wound and get measurements. During an interview on 5/10/21 at 4:13 p.m., LVN G said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/10/21 at 4:25 p.m., LVN J said he was aware the nurses were supposed to do weekly skin assessments. He all said he had not completed any assessments since the in-service on 4/5/21. He said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 3:50 p.m., LVN K said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 3:52 p.m., LVN L said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/11/21 at 5:33 p.m., LVN A said she was aware the nurses were supposed to do weekly skin assessments. She all said she had not completed any assessments since the in-service on 4/5/21. She said they were usually too busy to complete the assessments. During an interview on 5/13/21 at 9:39 a.m., the DON said she had a Quick Reference Guide for skin management so the nurses would have a guide. She said the physician should be notified when a resident has a change in condition including and changes in skin. The undated Quick Reference Guide for skin management indicated it was a guide to assist the center in actions required in the prevention and/or healing of wounds . 3. A Weekly Skin Evaluation must be completed the day of admission (including readmission), at least once every 7 days, any change in skin condition and prior to discharge or transfer of a patient. 4. A Weekly Pressure Ulcer Evaluation must be completed upon any identification of pressure ulcers and updated at least every 7 days and as necessary with significant change . 10. The Director of Nursing or Nurse Manager must observe every Resident/Patient wound weekly. The corporate undated Weekly Skin Assessment Policy indicated The following should be notified of alterations in skin integrity: Nursing Supervisor, Physician, and Resident/Responsible party. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 5/17/21/21 indicated: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss 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. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The administrator was notified on 5/12/21 at 2:34 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 5/12/21. The facility's Plan of Removal was accepted on 5/13/21 at 2:39 p.m. and included: NURSING STAFF, TO INCLUDE LICENSED NURSES, CNAs, CMAs AND NEW HIRES WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. The alleged immediate jeopardy allegations are as follows: Issue: The facility did not obtain the wound care consult for Resident CR#1 (RESIDENT #3). Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse reviewed the orders for residents with wounds to identify residents with orders for a wound care consult. This will be completed by 5/12/2021 - 11:59 PM. The Licensed Nurse reviewed the medical record of residents with orders for a wound care consult to validate that the consult was completed as ordered. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on following physician orders. Reeducation included the process for initiating orders for wound care consults and communicating resident information related to a wound care consultation to the wound care consultant. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Issue: The facility did not conduct weekly skin assessments for Resident CR#1 (RESIDENT #3) from 3/2/21 until 4/27/21. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated nursing staff (Licensed Nurses, CNAs, CMAs) on observing for and reporting resident changes in skin condition. Reeducation included when to observe for skin changes, what to observe for and actions to take, including required documentation when changes are identified. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the weekly skin evaluation process. Reeducation included when and how skin evaluations should be completed and documented, as well as completion of routine weekly skin evaluations as directed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion of resident weekly skin assessments by observing the skin status and reviewing the medical record for five residents weekly for four weeks, then monthly for two months. Issue: There were no wound care orders for Resident CR#1 (RESIDENT #3) from 4/28/21 until 5/7/21. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Licensed Nurse will review orders for residents with wounds to observe for and validate physician notification and the presence of wound care orders. This will be completed by 5/12/2021- 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on actions to take when changes in resident skin conditions are noted and/ or reported. Reeducation included required documentation, to include skin evaluations, obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the Skin and Wound Process. Reeducation included use of the process for wound care treatment options to be discussed with the MD/ NP. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician notification and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Issue: Assessment completed on 5/6/2021 for Resident CR#1 (RESIDENT #3) was based on prior documentation and not based on observation of the wound. Resident CR#1 (RESIDENT #3) was discharged to the hospital on 5/7/2021. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021- 11:59 PM. The Licensed Nurse reviewed the wound assessments for residents with wounds to identify residents who may not have current and/ or accurate wound assessments. Where applicable, wound assessments were completed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion and accuracy of wound assessments by reviewing documentation for three residents with wounds weekly for four weeks, then monthly for two months. Issue: The facility identified a wound on Resident #6's coccyx on 4/17/2021. There was no assessment of the wound. There was no physician notification of the wound. There was no treatment orders. Resident #6 was reassessed by the Registered Nurse related to wound status on 5/12/2021 with no changes identified in skin status. The Nurse Practitioner was made aware of the resident's wound status by the Registered Nurse with no new orders received. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021 - 11:59PM. The Licensed Nurse reviewed orders for residents with wounds to observe for and validate physician notification and the presence of wound care orders. This will be completed by 5/12/2021 - 11:59PM. The Licensed Nurse reviewed the wound assessments for residents with wounds to identify residents who may not have current and/ or accurate wound assessments. Where applicable, wound assessments were completed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on actions to take when changes in resident skin conditions are noted and/ or reported. Reeducation included required documentation, to include evaluation, obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the Skin and Wound Process. Reeducation included use of the process for wound care treatment options to be discussed with the MD/ NP. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with physician notification and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing and/ or designee will monitor compliance with completion and accuracy of wound assessments by reviewing documentation for three residents with wounds weekly for four weeks, then monthly for two months. Issue: The floor nurses said they were not doing weekly skin assessments. The Licensed Nurse completed a skin evaluation on facility residents to identify the status of resident skin conditions. This will be completed by 5/12/2021 - 11:59 PM. The Director of Nursing and/ or designee reeducated Licensed Nurses on the weekly skin evaluation process. Reeducation included when and how skin evaluations should be completed and documented, as well as completion of routine weekly skin evaluations as directed. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee reeducated the Treatment Nurse(s) and ADONs on the Skin Management Process. Reeducation included documentation associated with the skin process to include the wound evaluation and assessment. This will be completed by 5/13/2021 - 1:00PM. The Director of Nursing and/ or designee will monitor compliance with completion of resident weekly skin assessments by observing the skin status and reviewing the medical record for five residents weekly for four weeks, then monthly for two months. On 5/12/2021, an adhoc Quality Assurance Performance Improvement Meeting was held with the Administrator, Director of Nursing, Medical Director and two other staff members present to discuss the above plan. On 5/14/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: In-service dated 5/12/21 indicated the ADONs and treatment nurse were re-educated on the facility Skin Management Process. Re-education included documentation associated with the Skin Management Process to include Weekly Pressure Ulcer, Non-Pressure Ulcer and Skin Evaluation Forms. Re-education included notification process to include MD/NP and RP, as well as the DON and time-frames for notification. Attendees were also re-educated on the facility skin Management - PCC Quick Reference Guide related to skin and wound documentation and the Skin and wound Care Guidelines. In-services dated 5/12/21 indicated the DON in-serviced staff on the topics of changes in resident skin condition - actions to take, pain management, skin evaluation process, observing for and reporting resident changes in condition and actions to take, skin management (Quick Reference Guide), and wound care consultations/following physician orders. The in-services included sign in sheets and facility policies of the topics. During an interview on 5/14/21 at 8:50 a.m., the DON said her corporate nurse trained her on the plan of removal interventions prior to her educating the nursing staff. She said all nursing staff were educated on changes in resident skin condition - actions to take, pain management, skin evaluation process, observing for and reporting resident changes in condition and actions to take, skin management (Quick Reference G

Based on observation, interview and record review, the facility failed to ensure1 of 1 CNA observed demostrated competency in skills and techinque for 1 of 4 residents reviewed for ADL care. (Resident # 1. The facility did not provide Resident #1 proper incontinent care. CNA B did not change her gloves after touching dirty items before she touched clean items. CNA B did not wipe in the proper direction of dirty to clean. Resident #1 had itching and a white discharge with a cheese like texture in the crevices of her perineal area. This failure could place residents at risk of discomfort and diminished quaility of life. Findings included: A physician's orders [REDACTED].# 1 was admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #1 was cognitively intact and was able to make her needs known. The MDS indicated she required extensive assistance of 1 person with bed mobility, dressing, and personal hygiene. The MDS indicated she was frequently incontinent of bowel and bladder, was at risk for skin breakdown and had one stage 2 pressure ulcer at the time of the assessment. A care plan initiated [DATE] indicated Resident #1 had bowel and bladder incontinence and was to receive peri-care after each incontinent episode. During an interview on 1/22/20 at 9:28 a.m., Resident #1 said she had not been changed since about 5:00 a.m. that morning and did not know when she urinated or had a bowel movement. Resident #1 said she had been itching down there (indicating her vaginal area). Resident #1 said she did not think she was ever cleaned well. During an observation of incontinent care on 1/22/20 at 9:28 a.m., Resident #1 was noted to have loose bowels and dried feces on the draw sheet and on the resident's leg. LVN A assisted CNA B to roll Resident #1 to her right side for incontinent care. CNA B wore gloves and wiped the resident's buttocks, wiping from back to front. CNA B grabbed more wipes using the same soiled gloves. Still using the same soiled gloves, CNA B began putting a clean fitted sheet and draw sheet on the bed. LVN A and CNA B assisted Resident #1 to roll to her left side, and LVN A cleaned the resident's right buttock. She removed dirty linen and then pulled the clean sheet and draw sheet under the resident while wearing the same soiled gloves. Without changing gloves, LVN A placed a clean brief under the resident, and began pulling the brief up to close without cleaning Resident #1's peri-area. The surveyor intervened, and CNA B wiped the inside of each of Resident #1's legs, then wiped up and down on the outside of the resident's labia wearing the same soiled gloves. LVN A checked the labia at the surveyor's request and observed a white to yellow cheesy looking substance that appeared to be discharge in the crevices of the vaginal area. LVN A attempted to remove the discharge but used all the wipes. CNA B, still wearing the same soiled gloves, looked in the resident's drawer for more wipes. CNA B obtained a wash basin and LVN A washed the resident with soap and water. There was a greenish tint to the thick discharge below Resident #1's vaginal opening on the right side. CNA B took over cleaning the resident's vaginal area, and LVN A instructed CNA B to wipe in the correct direction. The staff used six washclothes to remove the substance. CNA B and LVN A never changed gloves or sanitized their hands during the procedure. During an interview on 1/22/20 at 12:15 p.m., the DON said CNA B should have known to perform hand hygiene and change gloves. She had just recently completed the nurse aide class and passed her nurse aide certification. During an interview on 1/22/20 at 1:15 p.m., the DON said they use Lippincott for their policy and procedures. The facility's undated perineal care policy indicated Perineal care, which includes care of the external genitalia and the anal area, should be performed during the daily bath and, if the patient is incontinent, at bedtime and after urination and bowel movements. The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions . For a female patient: -Ask the patient to bend her knees slightly and to spread her legs. -Assess the patient's perineal area for color changes, skin breakdown, drainage, discharge, or tenderness . -Separate the patient's labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum. Avoid the area around the anus, and use a clean section of washcloth for each stroke by folding each used section inward. -Turn the patient on her side to the Sims position, if possible, to expose the anal area. -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back. The facility's undated Hand Hygiene policy indicated Using an alcohol-based hand sanitizer is appropriated for decontaminating the hands before direct patient contact, before putting on gloves .when moving from a contaminated body site to a clean body site . Keep in mind that glove use doesn't eliminate the need for hand hygiene.

Based on observation, interview and record review, the facility failed to ensure necessary services to maintain ADLs were provided for 1 of 4 residents reviewed for ADL care. (Resident # 1). The facility did not provide Resident #1 timely and appropriate incontinent care. Resident #1 had itching and a white discharge with a cheese like texture in the crevices of her perineal area. This failure could place residents at risk of discomfort and diminished quaility of life. Findings included: A physician's orders [REDACTED].# 1 was admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #1 was cognitively intact and was able to make her needs known. The MDS indicated she required extensive assistance of 1 person with bed mobility, dressing, and personal hygiene. The MDS indicated she was frequently incontinent of bowel and bladder, was at risk for skin breakdown and had one stage 2 pressure ulcer at the time of the assessment. A care plan initiated [DATE] indicated Resident #1 had bowel and bladder incontinence and was to receive peri-care after each incontinent episode. During an interview on 1/22/20 at 9:28 a.m., Resident #1 said she had not been changed since about 5:00 a.m. that morning, and did not know when she urinated or had a bowel movement. Resident #1 said she had been itching down there (indicating her vaginal area). Resident #1 said she did not think she was ever cleaned well. During an observation of incontinent care on 1/22/20 at 9:28 a.m., Resident #1 was noted to have loose bowels and dried feces on the draw sheet and on the resident's leg. LVN A assisted CNA B to roll Resident #1 to her side for incontinent care. CNA B performed incontinent care and LVN A spread the resident's labia to check for cleanliness. There was a white to yellow cheesy looking substance that appeared to be discharge in the crevices of Resident #1's vaginal area. CNA B handed wipes to LVN A and she tried to remove the discharge. CNA B grabbed more wipes and wiped the inside of each leg and wiped up and down (back to front) on the outside of the resident's labia. LVN A used all the wipes while attempting to remove the thick discharge from Resident #1's vaginal area. LVN A told CNA B to get a wash basin so she could wash the resident with soap and water because the wipes were not working to get her clean. There was a greenish tint to the thick discharge below Resident #1's vaginal opening on the right side. It took more than six washcloths to clean the resident. During a phone interview on [DATE] at 2:10 p.m. Resident #1 said since the time she was admitted , she had never been cleaned as well as she was cleaned on 1/22/20. During an interview on 1/22/20 at 12:15 p.m., the DON said CNA B should have known to perform hand hygiene and change gloves. She had just recently completed the nurse aide class and passed her nurse aide certification. During an interview on 1/22/20 at 1:15 p.m., the DON said he had talked to his corporate nurse and was told they use Lippincott for their policy and procedures. The website www.cdc.gov/fungal/diseases/[CONDITION]/genital accessed on 2/3/20 indicated symptoms of vaginal [CONDITION] (yeast infection) included vaginal itching and soreness.abnormal vaginal discharge. The facility's undated perineal care policy indicated Perineal care, which includes care of the external genitalia and the anal area, should be performed during the daily bath and, if the patient is incontinent, at bedtime and after urination and bowel movements. The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions . For a female patient: -Ask the patient to bend her knees slightly and to spread her legs. -Assess the patient's perineal area for color changes, skin breakdown, drainage, discharge, or tenderness . -Separate the patient's labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum. Avoid the area around the anus, and use a clean section of washcloth for each stroke by folding each used section inward. -Turn the patient on her side to the Sims position, if possible, to expose the anal area. -Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back.

Based on observation, interview and record review, the facility failed to ensure necessary services to maintain ADLs were provided for 3 of 12 residents reviewed for ADL care. (Resident #s 1, 3, and 4). The facility did not provide Resident #3 showers, appropriate oral care or nail care. Resident #3 was admitted to the hospital with [REDACTED]. The resident had to be bathed 2 times in the hospital in one day to remove the built up dirt from her body and hair prior to surgery. The facility did not provide Resident #4 with a shower for 3 weeks nor timely incontinent care. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. The resident was upset and tearful about her lack of care. The facility did not provide for Resident #1 with showers or nail care and did not answer the call light timely. It took approximately 20 minutes for the call light to be answered. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The resident wanted to get out of the bed and receive a shower. Findings included: 1. Physician order [REDACTED].#3 was admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order with a start date of 10/2/19 indicated Resident #3 was to receive a pureed diet with nectar thick liquids. An order with a start date of 10/4/19 indicated staff were to encourage fluids every shift. An order with a start date of 10/25/19 indicated staff may crush medications. The annual MDS dated [DATE] indicated Resident #3 had moderately impaired cognition and was able to make herself understood. The MDS indicated she required extensive assistance of 1 person with bed mobility, dressing, and eating and was totally dependent with 1 person assistance with transfers, toilet use, personal hygiene, bathing. The MDS indicated she was always incontinent of bowel and bladder, was at risk for skin breakdown and did not have any ulcers, wounds or skin problems. A care plan initiated 11/1/2018 indicated Resident #3 had an ADL self-care performance deficit with interventions including to check nail length and trim and clean nails on bath day as necessary, resident was totally dependent on 1 staff to provide bath/shower, resident required extensive assistance by staff with personal hygiene and oral care and resident required extensive assistance by 1 staff to eat. The care plan did not indicate the frequency times the resident was to receive bath/shower. The care plan initiated 9/20/19 indicated Resident #3 had a swallowing problem and dysphasia (difficulty swallowing) with interventions including to provide pureed diet with nectar thickened liquids, feed resident every meal, monitor and report intake, monitor/document/report pocketing, choking, holding food in mouth, not swallowing and refusing to eat. A care plan dated 10/27/2019 indicated Resident #3 had a potential for dehydration related to poor intake with interventions including encourage fluids every shirt, monitor and document and report any signs or symptoms of dehydration including cracked lips and furrowed tongue (multiple grooves on the top of the tongue) A care plan initiated 12/3/19 indicated Resident #3 would be provided a sponge bath when a full bath or shower could not be tolerated. Resident had contractures of the right leg and left hand and would be provided with skin care daily and as needed to keep clean and prevent skin breakdown. The resident required skin inspection daily to observe for redness, open areas, scratches, cuts, bruises and to report changes to the nurse. Resident was totally dependent on 2 staff for transferring using a mechanical lift. The ADL sheets from (MONTH) 2019 indicated Resident #3 did not receive a shower, bed bath or tub bath from 11/22/19 through 11/30/19. A nursing note dated 12/03/19 indicated Resident #3 was observed with swelling to the right knee and was sent to the hospital. A hospital record dated 12/03/19 indicated Resident #3 had a fractured right knee and was admitted to the hospital for surgery. The resident was in ICU during surveyor visit. A hospital record dated 12/3/19 completed by an emergency room physician indicated Resident #3 was non-verbal and unable to answer question. The record indicated the physician contacted the SANE screener for possible abuse. A hospital record dated 12/3/19 at 10:12 a.m., completed by the hospital forensic nurse indicated Resident #3 came into the emergency department with the following: *Dirty teeth caked with a white substance *Something that looked like a pill in the back of her mouth *Lips and mouth were dry *Her tongue was dry, leathery and cracked *There was dried food in the sunken area above her collar bone, *A moist buildup with odor to her left breast *Dirt in and around both ears *Limited range of motion in both shoulders, both elbows and left knee due to contractures *Right knee swollen with deformity *8 cm x 9 cm blue/red/purple bruise to the right inner thigh *Patient complained of severe pain with movement of right leg During an interview on 12/03/2019 at 2:38 p.m. the hospital forensic nurse said she was called to see Resident #3 because the resident had a fractured right knee and a large bruise on her right inner thigh area. She said the resident was contracted and non-verbal. She said pictures were taken in the emergency room because the resident was dirty with poor oral care and appeared to have received overall very poor care. She said she called the facility and spoke with LVN B. LVN B said the resident was scheduled to get showers Tuesday, Thursday and Saturday. During an interview on 12/3/19 at 3:45 p.m. the hospital RN in charge of Resident #3 said the resident had to receive a bed bath at least twice in one day to remove the dirt and buildup on her body and hair before she could go to surgery. He said the resident had dirty nails, crusty buildup in the creases of her arms, legs, and under her breast which had an odor. He said she was taken to surgery due to the fractured right knee. The hospital RN said the resident was total care and non-verbal with upper and lower arm and leg contractures. He said he could not put an incontinent brief on the resident due to her contractures. 2. Physician orders [REDACTED].#4 was admitted to the facility on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #3 was to receive 80 mg of [MEDICATION NAME] by mouth 2 times daily. The admission MDS dated [DATE] indicated Resident #4 was cognitively intact, required extensive 2 person assistance with bed mobility and toilet use. The MDS indicated transferring from one surface to another did not occur, personal hygiene occurred only once or twice with 1 person assistance and bathing did not occur. The MDS indicated the resident was always incontinent of bowel and bladder. A care plan dated 09/26/2019 indicated Resident #4 had limited physical mobility and an ADL selfcare performance deficit with interventions to provide a sponge bath when a shower could not be tolerated, two person assistance to turn and reposition, extensive assistance by 1 staff to dress, extensive assistance by 1 staff for personal hygiene and oral care, extensive assistance by 1 staff for toileting and 2 staff assistance for transfers with the mechanical lift. Skin assessments for Resident #4 indicated the following: 10/14/19-no skin issues 10/17/19 - no abnormal skin - small amount of redness under right abdominal fold and buttock. 10/24/19-yes-abnormal skin; non pressure area, redness-barrier cream 10/31/19-no abnormal areas 11/06/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/09/19-no skin issues 11/13/19-no skin issues 11/20/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/27/19-no assessment done 12/04/19-yes abnormal skin; non pressure area, redness-barrier cream During an observation and interview on 12/04/19 at 7:26 a.m., Resident #4 said she received bed baths three days a week on Monday, Wednesday and Friday, and had not had a shower in at least 3 weeks. Resident #4 was tearful and said she was told nursing did not have time for 2 people to use the mechanical lift for her to go to the shower. She said she would rather have a shower at least once a week. She said her hair had not been washed in over 2 weeks. She said she had to wait over 30 minutes for her incontinent brief to be changed and it caused her bottom to burn. Resident #4 said some staff got upset with her and a CNA told her to tell her physician to take her off the [MEDICATION NAME] because it made her urinate too much. She said she had talked to the administrator, but nothing had been done. She said she felt bad and upset due to the aides complaining when they had to change her. She said it took 2 people and they would have to come back with help. She said it would take over 30 minutes for the aides to come back and change her and she would have to lay there in urine. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. During an interview on 12/04/19 at 12:03 p.m., LVN B said it took two aides to help Resident #4 with her care. She said it took a while to provide incontinent and showers for Resident #4 because it required 2 people to change her and the aides had to have the time to get her up with the mechanical lift, so the resident usually received a bed bath. 3. Physician orders [REDACTED].#1 was admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Diff), with contact isolation, cerebral infarction, dementia, [MEDICAL CONDITION]/[MEDICAL CONDITION] of right side, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A significant change MDS dated [DATE] indicated Resident #1 rarely understood, was rarely understood and displayed inattention and altered levels of consciousness The MDS indicated the resident required 2 people assist with mobility, transfers and toileting and 1 person assistance with bathing and personal care. The MDS indicated Resident#1 was always incontinent of bowel and bladder. A care plan updated 11/21/2019 indicated Resident #1 was incontinent with interventions including clean peri area with each incontinent episode, use disposable briefs and change prn (as needed). The care plan indicated Resident #1 was to have a bath 3 times weekly and was to have a sponge bath when a full bath or shower could not be tolerated. The care plan indicated the resident was to have nail care on bath days and as necessary and staff were to provide oral and hair care. The ADL sheets for (MONTH) 1, 2019 through (MONTH) 3, 2019 indicated Resident #1 received a bed bath on her bath days. The ADL sheets did not have documentation of nail care or shampoos. During an observation and interview on 11/27/2019 at 1:29 p.m., Resident #1 was lying in bed. She said she was getting a sponge bed bath at least 2-3 times a week instead of a shower and was not getting her hair washed. She said she wanted to get out of bed and go to the shower and have her hair washed in the shower. She said staff would come in her room and turn her call light off and never come back. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The call light was activated at 1:29 p.m. during surveyor observation. A CNA came into the room to pick up a tray and did not acknowledge the call light or ask the resident if she needed assistance. The call light was subsesquently answered at 1:46 p.m. by another CN[NAME] During an interview on 11/27/2019 at 1:35 p.m., Resident #1's son said they had a care plan meeting over 2 weeks ago and they discussed his mother's care, but he felt nothing was done. He said he complained of staff not turning the resident or checking on her every 2 hours and the room smelling due to dirty trash, and trash on the floor. He said his mother was not given water because she had to have a thickener. He said the call light was not answered in over 20 minutes and his mother has been thirsty and wet every time he visited, which was daily. He said his mother had not had a shower and had her hair washed with water and shampoo in at least 2 weeks. He said he was told he could pay for the beautician to shampoo her hair. During an interview on 11/27/19 at 1:22 p.m., the unit manager said there was enough staff to take care of the residents. She said it took longer to answer call lights because staff was picking up lunch trays. She said anyone could answer the call lights. During an interview on 12/04/19 at 8:30 a.m. the administrator said he was made aware today of Resident #4's concerns and was working on them. He said he was aware a CNA told Resident #4 she should not be taking [MEDICATION NAME] and he reprimanded the CN[NAME] He said he did not complete a grievance form regarding Resident #1 or #4. He said Resident #1's son had informed him of his concerns about the resident not having a shower, hair care, water not available, and call light not being answered timely. He said Resident #3 had been up in a wheel chair on some days and needed staff to transfer and change her. He said the aides provided nail and hair care with the showers and bed baths. The administrator said he was aware in the past there was a problem regarding not getting residents up, call lights not being answered timely and residents being found wet. He said he was working on resolving these issues. During an interview on12/16/19 at 10:30 a.m., the DON said 1 side of the hall received a shower on Monday, Wednesday and Friday and the other side of the hall received showers on Tuesday, Thursday and Saturday. He said staff knew which residents got a bath on which days. He said he did not have a shower schedule to send to the surveyor. The DON said the facility did not have an ADL policy. An in-service dated 11/27/2019 titled ADL Care indicated Baths were to be completed on scheduled day, shower preferred, bed bath acceptable, hair must be washed with every bathing. Check resident for nail care when bathing.

Based on observation, interview and record review, the facility failed to provide the right to be free from abuse for 3 of 12 residents reviewed for abuse. (Resident #s 1, 3, and 4). The facility deprived Resident #3 of showers, appropriate oral care or nail care. Resident #3 was admitted to the hospital with [REDACTED]. The resident had to be bathed 2 times in the hospital in one day to remove the built up dirt from her body and hair prior to surgery. The facility deprived Resident #4 of showers for 3 weeks and timely incontinent care. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. The resident was upset and tearful about her lack of care. The facility deprived Resident #1 with showers and nail care and did not answer the call light timely. It took approximately 20 minutes for the call light to be answered. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The resident wanted to get out of the bed and receive a shower. Findings included: 1. Physician order [REDACTED].#3 was admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order with a start date of 10/2/19 indicated Resident #3 was to receive a pureed diet with nectar thick liquids. An order with a start date of 10/4/19 indicated staff were to encourage fluids every shift. An order with a start date of 10/25/19 indicated staff may crush medications. The annual MDS dated [DATE] indicated Resident #3 had moderately impaired cognition and was able to make herself understood. The MDS indicated she required extensive assistance of 1 person with bed mobility, dressing, and eating and was totally dependent with 1 person assistance with transfers, toilet use, personal hygiene, bathing. The MDS indicated she was always incontinent of bowel and bladder, was at risk for skin breakdown and did not have any ulcers, wounds or skin problems. A care plan initiated 11/1/2018 indicated Resident #3 had an ADL self-care performance deficit with interventions including to check nail length and trim and clean nails on bath day as necessary, resident was totally dependent on 1 staff to provide bath/shower, resident required extensive assistance by staff with personal hygiene and oral care and resident required extensive assistance by 1 staff to eat. The care plan did not indicate the frequency times the resident was to receive bath/shower. The care plan initiated 9/20/19 indicated Resident #3 had a swallowing problem and dysphasia (difficulty swallowing) with interventions including to provide pureed diet with nectar thickened liquids, feed resident every meal, monitor and report intake, monitor/document/report pocketing, choking, holding food in mouth, not swallowing and refusing to eat. A care plan dated 10/27/2019 indicated Resident #3 had a potential for dehydration related to poor intake with interventions including encourage fluids every shirt, monitor and document and report any signs or symptoms of dehydration including cracked lips and furrowed tongue (multiple grooves on the top of the tongue) A care plan initiated 12/3/19 indicated Resident #3 would be provided a sponge bath when a full bath or shower could not be tolerated. Resident had contractures of the right leg and left hand and would be provided with skin care daily and as needed to keep clean and prevent skin breakdown. The resident required skin inspection daily to observe for redness, open areas, scratches, cuts, bruises and to report changes to the nurse. Resident was totally dependent on 2 staff for transferring using a mechanical lift. The ADL sheets from (MONTH) 2019 indicated Resident #3 did not receive a shower, bed bath or tub bath from 11/22/19 through 11/30/19. A nursing note dated 12/03/19 indicated Resident #3 was observed with swelling to the right knee and was sent to the hospital. A hospital record dated 12/03/19 indicated Resident #3 had a fractured right knee and was admitted to the hospital for surgery. The resident was in ICU during surveyor visit. A hospital record dated 12/3/19 completed by an emergency room physician indicated Resident #3 was non-verbal and unable to answer question. The record indicated the physician contacted the SANE screener for possible abuse. A hospital record dated 12/3/19 at 10:12 a.m., completed by the hospital forensic nurse indicated Resident #3 came into the emergency department with the following: *Dirty teeth caked with a white substance *Something that looked like a pill in the back of her mouth *Lips and mouth were dry *Her tongue was dry, leathery and cracked *There was dried food in the sunken area above her collar bone, *A moist buildup with odor to her left breast *Dirt in and around both ears *Limited range of motion in both shoulders, both elbows and left knee due to contractures *Right knee swollen with deformity *8 cm x 9 cm blue/red/purple bruise to the right inner thigh *Patient complained of severe pain with movement of right leg During an interview on 12/03/2019 at 2:38 p.m. the hospital forensic nurse said she was called to see Resident #3 because the resident had a fractured right knee and a large bruise on her right inner thigh area. She said the resident was contracted and non-verbal. She said pictures were taken in the emergency room because the resident was dirty with poor oral care and appeared to have received overall very poor care. She said she called the facility and spoke with LVN B. LVN B said the resident was scheduled to get showers Tuesday, Thursday and Saturday. During an interview on 12/3/19 at 3:45 p.m. the hospital RN in charge of Resident #3 said the resident had to receive a bed bath at least twice in one day to remove the dirt and buildup on her body and hair before she could go to surgery. He said the resident had dirty nails, crusty buildup in the creases of her arms, legs, and under her breast which had an odor. He said she was taken to surgery due to the fractured right knee. The hospital RN said the resident was total care and non-verbal with upper and lower arm and leg contractures. He said he could not put an incontinent brief on the resident due to her contractures. 2. Physician orders [REDACTED].#4 was admitted to the facility on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #3 was to receive 80 mg of [MEDICATION NAME] by mouth 2 times daily. The admission MDS dated [DATE] indicated Resident #4 was cognitively intact, required extensive 2 person assistance with bed mobility and toilet use. The MDS indicated transferring from one surface to another did not occur, personal hygiene occurred only once or twice with 1 person assistance and bathing did not occur. The MDS indicated the resident was always incontinent of bowel and bladder A care plan dated 09/26/2019 indicated Resident #4 had limited physical mobility and an ADL selfcare performance deficit with interventions to provide a sponge bath when a shower could not be tolerated, two person assistance to turn and reposition, extensive assistance by 1 staff to dress, extensive assistance by 1 staff for personal hygiene and oral care, extensive assistance by 1 staff for toileting and 2 staff assistance for transfers with the mechanical lift. Skin assessments for Resident #4 indicated the following: 10/14/19-no skin issues 10/17/19 - no abnormal skin - small amount of redness under right abdominal fold and buttock. 10/24/19-yes-abnormal skin; non pressure area, redness-barrier cream 10/31/19-no abnormal areas 11/06/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/09/19-no skin issues 11/13/19-no skin issues 11/20/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/27/19-no assessment done 12/04/19-yes abnormal skin; non pressure area, redness-barrier cream During an observation and interview on 12/04/19 at 7:26 a.m., Resident #4 said she received bed baths three days a week on Monday, Wednesday and Friday, and had not had a shower in at least 3 weeks. Resident #4 was tearful and said she was told nursing did not have time for 2 people to use the mechanical lift for her to go to the shower. She said she would rather have a shower at least once a week. She said her hair had not been washed in over 2 weeks. She said she had to wait over 30 minutes for her incontinent brief to be changed and it caused her bottom to burn. Resident #4 said some staff got upset with her and a CNA told her to tell her physician to take her off the [MEDICATION NAME] because it made her urinate too much. She said she had talked to the administrator, but nothing had been done. She said she felt bad and upset due to the aides complaining when they had to change her. She said it took 2 people and they would have to come back with help. She said it would take over 30 minutes for the aides to come back and change her and she would have to lay there in urine. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. During an interview on 12/04/19 at 12:03 p.m., LVN B said it took two aides to help Resident #4 with her care. She said it took a while to provide incontinent and showers for Resident #4 because it required 2 people to change her and the aides had to have the time to get her up with the mechanical lift, so the resident usually received a bed bath. 3. Physician orders [REDACTED].#1 was admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Diff), with contact isolation, cerebral infarction, dementia, [MEDICAL CONDITION]/[MEDICAL CONDITION] of right side, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A significant change MDS dated [DATE] indicated Resident #1 rarely understood, was rarely understood and displayed inattention and altered levels of consciousness The MDS indicated the resident required 2 people assist with mobility, transfers and toileting and 1 person assistance with bathing and personal care. The MDS indicated Resident#1 was always incontinent of bowel and bladder. A care plan updated 11/21/2019 indicated Resident #1 was incontinent with interventions including clean peri area with each incontinent episode, use disposable briefs and change prn (as needed). The care plan indicated Resident #1 was to have a bath 3 times weekly and was to have a sponge bath when a full bath or shower could not be tolerated. The care plan indicated the resident was to have nail care on bath days and as necessary and staff were to provide oral and hair care. The ADL sheets for (MONTH) 1, 2019 through (MONTH) 3, 2019 indicated Resident #1 received a bed bath on her bath days. The ADL sheets did not have documentation of nail care or shampoos. During an observation and interview on 11/27/2019 at 1:29 p.m., Resident #1 was lying in bed. She said she was getting a sponge bed bath at least 2-3 times a week instead of a shower and was not getting her hair washed. She said she wanted to get out of bed and go to the shower and have her hair washed in the shower. She said staff would come in her room and turn her call light off and never come back. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The call light was activated at 1:29 p.m. during surveyor observation. A CNA came into the room to pick up a tray and did not acknowledge the call light or ask the resident if she needed assistance. The call light was subsequently answered at 1:46 p.m. by another CN[NAME] During an interview on 11/27/2019 at 1:35 p.m., Resident #1's son said they had a care plan meeting over 2 weeks ago and they discussed his mother's care, but he felt nothing was done. He said he complained of staff not turning the resident or checking on her every 2 hour and the room smelling due to dirty trash, and trash on the floor. He said his mother was not given water because she had to have a thickener. He said the call light was not answered in over 20 minutes and his mother has been thirsty and wet every time he visited, which was daily. He said his mother had not had a shower and had her hair washed with water and shampoo in at least 2 weeks. He said he was told he could pay for the beautician to shampoo her hair. During an interview on 11/27/19 at 1:22 p.m., the unit manager said there was enough staff to take care of the residents. She said it took longer to answer call lights because staff was picking up lunch trays. She said anyone could answer the call lights. During an interview on 12/04/19 at 8:30 a.m. the administrator said he was made aware today of Resident #4's concerns and was working on them. He said he was aware a CNA told Resident #4 she should not be taking [MEDICATION NAME] and he reprimanded the CN[NAME] He said he did not complete a grievance form regarding Resident #1 or #4. He said Resident #1's son had informed him of his concerns about the resident not having a shower, hair care, water not available, and call light not being answered timely. He said Resident #3 had been up in a wheel chair on some days and needed staff to transfer and change her. He said the aides provided nail and hair care with the showers and bed baths. The administrator said he was aware in the past there was a problem regarding not getting residents up, call lights not being answered timely and residents being found wet. He said he was working on resolving these issues. During an interview on12/16/19 at 10:30 a.m., the DON said 1 side of the hall received a shower on Monday, Wednesday and Friday and the other side of the hall received showers on Tuesday, Thursday and Saturday. He said staff knew which residents got a bath on which days. He said he did not have a shower schedule to send to the surveyor. The DON said the facility did not have an ADL policy. An in-service dated 11/27/2019 titled ADL Care indicated Baths were to be completed on scheduled day, shower preferred, bed bath acceptable, hair must be washed with every bathing. Check resident for nail care when bathing.

Based on observation, interview and record review, the facility failed to provide a dignified existence with self-determination for 3 of 12 residents reviewed for resident rights. (Resident #s 1, 3, and 4). The facility did not provide Resident #3 showers, appropriate oral care or nail care. Resident #3 was admitted to the hospital with [REDACTED]. The resident had to be bathed 2 times in the hospital in one day to remove the built up dirt from her body and hair prior to surgery. The facility did not provide Resident #4 with a shower for 3 weeks nor timely incontinent care. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. The resident was upset and tearful about her lack of care. The facility did not provide for Resident #1 with showers or nail care and did not answer the call light timely. It took approximately 20 minutes for the call light to be answered. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The resident wanted to get out of the bed and receive a shower. Findings included: 1. Physician order [REDACTED].#3 was admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order with a start date of 10/2/19 indicated Resident #3 was to receive a pureed diet with nectar thick liquids. An order with a start date of 10/4/19 indicated staff were to encourage fluids every shift. An order with a start date of 10/25/19 indicated staff may crush medications. The annual MDS dated [DATE] indicated Resident #3 had moderately impaired cognition and was able to make herself understood. The MDS indicated she required extensive assistance of 1 person with bed mobility, dressing, and eating and was totally dependent with 1 person assistance with transfers, toilet use, personal hygiene, bathing. The MDS indicated she was always incontinent of bowel and bladder, was at risk for skin breakdown and did not have any ulcers, wounds or skin problems. A care plan initiated 11/1/2018 indicated Resident #3 had an ADL self-care performance deficit with interventions including to check nail length and trim and clean nails on bath day as necessary, resident was totally dependent on 1 staff to provide bath/shower, resident required extensive assistance by staff with personal hygiene and oral care and resident required extensive assistance by 1 staff to eat. The care plan did not indicate the frequency times the resident was to receive bath/shower. The care plan initiated 9/20/19 indicated Resident #3 had a swallowing problem and dysphasia (difficulty swallowing) with interventions including to provide pureed diet with nectar thickened liquids, feed resident every meal, monitor and report intake, monitor/document/report pocketing, choking, holding food in mouth, not swallowing and refusing to eat. A care plan dated 10/27/2019 indicated Resident #3 had a potential for dehydration related to poor intake with interventions including encourage fluids every shirt, monitor and document and report any signs or symptoms of dehydration including cracked lips and furrowed tongue (multiple grooves on the top of the tongue) A care plan initiated 12/3/19 indicated Resident #3 would be provided a sponge bath when a full bath or shower could not be tolerated. Resident had contractures of the right leg and left hand and would be provided with skin care daily and as needed to keep clean and prevent skin breakdown. The resident required skin inspection daily to observe for redness, open areas, scratches, cuts, bruises and to report changes to the nurse. Resident was totally dependent on 2 staff for transferring using a mechanical lift. The ADL sheets from (MONTH) 2019 indicated Resident #3 did not receive a shower, bed bath or tub bath from 11/22/19 through 11/30/19. A nursing note dated 12/03/19 indicated Resident #3 was observed with swelling to the right knee and was sent to the hospital. A hospital record dated 12/03/19 indicated Resident #3 had a fractured right knee and was admitted to the hospital for surgery. The resident was in ICU during surveyor visit. A hospital record dated 12/3/19 completed by an emergency room physician indicated Resident #3 was non-verbal and unable to answer question. The record indicated the physician contacted the SANE screener for possible abuse. A hospital record dated 12/3/19 at 10:12 a.m., completed by the hospital forensic nurse indicated Resident #3 came into the emergency department with the following: *Dirty teeth caked with a white substance *Something that looked like a pill in the back of her mouth *Lips and mouth were dry *Her tongue was dry, leathery and cracked *There was dried food in the sunken area above her collar bone, *A moist buildup with odor to her left breast *Dirt in and around both ears *Limited range of motion in both shoulders, both elbows and left knee due to contractures *Right knee swollen with deformity *8 cm x 9 cm blue/red/purple bruise to the right inner thigh *Patient complained of severe pain with movement of right leg During an interview on 12/03/2019 at 2:38 p.m. the hospital forensic nurse said she was called to see Resident #3 because the resident had a fractured right knee and a large bruise on her right inner thigh area. She said the resident was contracted and non-verbal. She said pictures were taken in the emergency room because the resident was dirty with poor oral care and appeared to have received overall very poor care. She said she called the facility and spoke with LVN B. LVN B said the resident was scheduled to get showers Tuesday, Thursday and Saturday. During an interview on 12/3/19 at 3:45 p.m. the hospital RN in charge of Resident #3 said the resident had to receive a bed bath at least twice in one day to remove the dirt and buildup on her body and hair before she could go to surgery. He said the resident had dirty nails, crusty buildup in the creases of her arms, legs, and under her breast which had an odor. He said she was taken to surgery due to the fractured right knee. The hospital RN said the resident was total care and non-verbal with upper and lower arm and leg contractures. He said he could not put an incontinent brief on the resident due to her contractures. 2. Physician orders [REDACTED].#4 was admitted to the facility on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated Resident #3 was to receive 80 mg of [MEDICATION NAME] by mouth 2 times daily. The admission MDS dated [DATE] indicated Resident #4 was cognitively intact, required extensive 2 person assistance with bed mobility and toilet use. The MDS indicated transferring from one surface to another did not occur, personal hygiene occurred only once or twice with 1 person assistance and bathing did not occur. The MDS indicated the resident was always incontinent of bowel and bladder A care plan dated 09/26/2019 indicated Resident #4 had limited physical mobility and an ADL selfcare performance deficit with interventions to provide a sponge bath when a shower could not be tolerated, two person assistance to turn and reposition, extensive assistance by 1 staff to dress, extensive assistance by 1 staff for personal hygiene and oral care, extensive assistance by 1 staff for toileting and 2 staff assistance for transfers with the mechanical lift. Skin assessments for Resident #4 indicated the following: 10/14/19-no skin issues 10/17/19 - no abnormal skin - small amount of redness under right abdominal fold and buttock. 10/24/19-yes-abnormal skin; non pressure area, redness-barrier cream 10/31/19-no abnormal areas 11/06/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/09/19-no skin issues 11/13/19-no skin issues 11/20/19- yes-abnormal skin; non pressure area, redness-barrier cream 11/27/19-no assessment done 12/04/19-yes abnormal skin; non pressure area, redness-barrier cream During an observation and interview on 12/04/19 at 7:26 a.m., Resident #4 said she received bed baths three days a week on Monday, Wednesday and Friday, and had not had a shower in at least 3 weeks. Resident #4 was tearful and said she was told nursing did not have time for 2 people to use the mechanical lift for her to go to the shower. She said she would rather have a shower at least once a week. She said her hair had not been washed in over 2 weeks. She said she had to wait over 30 minutes for her incontinent brief to be changed and it caused her bottom to burn. Resident #4 said some staff got upset with her and a CNA told her to tell her physician to take her off the [MEDICATION NAME] because it made her urinate too much. She said she had talked to the administrator, but nothing had been done. She said she felt bad and upset due to the aides complaining when they had to change her. She said it took 2 people and they would have to come back with help. She said it would take over 30 minutes for the aides to come back and change her and she would have to lay there in urine. The resident's hair was dry with an unpleasant odor and she had red unbroken skin to her perineal, between her legs and buttock area. During an interview on 12/04/19 at 12:03 p.m., LVN B said it took two aides to help Resident #4 with her care. She said it took a while to provide incontinent and showers for Resident #4 because it required 2 people to change her and the aides had to have the time to get her up with the mechanical lift, so the resident usually received a bed bath. 3. Physician orders [REDACTED].#1 was admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Diff), with contact isolation, cerebral infarction, dementia, [MEDICAL CONDITION]/[MEDICAL CONDITION] of right side, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A significant change MDS dated [DATE] indicated Resident #1 rarely understood, was rarely understood and displayed inattention and altered levels of consciousness The MDS indicated the resident required 2 people assist with mobility, transfers and toileting and 1 person assistance with bathing and personal care. The MDS indicated Resident#1 was always incontinent of bowel and bladder. A care plan updated 11/21/2019 indicated Resident #1 was incontinent with interventions including clean peri area with each incontinent episode, use disposable briefs and change prn (as needed). The care plan indicated Resident #1 was to have a bath 3 times weekly and was to have a sponge bath when a full bath or shower could not be tolerated. The care plan indicated the resident was to have nail care on bath days and as necessary and staff were to provide oral and hair care. The ADL sheets for (MONTH) 1, 2019 through (MONTH) 3, 2019 indicated Resident #1 received a bed bath on her bath days. The ADL sheets did not have documentation of nail care or shampoos. During an observation and interview on 11/27/2019 at 1:29 p.m., Resident #1 was lying in bed. She said she was getting a sponge bed bath at least 2-3 times a week instead of a shower and was not getting her hair washed. She said she wanted to get out of bed and go to the shower and have her hair washed in the shower. She said staff would come in her room and turn her call light off and never come back. Resident #1's nails had a brown crusty substance under them and her hair had an unpleasant odor and was not combed. The call light was activated at 1:29 p.m. during surveyor observation. A CNA came into the room to pick up a tray and did not acknowledge the call light or ask the resident if she needed assistance. The call light was subsequently answered at 1:46 p.m. by another CN[NAME] During an interview on 11/27/2019 at 1:35 p.m., Resident #1's son said they had a care plan meeting over 2 weeks ago and they discussed his mother's care, but he felt nothing was done. He said he complained of staff not turning the resident or checking on her every 2 hour and the room smelling due to dirty trash, and trash on the floor. He said his mother was not given water because she had to have a thickener. He said the call light was not answered in over 20 minutes and his mother has been thirsty and wet every time he visited, which was daily. He said his mother had not had a shower and had her hair washed with water and shampoo in at least 2 weeks. He said he was told he could pay for the beautician to shampoo her hair. During an interview on 11/27/19 at 1:22 p.m., the unit manager said there was enough staff to take care of the residents. She said it took longer to answer call lights because staff was picking up lunch trays. She said anyone could answer the call lights. During an interview on 12/04/19 at 8:30 a.m. the administrator said he was made aware today of Resident #4's concerns and was working on them. He said he was aware a CNA told Resident #4 she should not be taking [MEDICATION NAME] and he reprimanded the CN[NAME] He said he did not complete a grievance form regarding Resident #1 or #4. He said Resident #1's son had informed him of his concerns about the resident not having a shower, hair care, water not available, and call light not being answered timely. He said Resident #3 had been up in a wheel chair on some days and needed staff to transfer and change her. He said the aides provided nail and hair care with the showers and bed baths. The administrator said he was aware in the past there was a problem regarding not getting residents up, call lights not being answered timely and residents being found wet. He said he was working on resolving these issues. During an interview on12/16/19 at 10:30 a.m., the DON said 1 side of the hall received a shower on Monday, Wednesday and Friday and the other side of the hall received showers on Tuesday, Thursday and Saturday. He said staff knew which residents got a bath on which days. He said he did not have a shower schedule to send to the surveyor. The DON said the facility did not have an ADL policy. An in-service dated 11/27/2019 titled ADL Care indicated Baths were to be completed on scheduled day, shower preferred, bed bath acceptable, hair must be washed with every bathing. Check resident for nail care when bathing.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents reviewed for accidents. (Resident #8) The facility did not ensure Resident #8 was adequately supervised when CNA A left Resident #8 alone in her wheelchair in the bathroom, and returned to find her on the floor. Resident #8 sustained a fractured left hip. This failure could place 31 residents with a history of falls and fall with major injuries at risk for accidents and injuries. Findings included: An MDS dated [DATE] indicated Resident #8, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The MDS further indicated Resident #8's cognitive impairment was considered severe, and she required extensive 1 to 2 person physical assistance for activities of daily living (ADLs), utilized a wheelchair for mobility, and could only stabilize with staff assistance when moving from seated to standing position or surface-to-surface transfer (transfer between bed and chair or wheelchair). A Care Plan dated 04/04/17 indicated Resident #8 was at risk for falls related to her weakness and lack of safety awareness due to her dementia. An updated Care Plan dated 06/23/17 indicated Resident #8 was at risk for decreased ability to perform ADLs related to her limited mobility. A Fall Risk assessment dated [DATE] indicated Resident #8 had a high risk for falls. A nursing progress note for Resident #8 dated 01/15/18 at 9:48 a.m., indicated Resident #8 had a fall on 1/15/18, with no injury. Intervention included adding a cushion to the resident's wheelchair. The note indicated Resident #8 was at risk for falls related to her weakness and lack of safety awareness due to dementia. A statement dated 01/22/18 and completed by CNA A indicated: On Friday 01/19/18 I was giving Resident #8 a shower. I was getting her dressed. She was already in her wheelchair and I stepped out to get extra towels to dry her off. When I came back I noticed that she had fallen out of her wheelchair. I went to get help. I went and got CNA B and LVN A to help me put her back in her wheelchair. During an interview on 01/23/18 at 3:45 p.m., LVN A said CNA A called her into Resident #8's bathroom and found Resident #8 on the floor. She said Resident #8 was sitting sideways and next to the wheelchair. LVN A said she did not remember if the wheelchair was locked. She said Resident #8 did not grimace or complain of pain. LVN A said she helped CNA A and CNA B lift Resident #8 into her wheelchair. LVN A said CNA A told her Resident #8 was trying to fall and he eased her to the floor. She said LVN A said CNA A did not say he left Resident #8 alone to get extra towels. LVN A said she told LVN B what happened. An undated statement completed by LVN A indicated she and LVN B were informed by CNA A that Resident #8 was falling and he eased her to the floor. LVN A indicated she and CNA B went to help pick her up. Resident #8 did not report pain or signs of pain or discomfort. The statement indicated the staff helped Resident #8 into her wheelchair. A statement completed by LVN B and dated 01/24/18 indicated on 01/19/18 at approximately 4:00 p.m., a CNA informed her that Resident #8 was moved to the floor during a transfer, and noted LVN A assessed Resident #8 and found she had no complaints of pain, and her vital signs were stable. During an interview on 01/23/18 at 3:30 p.m., the Director of Nurses (DON) said he was not aware of Resident #8's fall on 01/19/18 until LVN C called him on 01/21/18. An undated statement completed by CNA B indicated on 01/19/18, CNA A asked CNA B to assist moving Resident #8 from the floor. The statement indicated CNA B asked CNA A if he notified the nurse that Resident #8 was on the floor, and CNA A said he did not. CNA B told CNA A that a nurse should always be notified after a fall, before the resident is moved, and CNA B got assistance from LVN A. The statement indicated assessed the resident and asked if she was hurting, and Resident #8 replied no. CNA B's note indicated Resident #8 stated that she sat on the floor. CNA B and CNA A transferred Resident #8 back to her wheelchair while LVN A was still in the room, noting Resident #8 never expressed pain. During an interview on 01/23/18 at 4:50 p.m., LVN C said on Saturday, 01/20/18 Resident #8 was in her wheelchair and complained of leg pain after the breakfast meal. She said Resident #8 was assisted back to bed and received pain medication. LVN B said on Sunday 01/21/18, Resident #8 was in her wheelchair and complained of leg pain before the breakfast meal was served. She said Resident #8 was assisted back to her bed and received pain medication. LVN C said she was not aware Resident #8 had fallen on 01/19/18. She said when CNA A came to work at 2:00 p.m., while she was discussing Resident #8's complaints of leg pain and leg swelling with LVN D, CNA A reported Resident #8 had fallen on 01/19/18. She said she called the DON and Resident #8's physician, who ordered an x-ray. She said the x-ray results indicated Resident #8 had a left [MEDICAL CONDITION]. A Nursing Progress Note for Resident # 8 dated 1/22/18 at 9:31 a.m. indicated Resident #8 had a fall in the shower room, and complained of pain to her left hip. The nursing note indicated an x-ray was ordered and the resident was sent to the ER for further evaluation. There was no further documentation of an assessment for Resident #8 dated 1/19/18 through 1/22/18. An Incident Report dated 1/22/18 indicated on 1/21/18 at 2:00 p.m., the facility became aware of Resident #8's fall on 1/19/18 and the physician and the responsible party were notified. The facility Falls Management Policy revised 03/15/19 included the following: *Response to a Patient Fall - 1. Evaluate and Monitor patient for 72 hours after the fall. Complete change of condition note and enter the fall as a new event into the Risk Management System (RMS). Review the patient's medical record and assessments to identify any causes that may have contributed to the fall. 2. Investigate fall circumstances utilizing the Fall Investigation QA tool in RMS. 3. Implement immediate interventions after the fall. 4. Notify physician and responsible party after the fall. 5. Update care plan with new interventions as appropriate. 6. Monitor patient response. The CMS Form 802 dated 01/19/18 indicated 31 residents with a history of falls and fall with major injuries.