Every finding on record at Sunset Valley Rehabilitation and Healthcare Center

Based on interviews, and record review, the facility failed to ensure residents had the right to send and receive mail for 11 of 11 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail on the weekend. This failure could put residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in the residents' psychosocial well-being and quality of life.Findings included: During a confidential group interview at an undisclosed date and time, 11 of 11 residents said mail was not being distributed on the weekend. They indicated they were unsure why mail was not delivered by the weekend staff. They indicated they had never received mail on the weekend, nor had they ever been asked at their regular monthly meetings about receiving mail on the weekend. They stated they thought that was not a service offered by the facility. In an interview on 02/26/2026 at 09:17 a.m. AD stated she passes out the resident's mail to them Monday through Friday. She stated the post office holds mail on Saturday and delivers it on Monday. She stated she was not sure why mail was not delivered on Saturday. In an interview on 02/26/2026 at 02:15 p.m. BOM stated she received mail for the facility including mail for the residents. She stated she works Monday through Friday. She stated the post office holds the mail for Saturday and delivers it to the facility on Monday. She stated she was not sure why but that has been the way it has been since she started. She stated she delivers all mail to AD, and she passes it out to the residents. In an interview on 02/26/2026 at 09:32 a.m. ADM stated he was not aware of the mail not being delivered on Saturday. He stated he was not sure if mail was delivered to the facility on Saturday. He stated when the mail was delivered the receptionist will deliver to the right person. He stated the receptionist and BOM work Monday through Friday. He stated the potential negative outcome could be a violation of resident rights. During an interview on 2/26/26 at 4:00 p.m. the ADM stated they followed the Federal Regulations requirements for any policies not provided. Record review of Federal Resident Rights dated 02/24/2022 found in the Resident admission packet reflected in the section Privacy and Confidentiality that a resident had the right to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the facility for you, including those delivered through a means other than the postal service.

Based on observation, interview, and record review, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 11 of 11 confidential residents. The facility failed to ensure 11 confidential residents were provided with access to the grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during an undisclosed date and time, 11 confidential residents stated they did not have access to the Grievance form, they did not know they could file a grievance anonymously, the grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the grievance procedure in prominent locations. The confidential Residents also said they did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. Record review of the facility Grievance policy revised date 12/2023; revealed the facility's grievance information should be posted in designated locations throughout the facility. Observation of prominent postings on 02/25/2026 at 03:20 p.m., observed the front door area, area around the nurses' station, area down halls A, B, C and D, no observation of grievance information found. No observed grievance forms were available, and there was no access to submit grievances anonymously. During an interview on 02/25/2026 at 03:30 p.m. with AD, she stated the SW keeps grievance forms in her office. She stated SW was not at the facility full-time. She stated the residents would let her know if they have a grievance and they would write them for them. She stated the residents do not have access to blank grievance forms. During an interview on 02/26/2026 at 09:32 a.m. with ADM, he stated the SW was responsible for grievance forms. He stated the SW resigned on 02/23/2026. He stated he was not aware there were no forms available for residents to file a grievance anonymously. He stated his expectations were for forms to be available to residents. He stated staff have been trained in grievance forms. He stated the potential negative outcome could be violation of resident rights. Record Review Grievance Policy revised date 12/2023 revealed the following: Policy Statement:It is the policy of the facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agencies/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have.Procedure: .2. Information is made available to the resident and/or representative and posted in designated locations throughout the facility. Information includes:Resident/resident representative have the right to file grievance orally, in writing and/or anonymously.

Based on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise, for 1 (Resident #46) of 15 residents reviewed for nutrition. The facility failed to implement monitoring and interventions to ensure that Resident #46 did not have a significant weight loss of 30.3 pounds, a 16.5% body weight loss, between 01/02/26 and 02/03/26. This failure could place residents at risk for decreased nutritional status, malnutrition, and a decline in health.Findings Included:Record review of Resident #46's face sheet dated 02/26/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #46 had diagnoses with included: end stage renal disease (the final stage of kidney failure), alcoholic cirrhosis of the liver (alcohol-associated liver disease), Type II Diabetes Mellitus (a disease resulting in inadequate control of glucose in the blood), major depressive disorder (a mental health disorder characterized by depressed mood and loss of interest in activities), and malignant neoplasm of the colon (cancerous tumor of the large intestine). Record review of Resident #46's quarterly MDS (Minimum Data Set) assessment, dated 02/05/26, reflected a BIMS (Brief Interview for Mental Status) score of 07, which indicated the resident had severe cognitive impairment. Further review of MDS, Section D - Mood, indicated the resident did not have a poor appetite. Section GG - Functional Abilities - indicated Resident #46 completed the task of eating independently and required set up and clean up assistance prior to and following the activity. Section K - Swallowing/Nutritional Status, indicated the resident had a weight 153 pounds. Section O - Special Treatments, Procedures, and Programs, indicated the resident received dialysis while a resident. Record review of Resident #46's Comprehensive Care Plan initiated on 02/01/26 and revised on 02/08/26, reflected:Focus: [Name] Resident #46 Has potential nutritional problem r/t risk for malnutrition and requiring a therapeutic diet to manage diabetes.Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date.Interventions/Tasks [in part]:Diet as ordered by the physician. LCS (Low concentrated sweets), No salt on tray, regular texture with thin liquids.Monitor and report to MD as needed for any s/s of: decreased appetite, N/V, unexpected weight loss, c/o stomach pain, etc.Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation [unusually thin or weak], (Cachexia) [muscle wasting], significant weight loss.Provide supplements as ordered: diabetic snack for risk of malnutritionProvide supplements as ordered: Med Pass 2.0 (nutritional supplement), Prostat (liquid protein supplement), Megace (medication for appetite stimulation). Record review of Resident #46's Physician's Orders dated 02/25/26 reflected [in part] the resident had a diet order for LCS (Low Concentrated Sweets) diet regular texture, thin liquids. Diabetic snack at bedtime for risk of malnutrition with a start date of 02/01/26. Med Pass 2.0 two times a day 90 ml BID with a start date of 12/19/25. Prostat three times a day 30 ml TID with a start date of 12/19/25. Further review reflected an order for Megace Oral Suspension 40 mg/ml - give 10 ml by mouth one time a day for weight loss with a start date of 10/24/25. Record review of Resident #46's February 2026 MAR reflected:Diabetic snack - give at bedtime for risk of malnutritionMegace Oral Suspension 40 mg/ml - give 10 ml by mouth one time per day for weight loss - start date 10/24/25Med Pass 2.0 - give 90 ml BID - start date 12/19/25ProStat - give 30 ml TID - start date 12/19/25 Record review of Resident #46's facility weight record reflected the resident was on weekly weights during the month of December 2025 and had one facility weight in January 2026 and one weight in February 2026. No facility weights were found in the resident's record following the significant weight loss on 02/03/26. The record reflected the following weights:02/03/26 - 153.2 pounds [-16.5% change, -30.3 pounds]01/02/26 - 183.5 pounds12/16/25 - 185.0 pounds12/17/25 - 185.7 pounds12/03/25 - 173.6 pounds11/28/25 - 176.8 pounds Record review of Resident #46's meal intake record for 02/02/26 - 02/25/26 reflected the resident consumed 50% or less of a meal on the following dates: 02/02/26, 02/07/26, 02/11/26, 02/15/26, 02/16/26, 02/17/26, 02/21/26, 02/22/26, 02/24/26, and 02/25/26. Record review for the month of January 2026 was not available. Record review of Resident #46's Annual Nutrition Evaluation, completed by the RD, dated 02/24/26 reflected [in part] a most recent weight of 153.2 pounds. Recommendations were made by the RD as follows: use dry weights [weight after dialysis] only for weight monitoring to ensure accuracy; Add house shakes (dietary supplement) daily for 30 days with a goal to maintain current weight. Record review of Resident #46's progress notes dated 02/25/26 reflected: Weight Warning: Value: 153.2-5.0% change [16.5%, 30.3]-7.5% change [17.3%, 32.1]-10.0% change [20.9%, 40.4]Resident is on a LCS regular diet. RD will review and notify DON, ADON of any new orders. During an observation and interview on 02/24/26 at 11:47 AM, Resident #46 was up in his wheelchair in his room Resident #46 was dressed and groomed. The resident stated he goes to dialysis three times per week on Monday, Wednesday, and Friday. He stated he was hard of hearing. Resident #46 stated he ate his meals in his room most of the time and he was offered snacks in between meals but stated he was not hungry some days. Resident #46 was asked if he had recently lost weight and the resident shrugged and stated, No. The resident did not respond to further questions and rolled himself out of his room. During a phone interview on 02/25/26 at 12:17 PM, the RD stated she had not been contacted by the facility regarding Resident #46's significant weight loss. She stated she was in the facility on 02/23/26 for her monthly visit and noted Resident #46's weight loss in the electronic medical record. The RD stated she did not see Resident #46 during her 02/23/26 onsite visit because he was out of the facility for dialysis. She stated she was in the facility 8 hours/month, but the facility could contact her at any time if a resident had a significant weight change or needed a virtual visit. The RD stated that when a resident had a significant weight change, she would expect to see the resident placed on weekly weights for a month, or until the weight stabilized. She stated Resident #46's weight loss was calculated as severe weight loss for a 30-day period and she made the following recommendations: Track weights using only post-dialysis weights for accuracy and consistency; Add a health shake once per day for 30 days and reevaluate resident status. The RD stated she believed Resident #46's weight loss and potential for further weight loss may have been reduced if weekly weights and implementations had been made when significant weight loss was demonstrated on 02/03/26. She stated she would follow up with Resident #46 on her next onsite visit or PRN if requested by the facility. During an interview on 02/25/26 at 3:32 PM, the Medical Director (MD) stated she had been Resident #46's physician for several years. She stated she did not recall the date the facility made her aware of Resident #46's significant weigh loss but she had seen him on a routine visit at the facility on 02/18/26. The MD stated she ordered lab work and a CT scan (a diagnostic tool that uses X-rays and computers to produce images of bones, organs and tissues) due to the resident having a previous history of colon cancer. She stated the CT scan was awaiting pre-authorization and the lab work did not show anything remarkable. The MD stated she was aware of the recommendations made by the RD and had signed the order for health shakes daily and to monitor post-dialysis weights following each dialysis session. She stated she would continue to follow Resident #46's progress on a weekly basis and PRN. During an interview on 02/26/24 at 11:44 AM, CNA F stated Resident #46 usually ate in his room. She stated the resident normally ate 50% or less at breakfast and ate more at lunch and dinner. She stated Resident #46 received a snack daily around 2 PM but he usually did not eat the snack. CNA F stated the resident had noticeably lost weight and his clothing was loose on him. She stated she recorded meal intakes in the computer and had been trained to report to the charge nurse when a resident consumed less than 25% of a meal. She stated the CNA's were responsible for obtaining resident weights at the first of the month. She stated she would weigh residents monthly as she was assigned and would turn the weights in to the charge nurse for review. During an interview on 02/26/26 at 11:50 AM, LVN C stated the CNA's were assigned to get resident weights at the first of the month. She stated the CNA's would give the completed weight list to the charge nurse and residents who showed weight changes were reweighed the following day. LVN C stated once all reweights were obtained, the weight list was given to the DON for review and MD notification, if needed. During an interview on 02/26/26 at 1:19 PM, the DON stated Resident #46 was his own representative and attempts to contact family members for updates with the resident's care had been unsuccessful. She stated residents were weighed at the beginning of every month. She stated new admissions and residents with significant changes in weight were weighed weekly. She stated the CNA's on day shift were responsible for weighing residents and entering weights in the health record. The DON stated she was responsible for reviewing the weights and determining significant weight changes. She stated, according to policy, if a resident experienced a significant change in weight, the policy was to contact the physician and monitor weight weekly. The DON stated she did not know why Resident #46 was not placed on weekly weights when he had a significant weight loss. She stated she was aware that Resident #46 had significant weight loss on 02/11/26 and she notified the physician of the weight loss. The DON stated the physician had ordered a CT scan for the resident, which was still pending authorization. She stated the physician saw the resident on 02/18/26 and ordered lab work. She stated Resident #46 should have been placed on weekly weights to monitor further changes in weight. The DON stated a potential negative outcome for failure to monitor weights and make timely interventions for significant weight changes was malnutrition, skin integrity changes and a decreased quality of life. During an interview on 02/26/26 at 12:53 PM, the ADM stated he was not aware that Resident #46 had significant weight loss until annual survey. He stated nursing staff and nursing administration were responsible for ensuring weights are monitored and timely notifications of significant weight changes are made to physicians and the RD. The ADM stated his expectation of staff was to monitor resident weight and make timely notification of changes to physicians because it can really affect a resident. The ADM stated a potential negative outcome for failure to monitor resident weight and make timely interventions for significant changes would depend on the diagnosis, but it could cause medical issues. Record review of the facility's undated policy titled, Policy/Procedure - Nursing Clinical reflected the following: Section: Care and Treatment Subject: Nutrition: Weight Management Policy: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Purpose: To provide care and services including: Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. Implementation of orders as written by the Doctor Clinical Evaluation: 1. Nutritional assessment may include: Weighing and weight changes 2. The Nurse will notify physician, family, and/or resident of weight loss/gain with interventions.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for 2 of 2 meals (lunch meals) and for 2 of 2 pureed food trays (on 2/24/26 and 2/25/26) reviewed for meal accuracy, in that: On 2/24/26, [NAME] E failed to serve the correct portion size of braised Swiss steak and mashed potatoes according to the prepared menu for lunch for 40 residents. 2. On 2/24/26, [NAME] E failed to follow the recipe for Braised Swiss Steak, causing dish to be served in the form of a loose meat in a liquid soup instead of a patty topped with gravy. 3. [NAME] E failed to include the wheat roll on the pureed food trays served during lunch on 2/24/26 and [NAME] D failed to include the cornbread on the pureed food trays served during lunch on 2/25/26. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.The findings included: Record review of the menu for the lunch meal on 2/24/26 at 11:30 AM revealed, Braised Swiss Steak, Mashed Potatoes, Steamed Broccoli, Wheat Roll, Margarine, Fruit Cobbler, Beverage. During an observation and interview on 02/24/26 at 11:30 AM [NAME] E, pureed the braised Swiss steak for the lunch meal, transferred it to a tray, and placed it on the steam table. [NAME] E stated she had pureed the broccoli already and she did not have to puree the mashed potatoes. [NAME] E lifted the foil from a tray on the steam table that contained the pureed broccoli. During an observation on 2/24/26 at 12:10 PM, [NAME] E tempted the hot food before serving the lunch meal. She removed the lid from the Braised Swiss Steak, and it was noticed to be a loose meat in a soup texture liquid, the temperature was 188 F, mashed potatoes 198 F, broccoli 196 F, pureed braised Swiss steak 148 F, and pureed broccoli 172 F. During an observation on 2/24/26 at 12:15 PM, [NAME] E used the following utensils to serve the regular meal #10 spoodle (3/8 cup) to serve the liquid braised Swiss, a #4 ladle (1/2 cup) to serve the steamed broccoli, a #20 scoop (3-1/3 Tbsp) to serve the mashed potatoes, 1 roll was served, and a small cup of fruit cocktail. Record review of the facility recipe for mashed potatoes revealed the serving size was 1/2 cup. Record review of the facility recipe for braised Swiss steak for 40 servings revealed the following: salt iodized table- 1 1/8 Tsp, milk homo gallon 3 1/8 cup, eggs whole easy eggs with citric 2 1/4 cup, beef ground fine 81/19 (Thawed) 8 1/2 lb., bread crumbs Japanese panko 1 1/8 Qt, pepper black ground 1 1/8 Tsp, Tomato diced in juice (drained) 6 lb., with brown gravy 2 7/8 cup, onion yellow jumbo (sliced) 1 cup. Serving Size: 3oz. (3/8 cup) Step #: 1 Wash hands before beginning preparation sanitize all surfaces and equipment. Combine all ingredients except gravy mix, mix on low speed only until blended, do not over mix. CCP- maintain at an internal temperature of < 41 F. Step #: 2 Portion meat using a #8 dipper (1/2 cup) onto a lightly greased or paper lined baking sheet. Flatten slightly. Refrigerate, 41 F until ready to cook. Step #: 3 Drain diced tomatoes and combine with peppered gravy, mix well Step #: 4 Layer patties slightly overlapping into 2-inch steam table pans. Place sliced onions over meat. Cover with gravy/tomato mixture. Cover with foil and bake. Serve 1 Swiss Steak with 1-2 oz of onion and gravy. CCP - cook to an internal temperature of 145 F held for 4 minutes. CCP - maintain at an internal temperature of > 140 F for only 4 hours. Record review of facility recipe for mashed potatoes for 40 servings revealed the following tap water 1 1/8 gallons, potatoes mashed real 2 lbs., margarine solids pure vegetable 1 cup. Step #: 1 Wash hands before beginning preparation sanitize all surfaces and equipment. Use water and follow for exact amount. Pour boiling water into mixer bowl. Use whip attachment to mix on low and slowly add potatoes. Mix for one minute. Scrape bowl then whip on high until fluffy (3-5 minutes). Step #: 2 Add margin. Reheat, if necessary, before serving. CCP - [NAME] to an internal temperature of one 145 F held for 15 seconds. CCP - maintain an internal temperature of >140 F for only 4 hours. CCP - cool: Product internal temperature must decrease from 140 F to 70 F within 2 hours and 70 F to 41 F within 4 hours. CCP - reheat to an internal temperature of 165 F held for 15 seconds comma within 2 hours one time only. Record review of facility recipe for wheat roll for 40 servings revealed the following: Dough roll honey wheat unbaked 40 each. Step #: 1 Wash hands before beginning preparation sanitize all surfaces and equipment. Per manufacturer instructions - for the wheat roll: pan 48 (6X8) for clusters or 24 (4X6) for singles on lined sheet pan. Thaw: retarder thaw time (35- 38 F) for 12-18 hours. Room temperature 60 minutes. Proof at 95 F / 85 % relative humidity for 40-50 minutes. Baking standard oven 375 F for 12-14 minutes with five second's steam. Deck oven 375 F for 12-14 minutes. Convection oven 325 F for 10-12 minutes and turn the tray 180 F after 5 to 6 minutes of baking mist water generously on rolls with a spray bottle just before rolls go in the oven. Step #: 2 For the whole grain roll: On lined greased pan, pan 24 (4x6) for singles or 48 (6x8) for clusters. Thaw: Retard at 38 F for 18 hours on a covered rack. Floor thaw to template #21 (2 3/4 x 1 3/4) for 60-90 minutes at ambient conditions to template #22. Baking: before placing in oven, spray product with water and sprinkle with seed if desired, Standard oven 375 F for 10-12 minutes (14-18 minutes if clustered baked) then steam for 20 seconds. Convection oven 325 for 10-12 minutes, rotate tray at 6-7 minutes. Optional: in place of wheat roll, serve a whole grain roll. During an interview on 2/24/26 at 12:20 PM, the DS stated it was important for staff to follow the menu, and they must follow the menu when serving meals to residents because it could cause someone to get sick, be served the wrong diet, or choke. He also stated it was important to serve correct portions as it could affect residents' diet or weight. The DS stated they did not have all the ingredients to make the fruit cobbler, so it was substituted with a cup of mixed fruit. During an observation on 2/24/26 at 12:41 PM, two trays of pureed food included braised Swiss steak, broccoli, mashed potatoes, and fruit. The wheat roll was not observed on the tray. Record review of the menu for the lunch meal on 2/25/26 at 11:30 AM revealed baked ham, sweet potato, seasoned greens, cornbread, margarine, bread pudding, beverage. During an observation on 2/25/26 at 12:42 PM, two trays of pureed food included sweet potatoes, green beans, ham with gravy, and lime-green colored ice cream. The cornbread was not observed on the tray. Record review of [name of certification] Certification certificate, dated 2/11/24, revealed [NAME] D had successfully completed the Texas Food Handler Training. During an interview on 2/26/26 at 11:30 AM, [NAME] D stated she prepared the lunch puree meal yesterday (2/25/26) and only prepared the starch and meat items on the menu. She stated she was trained to puree the starch, vegetables, meat, and bread items listed on the menu. She stated cornbread was on the menu yesterday, but she did not puree it yesterday for lunch because she was running behind but she normally purees the bread items listed on the menu. She stated she did not substitute the cornbread with anything else for that meal. She stated she was aware menu items count for certain proteins and carbohydrates and so those meals were short of those items. She stated it was important for residents who eat puree meals to be served all items listed on the meals so they could get the correct calorie count for their body, for their bones, and to have energy. She stated she was not trained to skip menu items when running late and that she was supposed to still puree the cornbread. She stated she was responsible for ensuring all items on the menu for puree meals were prepared. [NAME] D stated she must follow all recipes to ensure they cooked the right amount of food. [NAME] D stated the recipe book indicated the portion size or scoop they must use when serving the food. She stated it was better to give more food than not enough. She stated residents could lose weight if they did not use correct scoop size and didn't serve enough food on their plates. She stated she told her boss when she needed to substitute items for items they could not make. She stated she compared labels on the containers of the food items to ensure they were substituting something adequate, but they usually used food they had in the kitchen for the substitution. She stated residents could lose weight and lose protein and not have electrolytes they needed to function properly. During an interview on 2/26/26 at 12:29 PM, the RD stated staff should've followed recipes when preparing meals. She stated substituted food items should've been something of equal nutrient value and documented in a log or staff should've sent a text message or called herself or the DS for approval for substituted food items. She stated the Swiss steak dish should've been a patty steak with a sauce on top and should not have been served as loose meat in a liquid soup. She stated puree meals should've been served the same menu items as the regular and mechanical meals aside from things that could not be pureed such as rolls, bread, cornbread, etc., however those items should have been substituted for another food item that was of equal nutrient value. She stated staff should've followed all portion sizes according to the recipe when serving meals. She stated they were in the process of ordering new utensils since they did not have all the utensils listed on the recipes however in the meantime, staff should've still served the correct amount of food listed on the recipe. Record review of [name of training program] Texas Food Handler Training Program certificate, dated effective 8/14/25, revealed [NAME] E had successfully completed the [name of training program] Texas Food Handler Education or Training Program. During an interview on 02/26/2026 at 12:50 PM, [NAME] E she stated when she prepared the braised Swiss steak she did not have the correct meat, she needed a cubed steak, and she used a thin shaved like steak. She stated the braised Swiss steak didn't thicken, that it had a lot of tomato sauce. She stated that she had used 1 large can of tomato sauce (approximately 102 to 106 ounces). She didn't add enough flour, and it didn't thicken correctly because there was too much tomato sauce, so it was a soup consistency. She stated she followed the recipe to the best of her ability. She stated on the portion sizes / scoop sizes for the meal on the braised Swiss steak, she did as much as she could but might have had too much sauce and not enough meat, so she put more meat in the bowl, and there was too much liquid, she had made an error. She stated that she had not tried to puree bread before and it was an error on her part. She did not puree the roll for the two puree trays. She stated it was important to follow the recipe and correct portions size because of allergies, safety, weight loss, and lack of nutritional value. She stated if residents did not receive the correct portion sizes, they could not get the correct nutritional values they needed. She stated she received in-services and training; however, it was usually about abuse, neglect, and other topics like that, and not topics specific to her department. Record review of a National Restaurant Association license certificate, undated, revealed the DS had successfully completed the program set forth for Food Protection Manager Certification Examination with an expiration date of 12/1/26. During an interview on 2/26/26 at 1:39 PM, the DS stated he would make a list of approved substitutions for staff to follow in the future. He stated he expected staff to follow recipes because they could include ingredients that should not be in the recipe and then residents would be served those ingredients and could get sick. He stated staff should've served the portions listed on the recipe because this could cause residents to gain weight or cause malnutrition. He stated residents that ate pureed meals were vulnerable and not getting items listed on the menu would cause them to have a shortage of nutrition and prevent their ability to heal. He stated he expected staff to ask for help when running late. During an interview on 2/26/26 at 2:28 PM, the ADM stated he was recently hired and had not had a chance to go into the kitchen and inspect it for any concerns. He stated he was not aware staff were not following menus and he was not aware of any other issues going on in the kitchen. He stated he would provide resources for staff and monitor issues in the kitchen more closely. He stated the kitchen staff had not been in-serviced on kitchen related topics the kitchen since he started employment. He stated the DS would be responsible to ensure kitchen staff were trained. He stated he would meet with the DS and staff to see where they are and provide them with proper training because he was not aware if they were trained properly. He stated residents that ate a pureed diet should've been served all items on the menu or they would not receive the proper nutritional value. During an interview on 2/26/26 at 4:00 PM, the ADM stated they followed the Federal Regulations requirements for any policies not provided. Record review of the facility's policy titled Dietary, undated, revealed in part: Policy Statement: The facility shall ensure that all food service operations comply with applicable state and federal regulations, including those set forth by Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS), to protect residents from foodborne illness and ensure nutritional adequacy. 3. Following Approved Recipes Policy:All meals shall be prepared according to approved, standardized recipes to ensure consistency, food safety, and nutritional compliance. Procedure:Use only recipes approved by:-Registered Dietitian (RD)-Dietary ManagerRecipes must include:-Ingredients and quantities-Preparation steps-Cooking temperatures and times-Portion sizesStaff must:-Follow recipes exactly unless a documented substitution is approved-Use calibrated measuring toolsAny recipe modification must be:-Approved by the RD-Documented in writing Special diets (e.g., diabetic, renal, mechanically soft, pureed) must strictly follow physician orders and dietitian guidance. Record review of the facility's policy titled Portion Control, undated, revealed in part: Procedure:Standardized recipes should be used to avoid waste caused by over production. Recipes should be adjusted as needed and the yield and service size specified on each recipe. Record review of the facility's policy untitled and undated, revealed in part: Policy: Nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility's reasonable efforts, menus should reflect the religious, cultural, and ethnic needs of the population served, as well as input received from individuals and groups. Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. 6. Temporary changes in the menu will be noted on the menu substitution sheets and posted so that facility staff is aware of changes. The Registered Dietician Nutritionist or designee will approve all permanent menu changes.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. The facility failed to ensure no expired food items were in the kitchen. 2. Toxic items were not stored in a manner to prevent contamination of foods and food contact equipment (hand sanitizer). 3. Time Temperature Controlled for Safety cold foods were not maintained at 41 F or below (milk/supplements) due to refrigerators not functioning properly. 4. Foods were held for use beyond the manufacturers recommended Best if used by/ Best by dates (kitchen storage). 5. Clean plates and bowls were stored facing upward. These failures could place residents at risk for food contamination and foodborne illness. The findings included: On 2/24/26 at 9:44 AM an initial kitchen observation tour began. The tour ended at 10:30 AM and revealed the following: The external thermometer of Refrigerator B indicated an internal temperature of 45 F. The contents observed inside the refrigerator was a case of tomatoes, a case of butter, 2 large bags of unopened shredded cheddar cheese, a gallon sized sandwich bag filled with diced chicken, three heads of purple cabbage, an unopened bag of shredded cabbage, nine gallon sized containers of various condiments that were previously opened, four gallon size unopened bags of chopped iceberg lettuce, six cartons of pasteurized eggs, one gallon size unopened bag of shredded parmesan cheese, an opened gallon of whole milk 3/4 empty, a container filled with pureed sausage, a container of mechanically altered sausage, 6 unopened containers of chicken base, a container filled with puree egg, two packages of unopened chicken thighs, and a container of chicken noodle soup labeled use by 2/24/26. The external thermometer of the Refrigerator named Victory, indicated an internal temperature of 45 F. The internal thermometer on the left side of the refrigerator indicated an internal temperature of 38 F. The internal thermometer on the right side of the refrigerator indicated an internal temperature of 46 F. The DS stated he received a shipment of food this morning and was in the process of labeling the food before putting it in the refrigerators, which affected the temperatures of the refrigerators. The Dietary Supervisor stated refrigerator temperatures should be at or below 35 F. He stated the facility was currently working on getting everything up to code. He stated the facility had purchased new refrigerators and was waiting for them to be delivered. A personal beverage and a bottle of Premium Hand Sanitizer with Aloe was observed sitting on the bottom shelf of the preparation table next to a loaf of bread, a tub of peanut butter dated 2/16, and an opened bottle of Grape jelly dated 8/5. Additionally, the outside of the Grape Jelly was labeled, refrigerate after opening. The tour of the dried food pantry revealed five bags of corn tortilla chips dated 12/16, a tray of whole white onions dated 2/16 use by 2/29 had 3 white onions with large black spots and 5 onions that sprouted green stocks, and an opened 37 lb. tub of multi-use lemon filling over 1/2 empty dated 8/19 were all stored on shelves in the pantry. The DS stated the chips were probably expired and the lemon filling were expired and should both have been thrown away. During an observation and interview on 2/24/26 at 2:35 PM the external thermometer of Refrigerator B indicated 46 F and the internal thermometer indicated 44 F. Temperatures were taken of food items in Refrigerator B by the DS. A raw pasteurized egg had a temperature of 50.2 F. A tub of chick noodle soup had a temperature of 46 F. A tray of raw bacon had a temperature of 28 F. The dietary supervisor stated the bacon was still partially frozen. A bag of mechanical soft chicken had a temperature of 49 F. A bag of chopped lettuce had a temperature of 48.7 F. The Dietary supervisor stated refrigerator temperature should've been between 40 F and 30 F and the current temperature was not safe. The external thermometer of Refrigerator named Victory indicated 42 F. The left side internal thermometer indicated a temperature of 36 F and the right-side thermometer indicated a temperature of 42 F. Temperatures were taken of food items in Refrigerator named Victory by the DS. A pack of deli ham had a temperature of 43.3 F. A single carton of whole milk had a temperature of 41.5 F. A single-use carton of Mighty Shake had a temperature of 43.7 F. A 1/2 cup of whole milk poured from a gallon of whole milk had a temperature of 45.1 F. During an interview on 2/24/26 at 2:50 PM, the DS stated the temperatures of the food in the refrigerators were above safe temperatures and that he would contact his boss and notify him of the refrigerators and food temperatures. During an interview on 2/24/26 at 3:07 PM, the Clinical Practitioner stated all the food in the refrigerators was thrown away and a refrigerated truck was ordered to be brought to the facility by [food distribution company] to hold an emergency order of refrigerated food they purchased. During an interview on 2/24/26 at 3:59 PM, the DS supervisor stated he was in the process of placing an emergency order to the [food distribution company] who would deliver the refrigerated food truck by 5:00 AM on 2/25/26. He stated the refrigerated food truck would remain on the premises to hold refrigerated food. He stated he purchased the chicken being served this afternoon at the local grocery store. On 2/25/26 from 10:21 AM to 10:28 AM, a kitchen observation tour revealed the following: The dried food panty revealed five bags of corn tortilla chips dated 12/16 and an opened 37 lb. tub of multi-use lemon filling dated 8/19 were stored on shelves in the pantry. A personal beverage and a bottle of Advanced Gel Hand Sanitizer was observed sitting on the bottom shelf of the preparation table next to a loaf of bread, a tub of peanut butter dated 2/16, and an opened bottle of Grape jelly dated 8/5. Additionally, the outside of the Grape Jelly was labeled, refrigerate after opening. Two stacks of clean plates and two bowls were observed faced upwards on a shelf. During an interview on 2/26/26 at 11:30 AM, [NAME] D stated she was supposed to store clean dishes face down to dry because stuff would sit in them such as sanitizer if they were stored right side up. She stated she would leave them like that until they dried completely. She stated opened food was dated for the date it was opened and had to be thrown away after 3 days. She stated all staff were responsible for ensuring open food was thrown away within 3 days. She stated cold food was to be kept between 20 to 35 . She stated frozen food was to be kept at 20 or in the negative temperatures; hot food meat must be between 160 -170 ; veggies were to be between 145 - 150 . She stated she usually kept hand sanitizer by the sink, and the sanitation buckets were kept underneath the area they were working in, personal drinks for all staff were kept in the office. She stated she was certified in food handling and was due this month for renewal. She stated staff checked the dry food storage area every Tuesday to rotate and throw away expired food since this was when the truck brought in new food orders. She stated staff should've included the year when writing the date on the food. She stated the lemon pie filling should've been thrown away. She stated she had not had any new in-services since new company took over earlier this month. During an interview on 2/26/26 at 12:29 PM, the RD stated cold food should be kept at 41 or they run risk of possible infection as the food was in the danger zone of possible contamination. She stated she was contacted on Wednesday (2/24/26) about refrigerators not holding temperatures of 41 by the DS. She stated the DS threw food away all the food in the refrigerators and bought new food at the grocery store. She stated the DS placed an emergency food order to replace the discarded food and received a shipment for the supplement shakes today. She stated she sent a recipe for supplement shakes to the DON and approved for them to buy other premade supplement shakes to give residents that needed them on 2/25/26. During an interview on 02/26/26 at 12:50 PM, [NAME] E stated cold food items needed to be kept at a safe temperature of 30 F and 40 F. She stated if the refrigerator temperatures go over 40 F, she was to monitor and see if the temperature would go back down. That the seal on refrigerator marked B could be weird and staff would have to push on the door all the way, hold it and make sure it would seal. She stated if cold food was above 40 F, it could develop foodborne pathogens. She stated she reported to the DS if the temperature was above 40 F. [NAME] E stated the lunch she prepared on 2/24/26 was meat from the freezer, a package of peppered gravy, canned tomato sauce, frozen broccoli, and a can of fruit cocktail, instant mashed potatoes, wheat rolls. During an interview on 2/26/26 at 1:39 PM, the DS stated he expected staff to report temperatures on refrigerators to him immediately. The DS stated clean bowls and plates were to be placed in a dry rack and then put up once dried. He stated clean dishes were to be stored face down because any standing water would not drain and could grow bacteria. He stated unopened dry food was good until the expiration date, however opened dry food should've been discarded 3 to 5 days after being opened. The DS stated new refrigerators were scheduled to be delivered sometimes today. He stated 5 cases of supplement health shakes were received today and were stored in the refrigerated truck until the new refrigerators were set up. The DS stated he preferred staff to keep personal drinks in the office. He stated hand sanitizer should've been kept on the bottom shelf near the preparation station however, it should not have been stored next to the bread or any food items. He stated in-services that addressed food temperatures and notifications were completed with staff that were yesterday and today. He stated [NAME] E had not been in-serviced yet since she was not working. He stated he was a new employee and was still working on getting everything up to code in the kitchen. He stated they would use [food distribution company] as their provider in the future which was a different company than was used before the new company took over earlier this month. He stated he had ordered utensils and all supplies from [food distribution company] and this company should be able to provide everything else they need for the kitchen. He stated he was responsible for ensuring all guidelines in the kitchen were being followed. During an interview on 2/26/26 at 2:28 PM, the ADM stated he was not aware the refrigerators were not cooling to the appropriate temperature as he was recently hired and had not had a chance to go into the kitchen and inspect it for any concerns. He stated the DS also just started working at the facility last week. He stated he was not aware of any issues going on in the kitchen. He stated he would provide resources for staff and monitor issues in the kitchen more closely. He stated the kitchen staff had not been in-serviced on kitchen related topics the kitchen since he started employment. He stated the DS would be responsible to ensure kitchen staff were trained. He stated he would meet with the DS and staff to see where they are and provide them with proper training because he was not aware if they were trained properly. He stated cold food temperature issues could have caused sickness. He stated clean dishes should have been stored face down because they could have standing water that could grow bacteria. During an interview on 2/26/26 at 4:00 PM, the ADM stated they followed the Federal Regulations requirements for any policies not provided. Record review of the facility's policy titled Dietary Services, Subject: Food Sanitary Conditions for, undated, revealed in part: Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by Federal, State, and/or local authorities. Procedures:1. The facility will store, prepare, distribute, and serve food under sanitary conditions.2. Hot foods will leave the kitchen (or steam table) above 135 F and cold foods at or below41 F.5. Refrigerator temperatures should be at 41 F or below.7. Toxic items (i.e., insecticides, detergent, and polishes) will be properly stored, labeled, and used separately from the food. Record review of the facility's policy titled Dietary, undated, revealed in part: Policy Statement: The facility shall ensure that all food service operations comply with applicable state and federal regulations, including those set forth by Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS), to protect residents from foodborne illness and ensure nutritional adequacy. Scope: This policy applies to all dietary, nursing, and supervisory staff involved in food handling, preparation, service, and storage. Procedures1. Dish and Utensil StoragePolicy: All clean dishes, utensils, and food-contact equipment shall be stored in a sanitary manner to prevent contamination.Procedure:-Store clean dishes and utensils covered or inverted in designated clean storage areas.-Keep storage shelves at least 6 inches off the floor.-Separate clean items from soiled items at all times.-Air-dry dishes; do not towel-dry.-Inspect storage areas daily for cleanliness, dust, pests, or moisture.-Remove chipped, cracked, or damaged dishes from service immediately.2. Expired Food ControlPolicy: The facility shall not store, prepare, or serve expired, spoiled, or unsafe food.Procedure:All food items must be clearly labeled with:-Date received or prepared-Use-by or expiration dateImmediately discard:-Expired food-Food with signs of spoilage (odor, mold, discoloration)-Food from compromised packaging (swollen cans, broken seals).

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication cart (Hall D medication cart) reviewed for storage of drugs.The Facility failed to provide change direction labels for Resident #15's medication package of hydroxyzine (hydroxyzine is an antihistamine that reduces symptoms caused by allergies) which had medication order change from as needed every 6 hours to 10 mg twice a day. This failure could place residents at risk of medication misuse and diversion.The findings were:Record review of Resident #15's physician orders, dated 02/26/2026, revealed an order for hydroxyzine 10 mg give 1 tab by mouth twice a day with a start date of 01/29/2026 and no end date. Observation on 02/25/2026 at 08:32 a.m. revealed a package in the Hall D medication cart contained medication for Resident #15 with a label for 10 mg of hydroxyzine, and instructions to give 1 tab by mouth every 6 hours as needed. MA administered 10 mg of hydroxyzine to Resident #15. During an interview on 02/26/2026 at 09:08 a.m. the MA B stated she was aware Resident #15 hydroxyzine medication was changed from as needed to twice a day. She stated the process when medication order change was to place a label change sticker on the top of the medication blister pack until the new medication blister pack was received from pharmacy. She stated she was not sure why the sticker was not put on the blister pack. She stated she had been trained in medication changes. She stated the potential negative outcome could be resident not getting the medication as ordered. During an interview on 02/26/2026 at 09:10 a.m. LVN A stated when medication orders were changed, they notify the MA and remind them to place a medication change sticker on the medication blister pack. She stated she had been trained in medication order changes. She stated the potential negative outcome could be the resident getting the wrong medication dose. During an interview on 02/26/2026 at 09:23 a.m. the DON stated the process for medication order changes was there should be a sticker on blister pack and notifying the pharmacy. She stated all staff have been trained in medication order changes. She stated all nurses and MA were responsible for making sure a sticker was placed on the medication blister pack when the medication order has changed. She stated her expectations would be that once they have a new medication order, they address it with MA so the sticker can be placed on blister pack at that time. She stated the potential negative outcome could be over dosage or under dosage. During an interview on 02/26/2026 at 09:32 a.m. the ADM stated he was not aware Resident #15 medication label was wrong. He stated he was not sure what the process was and would have to talk with his DON. He stated his expectation was for the nurses to be following the facility policy and keeping the residents safe. He stated the DON, ADON and pharmacy consultant were responsible for monitoring medication order changes. He stated the potential negative outcome were lots of variables. On 02/26/2026 at 11:44 a.m. surveyor requested policy related to medication order changes and medication label changes from ADM. During an interview on 2/26/26 at 4:00 p.m. the ADM stated they followed the Federal Regulations requirements for any policies not provided.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #52) reviewed for infection control. LVN C did not wash her hands after removing PPE and exiting Resident #52's room. These failures could place residents at risk for cross contamination and infection. Findings included: Record review of the admission record for Resident #52 undated, revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: sepsis (infection which can result in widespread inflammation and damage to vital organs), epilepsy (seizure disorder), diabetes (high blood sugar) and quadriplegia (partial or complete loss of function in all four limbs and torso). During an observation on 0/24/2026 at 04:46p.m., LVN C was preparing G-Tube medications for Resident #52 at the medication cart located in the hallway outside of the resident's door. Observation of the PPE cart located beside Resident #52's door revealed an EBP sign above the cart. LVN C put on PPE (gown and gloves), gathered supplies off top of cart and entered Resident #52's room. LVN C put supplies and medications on the bedside table. LVNC determined she was missing a medication and she picked up medications off bedside table, removed PPE and exited Resident #52's room. LVN C did not wash her hands after removing PPE. During an interview on 02/24/2026 at 05:18 p.m., LVN C stated she was aware she did not wash her hand or use ABHR after removing PPE. She stated she should have washed her hands after removing PPE but she forgot. She stated she had been trained on proper hand hygiene and to wash hands after removing PPE. She stated the potential negative outcome could be spreading infection. During an interview on 02/26/2026 at 09:23 a.m., the DON stated staff should wash their hands after removing PPE. She stated all staff were responsible for following proper hand hygiene. She stated all staff have been trained in proper hand hygiene and PPE. She stated she expects all staff to wash hands or use ABHR after removing gloves. She stated the potential negative outcome could be spread of infection and cross contamination. During an interview on 02/26/2026 at 09:32 a.m., the ADM stated he was not aware staff were not washing hands or using ABHR after removing gloves. He stated all staff had been trained on proper hand hygiene. He stated staff should be washing hands or using ABHR after removing gloves. He stated the potential negative outcome could be possible cross contamination and infection control. Record review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of 10/2022 reflected the following: Policy Statement: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose:Hand hygiene is one of the most effective measures to prevent the spread of infection.Procedure: .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves; .

Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 2 residents reviewed for smoking. (Resident #29) The facility failed to ensure Resident #29 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) in their room. This failure could place residents at risk of injury or harm. The findings included: Review of Resident #29's face sheet, dated 2/25/26, revealed a [AGE] year-old male with an initial admission date of 1/28/20 with the following diagnoses: Acute Respiratory Failure with Hypoxia (inability for the lungs to adequately transfer oxygen to the blood), Unspecified Dementia, Unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss, inability to think/plan), Epilepsy, unspecified, intractable, without status epilepticus (neurological disorder characterized by unprovoked seizures), personal history of Transient Ischemic Attack, and cerebral infarction without residual deficits (temporary blockage of blood flow to the brain, resulting in stroke-like symptoms causing brain damage), major depressive disorder, recurrent severe without psychotic features (mental illness), and tobacco use. Record review of Resident #29's annual MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 1, indicating the resident had moderate problems with thinking and memory. Section J – Health Conditions, Other Health Conditions revealed Resident #29 used tobacco. Record review of Resident #29's comprehensive care plan, dated 2/2/26, revealed focus: resident #29 used tobacco, date initiated 2/2/26. Goal: Resident would adhere to the tobacco/smoking policies of the facility, dated initiated 2/2/26. Intervention: Educate Resident / Family on risks & health effects of tobacco use; Resident smoking materials will be kept at the nurse's station, dated 2/2/26. Record review of Resident #29's Smoking Evaluation, dated 2/2/26, revealed Resident #29 was alert and oriented and able to light his own cigarette and able to hold properly. Record review of facility policy titled: Smoking and Safety Measures, original date 3/2008, revealed in part: Safety Measures: 4. All smoking materials, charging devices and charging of electronic cigarettes will be secured at the nurse's station when not in use during designated smoking times. Additionally, the document was signed by Resident #29 on 2/2/26. During an interview on 2/25/26 at 10:39 AM, the Driver stated Resident #29 went outside on his own to smoke because he could smoke independently. During an interview on 2/25/26 at 10:43 AM, Resident #29 stated he kept smoking materials in his pocket. Resident #29 stated he had something else he needed to do and he ended the interview. During an observation on 2/25/26 at 10:45 AM, Resident #29 was observed outside in the smoking area. Resident pulled a container out of his sweater pocket. Resident #29 took a cigarette and lighter out of the container. Resident #29 put the cigarette in his mouth and lit it without staff assistance. The Driver observed Resident #29 light his cigarette as well. During an interview and observation on 2/26/26 at 9:44 AM, Resident #29 stated he kept his cigarettes and lighter in his sweater pocket. Resident #29 stated he had never been told he had to keep his cigarettes and lighter at the nurse station. Resident #29 pulled a container out of his sweater pocket and opened it in which cigarettes and a lighter were observed. During an interview on 2/26/26 at 10:13 AM, the ADM stated there was no one to his knowledge that kept smoking materials in their room. The ADM stated there was no variance given to any residents regarding the new smoking policy that was implemented when the new company took over the facility. During an interview on 2/26/26 at 12:45 PM, the Driver stated she supervised the 2:00 PM smoking breaks for residents. The Driver stated Resident #29 kept his smoking materials including cigarettes and lighters in his room. She stated Resident #29 kept his cigarettes and lighter in an empty deodorant container on his person when he brought them outside to smoke. She stated Resident #29 was able to light his own cigarette and smoke independently. She stated she previously was told by a nurse that no one was supposed to have smoking materials in their room. She stated she had gotten another resident to voluntarily hand over their lighter recently. She stated she had not asked Resident #29 for his smoking materials because he had always smoked on his own. The Driver stated she told some nurses that Resident #29 had smoking materials in their room after the new policy was implemented when the new company took over the facility. The Driver stated she could not recall what nurses she told. She stated she was not given any additional instructions after reporting the information to the nurses. She stated Resident #29 could be difficult at times. The Driver stated she had not received training on the new smoking policy since the switch over to the new company. The Driver stated Resident #29's family buys his smoking materials. She stated other residents' smoking materials were locked in the medication room. The Driver stated a potential negative outcome was that someone could accidentally set a fire, burn the facility down, an oxygen tank could explode, or a resident could get burned. The Driver stated someone else could get ahold of the smoking materials and have an accident. During an interview on 2/26/26 at 2:47 PM, the ADM stated residents were not allowed to keep smoking materials including lighters in their rooms and that all smoking materials must be kept at the nurse's station. The ADM stated the current smoking policy was implemented on 2/1/26 when the new company took over the facility. The ADM stated all residents that smoked reviewed the new policy and signed the agreement. The ADM stated he was not aware there were residents who kept smoking materials in their rooms. The ADM stated he would continue to educate residents about how smoking materials were safety hazards and fire hazards however he could not confiscate the smoking materials against their will due to resident rights. The ADM stated all staff had been in-serviced on the new smoking policy during morning meetings. The ADM stated he expected staff to tell him or the DON if they were to become aware of any residents that kept smoking materials in their rooms so they could educate the residents. The ADM stated potential negative outcome was that it was a fire hazard. Record review of the facility' policy titled Smoking and Safety Measures, original date March 2008 reflected the following in part: Safety Measures: . 4. All smoking materials, charging devices and charging of electronic cigarettes will be secured at the nurse's station when not in use during designated smoking times.

Based on observation, interview, and record review, the facility failed to ensure residents were aware of where to locate the State Agency (SA) survey inspection results such as surveys, certifications, and complaint/incident investigations, and post in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 facility in that: The facility failed on 02/25/2026 to make a survey binder that was readily available and easily identified to all residents or the public that included survey results for viewing. This failure placed residents at risk of not being able to fully exercise their rights and at risk of not being aware of the facility's past deficiencies.Findings included: During a confidential group interview at an undisclosed date and time, 11 of 11 residents stated they did not know where or how to access survey results in the facility. They all stated they had never seen a binder labeled with that information near the front door or receptionist desk. In an observation on 02/25/2026 at 10:45 a.m. of the facility's front door area, the receptionist desk, the area around the nurses' station, and the area near the administrative offices revealed there was no evidence of a survey results binder or notice of where to locate the binder. In an observation and interview on 02/26/2026 at 09:32 a.m. with the ADM who when asked where the state survey results binder was located, the ADM stated it was posted at the front door area, and the binder was in the receptionist office. During observation with the ADM there was no sign posted at the front door area and no survey binder available in the receptionist office. He stated his expectations were for proper signage to be always posted and survey binder available. He stated the potential negative outcome would be violation of resident rights. On 02/26/2026 at 11:44 a.m. surveyor requested policy related to posting and availability of State Agency (SA) survey inspection results such as (surveys, certifications, and complaint/incident investigations).During an interview on 2/26/26 at 4:00 p.m. the ADM stated they followed the Federal Regulations requirements for any policies not provided.

Based on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 (Resident #1) of 5 residents reviewed for behavioral health services. The facility failed to ensure Resident #1's comprehensive care plan included goals and interventions addressing her documented history of aggression, refusal of care and the use of psychotropic medication for behavioral management related to her behavioral diagnosis.This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety. Findings included:Record review of Resident #1's face sheet dated 12/22/2025 revealed she was a [AGE] year-old female resident originally admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's disease with late onset (memory loss, confusion), unspecified speech disturbance (difficulty in pronouncing words), intermittent explosive disorder (frequent impulsive anger outburst or aggression), major depressive disorder (depression) and generalized anxiety disorder (feeling anxious).Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 14 out 15 indicating her cognition was intact. The MDS further stated Resident #1 took an antianxiety medication and rejected care 1 to 3 days.Record review of Resident #1's active physician orders revealed an order for Depakote Sprinkles 125 mg, administered twice daily, related to intermittent explosive disorder, initiated on 11/29/2025.Resident #1 did not have any active orders for Lexapro.Record review of Resident #1's discontinued physician orders revealed an order for Lexapro Oral Tablet 10 mg discontinued on 11/5/2025. Record review of Resident #1's comprehensive care plan revised on 12/11/25 revealed it did not include goals or interventions related to her behaviors. The care plan did not address her intermittent explosive disorder or her anxiety disorder. There was no mention of her medication management or behavioral monitoring related to her medication. There was no documentation of Resident #1 having aggressive behaviors or refusing care. The care plan mentioned Resident #1's major depressive disorder, receiving Lexapro and to encourage frequent socialization as an intervention.Record review of Resident #1's Administration Record for November 2025 indicated behavioral monitoring documented that Resident #1 refused care on November 8, 12, 13, 27, and exhibited aggression on November 24 and 26. Record review of Resident #1's Administration Record for December 2025 indicated behavioral monitoring documented that Resident #1 refused care on December 5, 6, 10, 11, 15, 16 and exhibited aggression on December 2, and 6. In an interview on 12/22/2025 at 10:13 AM, LVN B stated Resident #1 could be aggressive with staff. If staff had something Resident #1 wanted, she would get agitated and try to grab it from the staff, such as food. LVN B stated she had not observed Resident #1 being aggressive toward other residents. LVN B stated Resident #1 liked to walk around the building so staff would take her on walks when she was agitated. LVN B further stated that interventions should be included in the residents' care plan so staff would be aware of what works for the residents when they become agitated or aggressive. In an observation and interview on 12/22/2025 at 11:30 AM, Resident #1 was in the dining room, she was clean and dressed for the day, she appeared calm, walking around in the dining room. Resident #1 did not verbalize any concerns related to her care. In an interview on 12/22/2025 at 1:30 PM, MDS Coord. stated he was responsible for updating the resident's care plan and if he was unavailable, the responsibility would fall to Administration. The MDS Coord. stated Resident #1's care plan was missing her diagnoses, her behavioral diagnosis with the medication management, her aggression and her refusal of care. The MDS Coordinator also stated he missed revising the documentation related to her Depression and the discontinued medication Lexapro. The MDS Coord stated that he did not feel the nursing staff used the care plans to check the status of a resident, it was more for when State would come into the building. The MDS Coordinator, however, said the care plan should reflect the current status of a resident. The MDS Coord. stated the facility does not do morning meetings every morning to relay this information. In an interview on 12/22/25 at 2:45 PM, LVN A stated she was not aware of any specific behavioral interventions for Resident #1 other than redirecting. LVN A stated Resident #1 could be aggressive toward staff or if she wanted something staff had, such as food or a drink, she would grab it from staff. LVN A stated if interventions were not addressed per specific behavior, then a possible negative outcome would be that the behavior could possibly get worse. LVN A stated the MDS Coordinator was responsible for ensuring care plans reflected the resident's status. In an interview on 12/22/2025 at 2:51 PM, the DON stated there were interventions in place for Resident #1, such as medication management and redirection. The DON said the AD was also working with Resident #1 in activities. The DON did not mention walking around the building as an intervention. The DON stated the resident's care plan should reflect the resident's diagnoses, medications and refusal of care and any interventions related to resident's behavior The DON stated the MDS Coordinator was responsible to update care plans with interventions or changes, but she was responsible to ensure it was completed. The DON was not sure what was in the care plan related to interventions related to Resident #1's behaviors. The DON further stated not including information in the care plan could result in a lapse in care for the resident. In an interview on 12/22/2025 at 3:00 PM, the AD said she had not been instructed to work specifically with Resident #1 related to behavioral interventions. The AD, however, said the resident does attend activities with the group. The AD stated that although the resident can be difficult to understand, she felt Resident #1 wanted to be heard, and she had made a point to sit with the resident to listen to her and felt doing that helped the resident. In an interview on 12/22/2025 at 3:45 PM during the exit conference, the ADM confirmed the care plan should reflect the resident's' status related to her behaviors and interventions and stated their approach was not where it should be with Resident #1. Record review of the facility's policy Behavioral Health Services dated February 2019 reflected the following:The facility will provide, and residents will receive behavioral health services as need to attain or maintain the highest practicable physical, mental and psychosocial wellbeing in accordance with eh comprehensive assessment and plan of care. Staff training regarding behavioral health services includes, but is not limited to:Recognizing changes in behavior and indicate psychological distress.Implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs.Monitoring care plan interventions and reporting changes in condition.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 37 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure proper hand hygiene techniques were practiced while feeding dependent residents (Residents #1, #2 and #3) during the luncheon service. This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life. Findings included: An observation of the luncheon service on 01/15/2025 at 11:55AM revealed CNA A, CNA B and LVN C feeding residents who required full assistance while eating. CNA A got up from the table where she was feeding Resident #1 to move her wheelchair closer to the table. She sat back down and before continuing to feed Resident #1, ran her hands through her hair to move her hair off her shoulders. CNA A resumed feeding Resident #1 without sanitizing her hands. LVN C sanitized his hands upon entering the dining room, walked to an empty chair at one of the dining room tables, lifted the chair and moved it to the table where dependent residents were being fed and began feeding Resident #2, without re-sanitizing his hands. CNA B was feeding Resident #3 when Resident #4 approached CNA B and asked her to refill his drink. CNA B took the glass from the hand of Resident #4, filled it with the drink the resident had requested, returned the glass to the hand of Resident #4 and then pushed his wheelchair to a dining room table so he could eat. CNA B resumed feeding Resident #3 without sanitizing her hands. An interview with LVN C on 01/15/2025 at 3:23PM revealed he had realized as he began to feed Resident #2, he had not re-sanitized his hands after handling the dining room chair. He stated a negative outcome of not practicing proper hand hygiene between the two tasks was the spread of infections. An interview with CNA A on 01/15/2025 at 3:26PM revealed she realized as she began to feed Resident #1, she had not sanitized her hands after touching the wheelchair of Resident #1 and then touching her own hair, before feeding resident #1. She stated the negative outcome of not practicing proper hand hygiene after moving Resident #1's wheelchair and touching her own hair was contamination. An interview with CNA B on 01/15/2025 at 3:29PM revealed she had realized she had broken hand hygiene by handling the glass of Resident #4, pushing his wheelchair and returning to feed Resident #3 without sanitizing her hands. She stated the negative outcome of not practicing proper hand hygiene between the two tasks was the spread of infections or diseases. An interview with the DON and the ADMN on 01/15/2025 at 4:45PM revealed they had completed in-service education on Hand Hygiene on 11/11/2024 and Universal Precautions on 12/10/2024. The DON stated there was no reason CNA A, CNA B, and LVN C would not know the steps to proper hand hygiene with regard to transmission of infections/disease, as all three had attended both in-services and demonstrated competency. Record Review of facility policy and procedures for Hand Washing/Hand Hygiene dated August 2015 revealed the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (anti-microbial or non-antimicrobial) and water for the following situations. b. Before and after direct contact with residents; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; o. Before and after handling food; q. Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were labeled and dated. 2. The facility failed to ensure refrigerator items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the walk-in refrigerator on 04/24/24 at 8:25 AM revealed the following: 1. (1) partially used package of ham lunch meat, in original package, with no date or label, open to air 2. (1) package of what looks to be lunch meat in saran wrap with no date or label 3. (1) bucket full of 1/2 sandwiches approximately 20 1/2 sandwiches with no date or label 4. (1) 1/2 sandwich with no date or label, open to air 5. (2) plastic container of what appeared to be fruit cocktail no label or date 6. (1) container with approximately 20 cupcakes in the container with no date or label Observation of the freezer on 11/20/24 at 9:40 AM revealed the following: 1. (2) large packages of lemon bread with no date. In an interview on 11/20/24 at 9:50AM, the DM stated that a possible negative outcome for not having labeled and dated food in refrigerator and freezers would be that the food could be outdated, and residents could get sick. The DM stated all staff were responsible for ensuring items were dated and labeled. The DM stated that she recently in-serviced her staff on this issue. In an interview on 11/21/24 at 1:56 PM, DA E stated that a possible negative outcome for not having labeled and dated food in refrigerator and freezers would be that they wouldn't be aware if the food was good, and we could serve bad food to the residents, and they could get sick. The DA E stated that all kitchen staff were responsible for labeling and dating foods. Record review of the facility-provided policy dated July 2014 titled Food Safety and Storage stated in part: .All foods stored in the refrigerator or freezer will be covered, labeled, and dated

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 13 residents (Resident #24) reviewed for resident rights. The facility failed to ensure Resident #24's catheter drainage bag was covered and urine in the bag was not visually exposed. This failure could place residents at risk of feeling uncomfortable and disrespected, and could decrease residents' self-esteem and/or quality of life. Findings included: Record review of Resident #24's face sheet, dated 11-21-2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #24 had diagnoses which included, but not limited to, quadriplegia (a type of paralysis that affects all four limbs and the body from the neck down), central cord syndrome at unspecified level of cervical spinal cord(spinal cord injury in the neck) and muscle wasting and atrophy(gradual loss of muscle mass) Record review of Resident #24's Quarterly MDS dated [DATE] reflected the following: Section C: Resident #24 had a BIMS of 05 out of 15, which indicated he was severely cognitively impaired. Section H; Resident #24 had an indwelling catheter. Record review of Resident #24's physician orders, dated 05-09-2024, reflected provide catheter care every shift. Record review of Resident #24's care plan reflected bladder incontinence with the presence of catheter with intervention to provide catheter care. During an observation on 11-20-2024 at 10:00 AM, revealed Resident #24's catheter bag had no protective cover and hanging from the left side of his bed. There was a small amount of amber liquid noted in the bag. During an observation on 11-21-2024 at 8:07 AM revealed Resident #24 lying in bed asleep. Resident #24's catheter bag was observed hanging from the left side of his bed with no protective cover, there was a small amount of amber liquid noted in the bag. During an interview on 11-20-2024 at 5:08 PM, Resident #24's family member stated during visits with Resident #24, she had observed the bag to be uncovered. The family member stated her grandchildren had wondered what was in the bag because it was uncovered and didn't think Resident #24 would want the bag covered. During an interview on 11-21-2024 at 8:10 AM, CNA D stated catheter bags should be covered at all times. CNA D stated a possible negative outcome for not having a bag covered could be an embarrassment for the resident. During an interview on 11-21-2024 at 10:07AM, CNA C stated all staff were responsible for ensuring privacy bags were put on catheter bags and not having a privacy bag was disrespectful to the resident. During an interview on 11-21-2024 at 1:33 PM, the ADON stated that all staff were responsible for making sure catheter bags were covered because it could be embarrassing to the resident. During an interview on 11-21-2024 at 1:39 PM, LVN A stated that all staff were responsible for making sure catheter bags were covered because it was a dignity issues. During an interview on 11-22-2024 at 8:48 AM, Resident #24 stated he would like his catheter bag covered. Record review of the facility provided policy titled, Quality of life-Dignity dated August 2009, reflected the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 13 residents (Resident #24) reviewed for quality of care, in that: The facility failed to reposition Resident #24 every two hours according to his person-centered care plan. This failure could place residents at risk for not being provided with adequate care and treatment. The findings included: Record review of Resident #24's face sheet, dated 11-21-2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #24 had diagnoses which included, but not limited to, quadriplegia (a type of paralysis that affects all four limbs and the body from the neck down), central cord syndrome at unspecified level of cervical spinal cord(spinal cord injury in the neck) and muscle wasting and atrophy(gradual loss of muscle mass) Record review of Resident #24's Quarterly MDS dated [DATE] reflected the following: Section C : Resident #24 had a BIMS of 05 out of 15, which indicated he was severely cognitively impaired. Section GG: Resident #24 was dependent(helper does all of the effort, Resident does none of the effort to complete the activity) on roll left to right, sitting to lying, eating, oral hygiene, shower/bathe, upper and lower body dressing. Record review of resident #24's care plan reflected that Resident #24's was at risk for alteration in comfort at risk for pain presence with intervention with turning and repositioning every 2 hours or as needed for comfort. Observation of Resident #24 on 11/21/2024 at 8:07 AM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side Observation of Resident #24 on 11/21/2024 at 10:00AM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side Observation of Resident #24 on 11/21/2024 at 12:27 PM, revealed the Resident was lying on his back, his head raised slightly 30-35 degrees, head drooping to the left side During an interview with Resident #24 on 11/22/24 at 8:34 AM, Resident #24 stated that he did not know how many times each day they reposition him but stated it would feel better if they would reposition him more. An interview with Resident #24's family member on 11/21/24 at 1:28 PM revealed she was able to see Resident #24 on the camera they installed in his room. The family member said she did not see the Resident repositioned every two hours. During an interview on 11/22/24 at 1:33 PM, the ADON stated that they did not reposition Resident #24 as much as they used to because he was becoming stiffer. When asked why it was still documented in the care plan, she stated she did not know why and said if it was in the care plan it should have been done. The ADON stated a possible negative outcome for not repositioning Resident #24 as noted in the care plan would be that it could cause pressure ulcers. During an interview on 11/21/24 at 1:39 PM, LVN A stated that Resident #24 should be repositioned every two hours. She said that CNAs were responsible for positioning residents, and the charge nurses were responsible for ensuring it was done. LVN A stated that a possible negative outcome for not repositioning residents every two hours could cause the resident pain. Record Review of the facility's Reposition Policy dated May 2013 reflected the following: Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for reposition to promote comfort for all bed-or chair bound residents and to prevent skin breakdowns, promote circulation and proved pressure relief for resident. Preparation: 1. Review the resident's care plan to evaluate for any special needs of the resident. General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . 2. Reposition is critical for a resident who is immobile or depend upon staff for repositioning . Interventions: Residents who are in bed should be on at least every two-hour repositioning schedule.

Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (09/06/2024) of the 90 days reviewed. The facility did not have an RN working in the facility on 09/06/2024. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings included: Record review of the facility's last 6 months (06/1/2024-11/18/2024) of RN coverage provided by the BOM revealed the facility had no RN working in the facility for the following date: 9/6/24. During an interview on 11/22/24 at 9:15 AM, the ADON stated that a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 11/22/24 at 10:25 AM, the BOM verified that the facility did not have an RN working in the facility on 9/6/24. She stated the consequences of not having an RN in the facility would be not having another set of eyes for the residents. She stated she did not know why there was no RN working the day of 9/6/24 and it was just missed. During an interview on 11/22/24 at 10:55 AM, the ADM stated that she was not aware that a day of RN coverage had not occured on 9/6/24. She stated the negative outcome for not having an RN on staff each day would be that anything could happen. A policy for RN coverage was requested on 11/21/24 at 8:14 AM but was not provided.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on one of two carts the Treatment Cart. Treatment cart contained 1 vial Lantus insulin found open with no expiration date in the top drawer. This failure could place residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health. Findings include: During observation/interview on [DATE] at 10:08 AM of Treatment Cart with LVN A, observation of top-drawer holding insulin, found 1 vial of Lantus insulin with opened date penned [DATE], but without an expiration date. LVN A was asked how many days after opening the insulin before it expires. LVN A replied, This insulin expires 28 days after opening it. That means it is expired. When asked what possible negative outcomes of giving a resident expired insulin could be, he responded, Negative outcome could be deceased effectiveness resulting in elevated blood glucose. LVN A was asked who is responsible for putting expiration dates on medications he stated the nurses are responsible. LVN A took the medication and placed it with the medications to be destroyed. During interview on [DATE] at 10:10AM LVN B was asked about the expiration date of Lantus insulin after opening and stated, That insulin has 28 days after first use before it expires. Asked what possible negative outcomes could be, she stated, If given after it expires it may not be effective in managing blood glucose like it is supposed to. When asked who is responsible for putting expiration dates on medications, she replied the nurses are. During interview on [DATE] with ADON regarding the expired vial of Lantus insulin she stated, That should have been caught. Pharmacy was here on Tuesday and went through the Medication Carts and the Treatment Cart. They didn't say anything about any expiration dates. We haven't been putting on the expiration dates, just the opening dates on the insulins. We need to start putting expiration dates on, so we know when to discard the insulin. When asked about adverse possibilities of using expired insulin on resident's she stated, The insulin won't work well or maybe not at all. During record review of the facility's policy, 'Labeling of Medication Containers' dated revised [DATE] revealed in part: 3. Labels for individual drug containers shall include all necessary information such as: f. The date that the medication was dispensed h. The expiration date when applicable 5. Labels for each single unit dose package shall include all necessary information, such as: c. The date dispensed e. The expiration date when applicable During record review of facility's policy, 'Storage of Medications' date revised [DATE] revealed in part, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

Based on interview, and record review the facility failed to immediately inform the resident's physician and resident representative of a significant change in the residents' physical status and the need to significantly alter the resident's treatment for 1 of 4 residents (Resident #1) reviewed for Change in Condition. The facility failed to correctly notify the physician and resident representative of the extent of one facility-acquired Stage IV pressure injury for Resident #1, thus delaying proper treatment for 2 days. An Immediate Jeopardy (IJ) was identified on 08/22/2024. The IJ Template was provided to the facility on [DATE] at 4:53PM. While the IJ was removed on 08/26/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of Isolated due to the need for implementation of corrective measures and the effectiveness of its corrective plan. This failure could place residents at risk of not having their physician or resident representative informed of changes in their conditions. Findings included: Record review of Resident #1's admission record revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: PRIMARY LATERAL SCLEROSIS (A motor-neuron disease which causes nerves within the brain to slowly break down) DYSPHAGIA, OROPHARYNGEAL PHASE (difficulty swallowing) CHRONIC PAIN SYNDROME PAIN IN UNSPECIFIED SHOULDER OTHER SPEECH DISTURBANCES APHASIA (disorder causing difficulty in verbal communication) MUSCLE WEAKNESS (GENERALIZED) MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE OTHER REDUCED MOBILITY HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE PARKINSON'S DISEASE WITH DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS OTHER MUSCLE SPASM ENCOUNTER FOR SCREENING FOR COVID-19 PERSONAL HISTORY OF COVID-19 OTHER SEASONAL ALLERGIC RHINITIS OTHER CONSTIPATION Record review of skin assessments on 07/28/2024 revealed Resident #1 had a skin assessment performed by LVN C, which indicated no alterations in skin integrity to any part of Resident #1's body. Progress notes written by LVN I on 7/29/2024 stated Resident #1 had open sores with visible tissue deterioration to the bilateral antecubital. areas (inner elbows), but there was no accompanying skin assessment. A phone order dated 07/29/2024 from the RP indicated the wounds were to be treated with Diflucan 150 milligrams (an anti-fungal), once per day, for 3 days and Nystatin Powder with Inter-Dry until the wounds healed. This order was received and recorded by LVN I for the treatment of topical fungus to the bilateral antecubital areas. There was no mention of open sores to the bilateral antecubital areas in the communication notes, while the progress notes from the same date, indicated open areas with visible skin deterioration. Review of skin assessments for Resident #1 revealed LVN C performed an additional skin assessment on 7/31/2024, which indicated during treatment to Resident #1's bilateral antecubital areas, open sores were noted with tendon exposed. There were no wound measurements or staging of the wound performed. A phone order from the RP indicated Resident #1 was to be sent to the hospital for further evaluation of the wounds. Resident #1 was transported to the hospital via ambulance at approximately 10:45AM. On 08/02/2024 at 6:30PM an interview with the DON revealed CNAs are supposed to look at the resident's legs, arms, feet, back, buttocks, face, etc. during showers, to detect any skin tears or bruises that had not been detected prior. The DON stated she had not provided any hands-on training to CNAs regarding identification of wounds. The DON stated that the CNAs are often at bedside when wounds are dressed, so they have seen wounds and how to care for them but have not been specifically trained on looking for wounds during showers or resident rounds. The Administrator came into the office while we were speaking and stated there was a notebook that showed the teach-back assessments the CNAs do yearly, but she could not locate the notebook. The Administrator stated when the CNAs came to work, they were trained on showers, but not on assessing skin. She stated they have an in-service scheduled to train the CNAs on hydration and skin in November, but there had been no in-service done when Resident #1's wounds were discovered. The Administrator stated the facility had a shower schedule for each resident and Resident #1's showers were scheduled for MWF. The DON then stated that Resident #1 was very clean and would take a shower every day if they would let him. She was asked by this investigator if Resident #1 was so clean, why were the wounds to the inside of his elbows not detected during his shower on Monday, 07/29/2024. The DON could not provide a response to this question. The DON stated Resident #1 wore protective sleeves on his arms to keep from getting pressure sores due to his contractures. She stated the sleeves were removed prior to the shower in case they were soiled and need to be replaced. When asked by this investigator why the wounds would not have been detected if the CNA took Resident #1's sleeves off prior to his shower on 07/29/2024, the DON could not provide a response. She stated the CNAs were not in-serviced on skin assessments and reporting after Resident #1's wounds were found. The DON stated the negative outcome of not in-servicing the CNAs might have been that they thought it was not their job to deal with the wounds and possibly a nurse already knew about them. The DON stated when the wounds were first found to Resident #1, LVN I described them to the RP as a fungal infection. Nystatin powder and Diflucan were provided to Resident #1, per the physician's order. On 08/02/2024 at 7:29PM and interview with CNA P revealed she had not been trained specifically on looking for wounds but had been a CNA for a long time and knew what to look for during resident showers and rounds. CNA P stated the facility conducted in-services on Abuse and Neglect and reporting of incidents, but she had not been told to report wounds, specifically. She stated the negative outcome of not reporting a wound was the resident could become very sick with an infection. CNA P stated Resident #1 had indicated to her on 07/29/2024, through his communication device, that he had not received a shower on Friday 07/26/2024 and was still wearing the same sleeves from Wednesday. Review of Progress Notes revealed CNA P showered Resident #1 on 07/29/2024 and found the open areas to his inner elbows which had a purulent smell and green drainage. CNA P stated she told LVN I on 07/29/2024 that Resident #1 had open areas to his inner elbows which required his attention. LVN I applied Nystatin Powder to the wounds and left Resident #1's protective sleeves off so air could get to the wounds. Record review of Resident #1's Braden Scale completed on 7/31/24 revealed a score of 14, indicating that the resident was a moderate risk for skin integrity issues. On 08/02/2024 at 7:44PM an interview with LVN C revealed she could not explain why a Braden Scale which she had completed on 7/31/24 indicated Resident #1 was a Potential Problem for friction and shear, while his Mobility indicated he was Completely Immobile and Bedfast. LVN C stated residents who are bedfast and immobile are usually coded as Problem for friction and shear, due to not making even slight changes in body or extremity position without assistance. LVN C did not note any skin integrity issues for Resident #1 during this evaluation. LVN C stated she performs Braden Scale assessments for all residents in the facility, quarterly. An interview with POA regarding Resident #1 on 8/03/2024 at 1:10PM revealed she had been called by LVN I on 7/29/2024 and was informed Resident #1 had open areas to his inner elbows which were described to her as cuts that were infected. The POA was told by LVN I that Resident #1's wounds were treated with Diflucan and Nystatin Powder. On 7/31/24 the POA was called again by LVN I who stated the cuts had worsened and the facility had contacted the RP to see about transferring Resident #1 to the hospital for further evaluation. The POA stated upon his arrival at the hospital ED, x-rays were performed to ensure there was no bone infection which needed to be addressed. The x-rays were negative for bone infection, but when the POA arrived at the hospital and looked at Resident #1's wounds, they were much worse than what had been described to her on the telephone. She stated she immediately thought that the wounds had been there for more than a day or two. Resident #1 was admitted to the hospital in the early hours of 08/01/2024, where he received IV antibiotics of Vancomycin and Rocephin, until his release in the early hours of 08/03/2024. An interview with the DON on 08/03/2026 at 4:39PM revealed Resident #1 had returned to the facility early this morning with dressings applied to both antecubital areas. When asked if she could show this investigator the wounds, she stated she had been informed not to touch the dressings until Monday due to Resident #1 being scheduled for dressing changes on MWF. The DON stated there was Aquacel packed into the wound and the RP does not want it pulled off until it had a couple of days to heal over the weekend. The DON was asked about the hospital's report of exposed tendon, and she stated that it probably happened when the hospital removed the dressing that the facility put on due to the fact that Resident #1's skin was so thin that it would tear easily. Review of a hospital discharge summary revealed Resident #1 returned from the on hospital 08/03/2024 with new orders to protect wounds and wound dressing with water repellent cover. The dressing was to be removed and replaced if the dressing became wet, every MWF for shower days. Aquacel Ag Foam External Pad (Silver) was to be applied to the bilateral antecubital areas every MWF for wound care. Directions: Cleanse wound with wound cleanser, pat dry with 4x4 gauze, apply Aquacel AG and wrap with kerlix. The hospital discharge summary Quality Measures Documentation on page 8 revealed: Wound 07/32/24: Pressure Injury Right antecubital (active); Would 07/31/24: Pressure Injury Left anterior; upper arm (active). On page 9 of the hospital discharge summary, the following was noted: Musculoskeletal: chronic contracures of bilateral upper extremities. Skin: Chronic wounds to bilateral antecubital fossae, left antecubital fossa wound weeping purulent discharge. An interview with the RP on 08/04/2024 at 12:40PM revealed when she was first called by the facility on 07/29/2024 regarding Resident #1, she was told by LVN I Resident #1 had a rash in his armpits. She prescribed Nystatin Powder and Diflucan thinking Resident #1 had a heat rash due to the extreme heat outside, the fact that Resident #1 sweats a lot and had probably developed a heat rash, due to the inability to move his arms. The RP stated she received a photo on 07/31/2024, of a wound to Resident #1's left antecubital area which was taken by an unnamed member of facility staff that clearly showed exposed tendon to the antecubital area. She immediately gave orders for Resident #1 to be transported to the hospital, via EMS, for treatment. The RP stated in her professional opinion there was no way the wound presented in the photo could have developed in 2 days' time, unless Resident #1 had been sitting in a tub of water, with elbows submerged for the entire 2 days. The photo of the wound was sent by the RP to this investigator and clearly revealed the infected wound and exposed tendon of Resident #1's inner elbow. On 08/04/2026 at 2:16PM an interview with the Administrator revealed CNAs and LVNs usually report any wounds that they see during showers and rounding to the Charge Nurse, which records indicated on 07/29/2024, was LVN I. The Administrator stated she was aware of the skin integrity issue to Resident #1's antecubital areas on 07/29/2024 but had been told by LVN I that Resident #1 had a rash to his inner elbows, not open wounds. When the Administrator reviewed LVN I's documentation, she discovered LVN I had reported to the RP that Resident #1 had a rash to the armpit, not the inner elbow. The Administrator asked LVN I if he knew the difference between and armpit and an elbow and why the documentation did not match the description of the wounds. LVN I stated he had made a mistake in documentation, and it was an easy fix in charting. The Administrator stated Resident #1's wound had been treated with Diflucan and Nystatin Powder starting on 07/29/2024, after a phone order was received from the RP. Resident #1 was treated with Diflucan and Nystatin Powder from 07/29/2024 through 07/31/2024 when the true extent of the wounds to Resident #1 were revealed and he was transported to the hospital. LVN I was relieved of his duties at the facility on 07/31/2024. An interview with the Administrator and DON on 08/26/2024 at 11:04AM revealed staff were now acutely aware of the importance of correct, concise documentation after an in-service was held on 08/22/2024. In this in-service, the DON emphasized the importance of documenting exactly what has been seen, with regard to wounds, taking concerns, even if thought to already be reported, to the Charge Nurse on duty. If those concerns were not addressed by the Charge Nurse, staff was instructed to move up the chain of command to ensure residents are receiving the proper care and attention they deserve. Record review of a policy provided by the facility titled Pressure Ulcer/Injury Risk Management dated July 2017 revealed: Reporting - Notify attending MD if new skin alteration noted. An Immediate Jeopardy (IJ) was identified on 08/22/2024 at 4:53PM. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 08/23/2024 at 8:50AM and read as follows: Name of Facility Facility Address August 22, 2024 The plan of removal represents the center's allegation of compliance. This plan of removal serves as the facility's response to the immediate jeopardy notification the center received during the exit conference on August 22, 2024, at 5:09PM from the Texas Health and Human Services Commission related to identification of changes in skin integrity. The allegation is that staff did not identify changes in skin integrity for Resident #1 and that CNAs (certified nurse's assistants) were not trained to identify changes in skin integrity. The allegation also indicated the physician and resident representative were not informed of skin integrity issues in a timely manner. Immediate Actions 1. A routine skin assessment was completed and documented on in Resident #1's chart, indicating no new concerns on July 28, 2024, at 11:09 AM. On 07/29/2024, during routine shower, the CNA reported the change in skin integrity noted for Resident #1 to the charge nurse. The CNA noted open areas to bilateral antecubital areas. The charge nurse assessed the area, notified the physician, and initiated new orders, including the administration of Diflucan and wound care to both areas. The family was notified at that time as well. The nurse documented in the progress notes that the areas of concern were bilateral antecubital areas. 2. On 7/31/24, the charge nurse noted the areas to the bilateral antecubital areas were not improving and notified the physician. Orders were received at that time to transfer residents to the hospital of the family's choice. Resident #1 was transferred to the emergency room for treatment. 3. On 08/02/2024, Resident#1 returned to the facility with wound care orders. There were no changes in the resident's medications and no antibiotics were ordered. In-Service Education Facility implemented the following action plan that had the potential to affect 39 residents. 1. Facility conducted in person education to all CNAs who were in the facility on August 22, 2024, at 1800 PM. The education included prevention of developing or worsening contractures, proper use of shower/skin monitoring sheets, reporting changes in skin integrity to charge nurses and documentation. All staff will receive this education by Friday. August 23,2024. 2. The facility conducted in person training to all nursing staff who were on the schedule on August 22, 2024, at 1800. The education included identification and documentation of skin integrity as well as completing all associated assessments such as Braden Scale and Skin assessments. The education also included notification of physician and resident representative immediately and the documentation of this. All staff will receive this education by Friday, August 23, 2024. Monitoring The following systems of monitoring have been implemented: 1. DON (director of nursing) or designee, will collect all shower/skin monitor sheets daily and address any changes or concerns. This will be completed for the next 3 months or until substantial compliance is achieved. They will ensure all issues or concerns are addressed, assessed, and all notifications made. 2. Assessments, such as Braden Scale and Skin Assessments will be monitored by the DON or designee for completeness, timeliness, and accuracy for 3 months or until substantial compliance has been achieved. 3. Skin integrity and prevention of new skin concerns or contractures will be discussed in monthly QAPI meetings for the next 3 months. 4. The DON or designee will monitor all changes in condition and will monitor for notification of physician and resident representative for the next three months or until substantial compliance is achieved. Quality Assurance and Performance Improvement The facility's QAPI Committee meeting has been scheduled for 08/26/2024. The Medical director will review interventions and monitoring put in place to identify root causes and to provide directions of identified areas of concern. Date initiated 08/22/2024. On 08/26/2024 at 10:24AM, a return visit was made to the facility to verify the facility's implementation of the Plan of Removal. Record review revealed the facility conducted in person training to all licensed nursing staff who were scheduled and in the facility on August 22, 2024, at 6:00PM. The education included identification and documentation of skin integrity as well as completing all associated assessments such as Braden Scale and Skin assessments. The education also included notification of physician and resident representative immediately and the documentation of this. All staff will receive this education by Friday, August 23, 2024. 08/26/2024 at 12:46PM Interview with CNA Q regarding what she learned from the in-service that was held on 8/22/24 with regard to Resident Change of Condition; she stated that they went over the importance of shower sheets and filling them out correctly; making sure that they turn the shower sheets in every day; asked how this training will or has changed what she was doing prior to this in service and she stated that she had always been using the shower sheet that everyone is using now and is being diligent to make sure that they are filled out correctly and turned in to the DON. 08/26/2024 at 12:57PM Interview with CNA P regarding what she learned from the in-service that was held on 8/22/24 with regard to Resident Change of Condition; she stated that they talked about the shower sheets, which one everyone should be using and making sure that all are using that sheet; reporting even the smallest skin tear or bruise and to keep reporting it on the shower sheet until it is healed; if a bruise has been on a resident's arm for two weeks then you should have 2 weeks of shower sheets that show that bruise. 08/26/2024 at 1:02PM Interview with CNA W regarding what she learned from the in-service that was held on 8/22/24 service that was held on 8/22/24 with regard to Resident Change of Condition; she stated that the main thing that she learned was to report anything that you see on a resident's body, even if you think it's already been reported; asked how this changed what she you see on a resident's body, even if you think it's already been reported; asked how this changed what she was doing and she stated that she is documenting on the shower sheet now and not just in the computer on the shower sheet now and not just in the computer; she was only using the computer and was not using the shower sheets to report; will do a better job now. 08/26/2024 at 1:18PM Phone interview CNA R regarding what she learned at the in-service on 8/22/24 with regard to Resident Change of Condition; she stated that they were told to keep a close eye on all resident's skin and report anything that you see, even if you think it has been reported already; using better documentation; asked how the how the in-service changed what she has been doing and she stated that it didn't change much for her due to being a CNA for so long, but reminded her to report anything that you see and document on paper as well as the computer. 08/26/2024 at 1:22PM Phone interview with CNA M regarding what she learned at the in-service on 8/22/24 and she stated that they talked about skin integrity and watching and reporting anything new or old that you see on a resident's skin; checking your resident's skin, especially after your days off to ensure that there is no new conditions; reporting and documenting are essential and if you don't get the first person to listen to you, go up the chain of command; don't just let it go. 08/26/2024 at 1:28PM Phone interview with CNA T regarding what she learned at the in-service on 8/22/24 with regard to skin integrity and Change in Condition ; she stated that they need to be documenting better; use the paper shower sheet and document in the computer; not just one of the two; report anything that you see to the Charge Nurse and if they don't listen, go up the chain; asked how this changes what she had been doing in the past and she stated that she feels like communication will be better, because a licensed staff member licensed staff member has as to sign off on whatever they find and record on the shower sheet. 08/26/2024 at 1:48PM Phone interview with CNA Y regarding what she learned in the in-service on 8/22/24; she stated that they talked about skin and shower sheets and the importance of filling them out correctly and then having a Charge Nurse sign off on them; document on paper and not just in the computer; this will remind her more attentive to any changes in resident's skin. 08/26/2024 at 1:52PM Interview with CNA N regarding what she learned in the in-service on 8/22/24; she stated that she needs to do a better job of filling out the shower sheets and turning them in so that a Charge can sign off on them; look between toes and fingers, elbows and knees to see if there are any skin changes and then record on the shower sheet and report to a Charge so that they can sign off on your shower sheet. 08/26/2024 at 1:55PM Phone interview with CNA L regarding what she learned in the in-service on 8/22/24; she stated that they need to do a better job of filling out the shower sheet and reporting anything, even if it's small to the Charge Nurse so that they can look at it; fill out the skin assessment sheet as well and make sure that all documentation is on paper and in the computer. 08/26/2024 at 1:58PM Interview with DON regarding the in-service on the on 8/22/24; she stated that they really pushed to both the CNAs and the licensed staff, the importance of documenting everything; don't let little things go, because they turn into big things; report to herself or [NAME] and if you think we're not listening, bug us until we do. 08/26/2024 at 2:03PM Interview with LVN G regarding what they learned in the in-service on 8/22/24; she stated that they talked about both the shower sheet and the skin assessment sheet and ensuring that they are filled out correctly and turned in; check with your CNAs to see what they have documented on the sheets and if she needs to look at any skin issues; reporting up the chain of command, as well as the family and the MD if you see a problem developing with a resident's skin. 08/26/2024 at 2:06PM Phone interview the ADON who is out sick today regarding what was talked about in the in-service on 8/22/24; she stated that they really emphasized the fact that everyone, not just the CNAs need to be checking their residents for any skin integrity issues; the importance of reporting even if you think someone else has already reported it; she and the DON met to make a system of checking to ensure that shower sheets/skin assessments are done and recorded accurately; informing the family and the MD as soon as you see something. 08/26/2024 at 2:26PM Interview with MDS Nurse regarding the in-service on 8/22/24; she stated that they talked about Change in Condition and reporting anything that you see to a Charge Nurse; documentation of everything, both on paper and in computer; if you're not sure if something that you see has been reported already, report it anyway; all of the licensed staff need to do a better job of following up with their CNAs of following up with their CNAs and fell ow workers 08/26/2024 at 2:58PM Phone interview with LVN E regarding what she learned at the in-service that was held on service that was held on 8/22/24 regarding Change of Condition and reporting; she stated the in-service reminded her to look for anything that might warrant a Change of Condition for a resident and the notification of the MD, family DON, et; making sure that risk management paperwork is completed and documented correctly; any new orders that show up on the dash board-check on that resident and chart according to that order; she stated that the CNAs that are hers are very diligent about the shower sheets and reporting anything that they see as far as a change in skin integrity to her; she stated she checks in with her CNAs every shift to make sure that they have completed documentation correctly. 08/26/2024 at 3:07PM Phone interview with LVN C regarding what was covered in the in-service on 8/22/24; she stated that they talked in depth about Change in Condition and the detailed expectations for both hand- written documentation and electronic documentation; reporting of any changes in a resident to the DON, MD, Family and Administrator; she is going to inform both the DON and the Administrator if she observes anything new with her residents and ensure that there is follow-through on what needs to be done the resident; stated that they received a pocket version of the expectations and reporting that she will carry in her pocket to remind herself of what needs to be done and check it off of the list. 08/26/2024 at 3:29PM Interview with LVN H regarding what was covered in the in-service on 8/22/24 and how it will change her work within the facility; she stated that they covered the expectations that are on the LVNs and RNs to ensure that documentation is correct and done in a timely manner; if you wait even a few minutes to chart something, you may leave out very important details about the resident; if there is a change in condition they have to update the SBAR, notify the MD, family, DON and administrator immediately, as well; make sure that you are checking your residents daily and checking in with your CNAs to ensure that all the bases have been covered with documentation and notifications. The Administrator was informed the IJ was removed on 08/26/2024 at 4:16PM. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of Isolated due to the need for implementation of corrective measures and the effectiveness of its corrective plan.

Based on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident # 1) reviewed for contractures. The facility did not prevent the development of one facility-acquired Stage IV, exposed tendon, pressure injury for Resident #1. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life. An Immediate Jeopardy (IJ) was identified on 08/04/2024. The IJ Template was provided to the facility on [DATE] at 4:00PM. While the IJ was removed on 08/06/2024, the facility remained out of compliance at a level of more than minimal harm and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of Isolated due to the need for implementation of corrective measures and the effectiveness of its corrective plan. Findings included: Record review of Resident #1's admission record revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: PRIMARY LATERAL SCLEROSIS (A motor-neuron disease which causes nerves within the brain to slowly break down) DYSPHAGIA, OROPHARYNGEAL PHASE CHRONIC PAIN SYNDROME PAIN IN UNSPECIFIED SHOULDER OTHER SPEECH DISTURBANCES APHASIA MUSCLE WEAKNESS (GENERALIZED) MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE OTHER REDUCED MOBILITY HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE PARKINSON'S DISEASE WITH DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS OTHER MUSCLE SPASM ENCOUNTER FOR SCREENING FOR COVID-19 PERSONAL HISTORY OF COVID-19 OTHER SEASONAL ALLERGIC RHINITIS OTHER CONSTIPATION Record review of Resident #1's MDS dated [DATE] indicated no pressure injury over a scar or bony prominence, no current unhealed pressure injury, and no detection of a Stage IV pressure injury. There were also no noted skin conditions. Record review of Resident #1's care plan dated 7/3/24 indicated no pressure injury over a scar or bony prominence, no current unhealed pressure injury and no detection of pressure injuries. There was no documentation of any noted skin conditions. An interview with the DON and Admn. on 08/02/2024 at 6:30PM revealed CNAs had not been formally trained on performing resident skin checks while giving showers. She stated CNAs looked for skin conditions such as scratches, bruises, skin tears and any injury of unknown source, but did not specifically check a resident's contractures for any skin deterioration. The DON stated CNAs were often at bedside when wounds were treated by licensed staff but had not been specifically trained on looking for open wounds during showers or rounding. The Admn. stated there were teach-back assessments done yearly for CNAs regarding showering residents and assessing them for bruises, cuts, skin tears and any skin condition which would require further assessment by a licensed staff member. The Admn. was asked to produce the teach-back documentation for CNAs, but the binder could not be located. The DON stated Resident #1 was extremely clean and would take 2 showers per day, if allowed. She stated his scheduled shower days were MWF. The DON stated she was unsure why CNAs would not have found the open area to Resident #1's left antecubital (inner elbow) area when he was showered on Monday, 7/29/2024. When asked what a negative outcome of not instructing CNAs on proper showering techniques and skin assessment, the DON stated CNAs might think that any wound they found had already been seen by a licensed staff member and therefore were not their responsibility. Review of Resident #1's Progress Notes dated 07/29/2024 indicated an open area to the left antecubital area, which was treated with Nystatin Powder and Diflucan, both of which were ordered by the RP. An observation of Resident #1 on 8/3/2024 at 2:22pm revealed Resident #1 was laying in bed. Resident #1's elbows were loosely wrapped with gauze and there was folded gauze in the crease of both elbows. Resident #1 had a washcloth rolled in the palms of both hands due to contractures. On 08/02/2024 at 7:29PM an interview with CNA P revealed she had not been trained specifically to look for wounds or open areas to resident's skin, while performing showers. She stated the Admn. and DON trained the CNAs at least monthly on Abuse and Neglect of Residents and Reporting of Resident Incidents and Accidents, but she had not been specifically trained on reporting wounds. When asked the negative outcome of not reporting a new or worsening wound to licensed staff, she stated the wound could become infected and the resident could become very sick. Review of Resident #1's Physician Orders revealed Resident #1 was to have had skin assessments performed every Sunday by licensed staff and CNAs. Review of skin assessments dated 07/04/2024, 07/15/2024, 07/22/2024 and 07/28/2024 indicated no skin breakdown to any part of Resident #1's body. Review of Progress Notes revealed CNA P showered Resident #1 on 07/29/2024 and found the open areas to his inner elbows which had a purulent smell and green drainage. CNA P stated she told LVN I on 07/29/2024 that Resident #1 had open areas to his inner elbows which required his attention. LVN I applied Nystatin Powder to the wounds and left Resident #1's protective sleeves off so air could get to the wounds Record review of a skin assessment completed 7/31/24 on Resident #1 revealed suspected deep tissue injuries to right antecubital and left antecubital. The skin assessment further documented: During treatment to resident's bilateral antecubital, both sites noted open. Contacted physician. New order received to send resident out for further assessment and treatment . An interview with the LVN C on 08/02/2024 at 7:44PM revealed weekly skin assessments were placed in the Treatment Administration Record or Miscellaneous sections of the resident's charts. She stated Resident #1's skin assessments may not have been completed on Sundays specifically, but they were done within the next day. She stated CNAs were supposed to perform skin checks when they gave showers but had not been trained on looking for wounds. An interview with Resident #1's POA on 08/03/2024 at 1:10PM revealed she felt as if the facility had been negligent in finding the open area with exposed tendon, to Resident #1's elbow. She stated she received a call from the facility on 07/29/2024 informing her that a small, open wound had developed on the inside of Resident #1's left elbow. Resident #1's arms are contracted at the elbow, so the skin between his upper arm and forearm were always touching. He did not have any protection from skin deterioration in this area unless the staff put his arm sleeves on him. She stated the facility told her they were treating the area with Diflucan and Nystatin Powder and would continue to keep her informed of any changes in Resident #1's overall health (ie. fever, chills, bleeding in the area). On Wednesday, July 31st the POA received another call from the facility which stated the area to Resident #1's inner elbow had gotten worse, and they were going to transport the resident to the hospital of her choice for further evaluation. He was transferred to a hospital at approximately 11:15AM on 7/31/24. Record review of the hospital discharge summary dated 8/2/24 revealed Resident #1 was admitted to the hospital on 7/31/2024 with a primary diagnosis of Cellulitis (skin infection) of the Left Antecubital (left inner elbow). Resident #1 had received IV antibiotics of Vancomycin and Rocephin for the skin infection. Resident #1's POA stated when she saw the open area to Resident #1's inner elbow it was much worse than what the facility had described on the telephone. The tendon was exposed through a hole in Resident #1's inner elbow and the surrounding skin was red and warm to the touch. Resident #1 remained in the hospital on IV antibiotics until 08/02/2024, when he returned to the facility. The discharge summary indicated the following: Quality Measures Documentation on page 8 - Wound 7/31/24 pressure injury right antecubital and wound 7/31/24 pressure injury left anterior upper arm. Page 9 of the discharge summary indicated muscoskeletal - chronic contractures of bilateral upper extremities and skin - chronic wounds to bilateral antecubital fossae; left antecubital fossa wound weeping purulent discharge. On 08/03/2024 at 4:39PM during an interview, the DON was asked to show this investigator the wound to the inside of Resident #1's left elbow. She declined taking the dressing off, as the wound had been packed with Aquacel (antibiotic gel dressing) and she was worried the wound site would open again if the dressing were removed. An interview with the RP on 08/04/2024 at 12:40PM revealed when she was first called by the facility on 07/29/2024 regarding Resident #1, she was told that Resident #1 had a rash in his armpit. She prescribed Nystatin Powder and Diflucan thinking Resident #1 had a heat rash due to the extreme heat outside, the fact that Resident #1 sweats a lot and had probably developed a heat rash, due to the inability to move his arms. She received a photo of a wound to Resident #1's left antecubital area which was taken by an unnamed member of facility staff. She immediately gave orders for Resident #1 to be transported to the hospital, via EMS, for treatment. She stated in her professional opinion there was no way the wound presented in the photo could have developed in 2 days' time, unless Resident #1 had been sitting in a tub of water with elbows submerged for the entire 2 days. Record review of the photo of the wound was sent by the RP to this investigator and clearly revealed the infected wound and exposed tendon of Resident #1's inner elbow. An interview with the Admn. on 08/04/2024 at 2:16PM revealed she was aware of the skin integrity issue of Resident #1 on 07/29/2024. She stated LVN I, who has since been relieved of his duties at the facility, told her about the wound and the orders for Nystatin and Diflucan from the RP. When the Admn. reviewed the progress notes entered by LVN I they stated Resident #1 had a rash to his left armpit. She stated she asked the LVN I if he knew the difference between an elbow and an armpit and was given no reason why the call to the RP was made stating Resident #1 had a rash and the charting of the call indicated an open wound to the inner elbow. The LVN I told the Admn. it was a mistake and an easy fix in charting. She stated Resident #1 remained in the facility with the open wound until 07/31/2024 when he was transported to the hospital for further evaluation. Review of facility policy and procedure for Pressure Ulcer/Injury Risk assessment dated [DATE] stated: Purpose: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. General Guidelines: 1. The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. 2. Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include, but are not limited to: a. Under nutrition, malnutrition, and hydration deficits; b. Impaired/decreased mobility and decreased functional ability; c. The presence of previously healed pressure ulcers/injuries (Areas of healed Stage 3 or 4 PU/PIs are more likely to have recurrent breakdown.); d. Exposure of skin to urinary and fecal incontinence; e. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; f. Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus; g. Drugs such as steroids that may affect healing; h. Cognitive impairment; and i. Resident refusal of some aspects of care and treatment. 3. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. 4. Use only a facility-approved risk assessment tool to obtain risk assessment data. 5. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. 6. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Steps in the Procedure: 1. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 2. If necessary, allow the resident to take rest periods during the assessment. 3. Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. 4. Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Skin and Wound Management: 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation: The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. 9. Observations of anything unusual exhibited by the resident. 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. 13. Documentation in medical record addressing family, guardian, or resident notification if new skin alteration noted with change of plan of care, if indicated. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. 3. Notify attending MD if new skin alteration noted. 4. Notify family, guardian or resident update if new skin alteration noted. Review of facility policy Prevention of Pressure Ulcers/Injuries dated July 2017 stated: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Prevention: Moisture I. Keep the skin clean and free of exposure to urine and fecal matter. Nutrition: 1. Monitor the resident for weight loss and intake of food and fluids. 2. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Skin and Wound Management: 5. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Review of facility policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol dated March 2014 stated: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 4. The physician will assist the staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state and macerated or friable skin. 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/Management: 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure ulcers. There are no pressure ulcer-specific nutritional measures that should be provided routinely to those with or at risk for developing a pressure ulcer. Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect appetite, weight, and overall nutritional balance. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: a. Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or Prevention Possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability: wounds reflect the individual's overall medical instability; an existing wound is unlikely to improve significantly; additional wounds are likely to occur despite preventive efforts. 4. As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, because of end-stage heart disease or because cause-specific treatment is not advisable, not feasible, or not desired by the resident or family. a. Advance directives may limit the scope, intensity, duration, and selection of various wound-related or adjunctive treatments such as a choice to forego artificial nutrition and hydration. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. It may be appropriate to maintain some or all of the existing approaches, if they are pertinent to the resident's medical conditions, other relevant factors influencing wound development or healing, and specific treatment choices made by the resident or a substitute decision-maker. Review of facility policy for Pressure Ulcer/Skin Breakdown-Clinical Protocol dated March 2014 stated: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 4. The physician will assist the staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state and macerated or friable skin. 2. The physician will help clarify' relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/Management: 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure ulcers. There are no pressure ulcer-specific nutritional measures that should be provided routinely to those with or at risk for developing a pressure ulcer. Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect appetite, weight, and overall nutritional balance. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: a. Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or Prevention Possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventive efforts. c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability; wounds reflect the individual's overall medical instability; an existing wound is unlikely to improve significantly; additional wounds are likely to occur despite preventive efforts. 4. As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, because of end-stage heart disease or because cause-specific treatment is not advisable, not feasible, or not desired by the resident or family. a. Advance directives may limit the scope, intensity, duration, and selection of various wound-related or adjunctive treatments such as a choice to forego artificial nutrition and hydration. Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. An Immediate Jeopardy (IJ) was identified on 08/04/2024 at 4:00PM. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 08/05/2024 at 10:18AM and read as follows: Facility Name Facility Address August 4, 2024 The plan of removal represents the center's allegation of compliance. This plan of removal serves as {facility} response to the immediate jeopardy notification the center received during the exit conference on August 4, 2024, at 1550 from the Texas Health and Human Services Commission related to identification of changes in skin integrity. The allegation is that staff did not identify changes in skin integrity for resident #1 and that CNAs (certified nurse's assistants) were not trained to identify changes in skin integrity. Immediate Actions 1. A routine skin assessment was completed and documented in Resident #1's chart, indicating no new concerns on July 28, 2024, at 11:09 AM. On 07/29/2024, during routine shower, the CNA reported the change in skin integrity noted for Resident #1 to the charge nurse. The CNA noted open areas to bilateral antecubital areas. The charge nurse assessed the area, notified the physician, and initiated new orders, including the administration of Diflucan and wound care to both areas. 2. On 7/31/24, the charge nurse noted the areas to the bilateral antecubital areas were not improving and notified the physician. Orders were received at that time to transfer residents to the hospital of the family's choice. Resident #1 was transferred to the emergency room for treatment. 3. On 08/02/2024, Resident #1 returned to the facility with wound care orders. There were no changes in the resident s medications and no antibiotics were ordered. In-Service Education Facility implemented the following action plan that had the potential to affect 43 residents. 1. Facility conducted in person education to 9 of 11 CNA staff (82%) on August 4, 2024, at 1745 PM. The education included prevention of developing or worsening contractures, proper use of shower/skin monitoring sheets, reporting changes in skin integrity to charge nurses and documentation. 2. The facility conducted in person training to 100% of nursing staff on August 4, 2024, at 1745 PM. The education included identification and documentation of skin integrity as well as completing all associated assessments such as Braden Scale and Skin assessments. 3. 100 % of residents will receive a skin assessment today, August 4, 2024. These will be documented in the individual charts. The following systems of monitoring have been implemented: DON (director of nursing) or designee, will collect all shower/skin monitor sheets daily and address any changes or concerns. This will be completed for the next 3 months or until substantial compliance is achieved. Assessments, such as Braden Scale and Skin Assessments will be monitored by the DON or designee for completeness, timeliness, and accuracy for 3 months or until substantial compliance has been achieved. Skin integrity and prevention of new skin concerns or contractures will be discussed in monthly QAPI meetings for the next 3 months. Quality Assurance and Performance Improvement {Facility} QAPI Committee meeting has been sche

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #1) of 5 residents reviewed for baseline care plans. The facility failed to ensure CNA D used the necessary mechanical lift to transfer Resident #1 as documented in the baseline care plan. This failure could place residents at risk of accidents and/or injury. Findings Included: Record review of Resident #1's admission record dated 06/04/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, quadriplegia (paralysis that affects all limbs and body from the neck down), muscle wasting and atrophy, reduced mobility, generalized anxiety disorder (inability to control constant worrying), and panic disorder (anxiety disorder that causes sudden and intense fear). Record review of Resident #1's Admission MDS completed on 05/26/24 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS indicated Resident #1 had impairment to both sides of his upper and lower extremities and utilized a wheelchair. Section GG indicated Resident #1 was dependent across all ADLs with Sit to stand, Toilet transfer, Car transfer, and Walk 10 feet coded as Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Section K revealed Resident #1 was 72 inches tall and weighed 235 pounds. Record review of Resident #1's Care Plan face sheet in his EHR, dated 06/04/24 revealed no completed care plan. There was a care plan in progress with a start date of 05/21/24 and a completion target date of 06/04/24. The care plan only had three focus areas listed. They were diet, advance directive, and activities. Of the three, only activities had accompanying goals and interventions. Record review of Resident #1's baseline care plan, dated 05/14/24, revealed he was TOTAL ASSIST-HOYER for transfers and Total assist for all ADLs. The baseline care plan was completed and signed by MDS LVN. During an observation and interview on 06/04/24 at 08:25 AM Resident #1 was lying in his bed on his back under a blanket with HOB raised watching television. He stated he was unable to get out of bed by himself. He stated staff used the Hoyer lift to transfer him except for CNA D. Resident #1 stated CNA D was in the Army or Marines and thought he was strong enough to just lift Resident #1. Resident #1 stated he did not feel safe when CNA D lifted him. He stated he did not tell CNA D or any other staff member that he did not feel safe when CNA D lifted him for transfers. During an interview on 06/04/24 at 12:50 PM CNA D stated he did transfer Resident #1 without a Hoyer lift. He stated he picked Resident #1 up out of his bed by placing his arms beneath Resident #1's arms and around Resident #1's back so they two of them were chest-to-chest. He stated he was an agency CNA and had worked in the facility 5-6 times prior to this incident. During an interview on 06/04/24 at 01:16 PM CNA F stated she had been a CNA at the facility for [AGE] years. She stated she knew if a resident needed a two-person transfer or Hoyer lift transfer by looking at their POC on the tablet the CNAs used. She stated Resident #1 was a Hoyer transfer. During an interview on 06/04/24 at 01:22 PM CNA E stated the nurses typically told the CNA's which resident's needed Hoyer lifts and which one's needed 2-person transfers. She stated Resident #1 was a 2-person transfer. During an interview on 06/04/24 at 01:24 PM when asked how direct care staff knew how to transfer a resident, DON stated she would ask employees who had been in the facility a long time how a certain resident should be transferred. During an interview on 06/04/24 at 01:25 PM ADM stated a resident's baseline care plan would indicate how they were to be transferred. During an interview on 06/04/24 at 02:14 PM MDS LVN stated Resident #1 was to be transferred with a Hoyer lift as his baseline care plan indicated. She stated a CNA transferring Resident #1 alone could result in injury to Resident #1 or to the CNA. During an interview on 06/04/24 at 07:19 PM CNA I stated she had worked for the facility for [AGE] years. She stated she knew a resident needed a Hoyer lift if the resident was unable to stand. CNA I stated Resident #1 needed a Hoyer lift. During an interview on 06/05/24 at 09:11 AM CNA D stated he knew Resident #1 was to be transferred with a Hoyer lift. He stated he knew because he asked Resident #1 how staff transferred him. CNA D stated Resident #1 told him if he could transfer him without the Hoyer lift it was fine. CNA D stated he could not think of any negative outcome of transferring Resident #1 on his own without using the Hoyer lift. During an interview on 06/05/24 at 09:27 AM CNA G stated she was an agency CNA. She stated she knew if a resident needed a Hoyer lift or two-person transfer by finding out in report from the off-going CNA. She stated it was important to ask the CNA's who were used to working with the residents especially if it is your first time in the facility. During an interview on 06/05/24 at 09:37 AM Resident #1's family member stated she was told by Resident #1 that CNA D transferred him alone without using the Hoyer lift. She stated she was worried that Resident #1 might get hurt. During an interview on 06/05/24 at 09:40 AM LVN C stated there was always the possibility of injury if a resident was not transferred as indicated in the care plan. During an interview on 06/05/24 at 09:43 AM ADM stated, A lot can happen; accidents can happen if a resident was not transferred as indicated in the care plan. During an interview on 06/05/24 at 09:49 AM DON stated if residents were not transferred as indicated in their care plans staff or the resident is gonna get hurt. Record review of facility policy dated December 2016 and titled Care Plans-Baseline revealed the following: . A baseline plan of care to meet the resident's immediate needs shall be developed for each resident . 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Record review of facility policy dated April 2006 and titled Departmental Supervision revealed the following: . 4. The Director of Nursing Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: c. Reviewing individual resident care plans for appropriate goals, problems, approaches, and revisions based on nursing needs; d. Assuring that the resident's plan of care is being followed; .

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to ensure CNA D followed Resident #2's care plan by transferring the resident as a 2-person assist. This failure could place residents at risk of accidents and/or injuries. Findings Included: Record review of Resident #2's admission record dated 06/05/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, primary lateral sclerosis (a neuron disease that affects the nerve cells in the brain that control movement resulting in weakness in the muscles that control the legs, arms and tongue), muscle weakness, muscle wasting and atrophy, reduced mobility, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) with dyskinesia (abnormality or impairment of voluntary movement), and muscle spasm. Record review of Resident #2's Quarterly MDS completed on 03/17/24 revealed a BIMS of 00 which indicated severely impaired cognition. Section GG indicated Resident #2 had impairment in his upper and lower extremities on both sides and was dependent across all ADLs. Section I indicated Resident #2's primary medical condition was Progressive Neurological Conditions. Section K indicated Resident #2 was 67 inches tall and weighed 159 pounds. Record review of Resident #2's baseline care plan, dated 12/03/20 indicated he was TOTAL ASSIST for transfers. Record review of Resident #2's main care plan revealed he had limited mobility due to his diagnoses. It was further noted, Requires assistance for all transfers and ADLs. This focus area was initiated on 07/05/2022. Record review of Resident #2's care plan completed on 03/18/24 revealed an intervention that noted Resident #2 was (X )dependent for transfers. This intervention was initiated on 07/05/2022. Record review of Resident #2's progress notes revealed a note written by LVN H on 06/02/24 at 07:56 PM. LVN H noted that LVN C told her about an incident from earlier that day where Resident #2 was lowered to the ground by CNA D and CNA D called for assistance. According to LVN H's note, LVN C assessed Resident #2 at the time and no injuries were noted. Then LVN C, a housekeeping staff member, and CNA D transferred Resident #3 from the floor into the shower chair. During an observation and interview on 06/04/24 at 08:57 AM Resident #2 was seated in his w/c in the common area near the nurses' station watching TV. When he was asked if anyone had dropped him in the shower, he shook his head side to side, which indicated 'no'. During an interview on 06/04/24 at 12:50 PM CNA D stated he was attempting to transfer Resident #2 on 06/02/24 into the shower chair and when he got Resident #2 to the shower chair, he began to slip so CNA D lowered Resident #2 to the ground gently. He stated he thought Resident #2 got mad and jerked in his arms and that is why Resident #2 began to slip. CNA D stated he was holding Resident #2 under his arms and they were chest-to-chest. CNA D stated LVN C looked at Resident #2 after he was lowered to the ground and Resident #2 had no injuries, no nothing. He stated he and LVN C and another staff member picked Resident #2 up off the floor and placed him in the shower chair. During an interview on 06/04/24 at 01:16 PM CNA F stated she had been a CNA at the facility for [AGE] years. She stated she knew if a resident needed a two-person transfer or Hoyer lift transfer by looking at their POC on the tablet the CNAs used. She stated Resident #2 was a two-person transfer. During an interview on 06/04/24 at 01:22 PM CNA E stated the nurses typically told the CNA's which resident's needed Hoyer lifts and which one's needed 2-person transfers. She stated Resident #2 was a 2-person transfer. During an interview on 06/04/24 at 01:24 PM when asked how direct care staff knew how to transfer a resident, DON stated she would ask employees who had been in the facility a long time how a certain resident should be transferred. During an interview on 06/04/24 at 01:25 PM ADM stated a resident's baseline care plan would indicate how they were to be transferred During an interview on 06/04/24 at 01:44 PM LVN C stated she assessed Resident #2 after CNA D lowered him to the ground in the shower room. She stated they had to have a third staff member help them lift Resident #2 off the ground because he got real stiff .and he wouldn't bend his knees. She stated Resident #2 did not fall and was not in any distress. During an interview on 06/04/24 at 07:19 PM CNA I stated she had worked for the facility for [AGE] years. She stated she knew a resident needed a Hoyer lift if the resident was unable to stand. CNA I stated Resident #2 needed a two-person transfer. During an interview on 06/05/24 at 09:11 AM CNA D stated he did transfer Resident #2 on his own. He stated he knew Resident #2 was a two-person transfer but unfortunately the rest of the staff was beyond busy so that was not able to happen. CNA D stated after the incident where he had to lower Resident #2 to the floor and get help from two staff members to transfer Resident #2 from the floor to the shower chair the nurse told him Resident #2 was a two-person transfer. During an interview on 06/05/24 at 09:27 AM CNA G stated she was an agency CNA. She stated she knew if a resident needed a Hoyer lift or two-person transfer by finding out in report from the off-going CNA. She stated it was important to ask the CNA's who were used to working with the residents especially if it is your first time in the facility. During an interview on 06/05/24 at 09:30 AM MDS LVN stated total assist in a baseline or regular care plan meant two-person assist. She stated Resident #2 required a two-person assist with transfer. She stated the (X )dependent in Resident #2's care plan meant he needed a two-person transfer. During an interview on 06/05/24 at 09:40 AM LVN C stated there was always the possibility of injury if a resident was not transferred as indicated in the care plan. During an interview on 06/05/24 at 09:43 AM ADM stated, A lot can happen; accidents can happen if a resident was not transferred as indicated in the care plan. During an interview on 06/05/24 at 09:49 AM DON stated if residents were not transferred as indicated in their care plans staff or the resident is gonna get hurt. Record review of facility policy dated December 2016 and titled Care Plans, Comprehensive Person-Centered revealed the following: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in developed and implemented for each resident. The comprehensive, person-centered care plan will . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . Record review of facility policy dated April 2006 and titled Departmental Supervision revealed the following: . 4. The Director of Nursing Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: c. Reviewing individual resident care plans for appropriate goals, problems, approaches, and revisions based on nursing needs; d. Assuring that the resident's plan of care is being followed; .

Based on interview, and record review, the facility failed to ensure that the resident with pressure ulcers receives appropriate treatment/services received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers, for 1 closed record (CR #1) of 2 residents reviewed for pressure ulcers. CR #1 acquired a pressure ulcer to her coccyx that deteriorated to a stage IV wound while residing at the facility. The facility failed to have NP wound care consultant assess CR #1 while on isolation for COVID. The facility delayed wound care interventions for CR #1 for 5 days after identifying coccyx wound had a foul odor and dead tissue inside the wound bed. The facility failed to obtain a wound care culture for CR #1 after wound had a foul odor and wound bed worsening. The facility failed to provide CR #1 with proper nutrition and supplements to aid in wound healing. These failures could place residents with pressure ulcers at risk for improper wound management, the development of new pressure ulcers, deterioration in existing pressure ulcers, infection, sepsis, and pain. Findings included Record Review of CR's #1's Face Sheet who was a [AGE] year-old female originally admitted to facility on 5/31/2012. CR #1 was transferred to the hospital on 5/7/23. Her primary diagnoses included primary generalized (osteo) arthritis (degenerative disease of the joints that worsens over time); major depressive disorder, moderate intellectual disabilities; muscle weakness; personal history of COVID 19, sickle cell trait (red blood cell disorder); iron deficiency (anemia); other chronic pain. Record review of CR #1's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating mild cognitive impairment. CR #1's Functional Status revealed she was total dependence in ADL care with 2 staff assist. Her range of motion was impaired on both sides of her lower body. CR #1 was identified as total dependent on staff to eat with maximum assistance from staff. CR #1 was not at risk of pressure injuries/ ulcers, and she had no pressure ulcers. Record review of CR #1's Comprehensive MDS dated [DATE] revealed a BIMS score of 12. CR #1's Functional Status revealed she was total dependent of 2 staff with ADL care. Her range of motion was impaired on both sides of her upper and lower body. CR #1 was total dependent on staff to eat with maximum assistance. CR #1 was identified at risk of pressure injuries and had one Stage 2 pressure injury and 1 Stage 3 facility acquired. Record review of CR #1's care plan prior to discharge: Pressure ulcer to coccyx and have potential for additional pressure ulcer development related to immobility, initiated 4/24/23. Interventions: Administer treatments as ordered and monitor for effectiveness. Asses, record and monitor wound healing with each wound change and PRN. Report improvements and declines to the MD. I require supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Required pressure relieving/ reducing mattress on bed. Add air mattress and heel protectors PRN as ordered. Use professional services for wound care consultants for recommendations of wound care. Record review of CR #1's hospital record admitted [DATE] for higher level of care with diagnoses of sepsis (infection in blood), stage IV wound, anemia, renal failure, and dehydration. The hospital record review read in part . Transferred with complaint of stage 4 decubitus ulcers to her coccyx . While recovering from COVID, her wound worsened . It was discovered she had developed oral ulcers from poor oral hygiene . Patient refused to eat or drink and stopped taking her medications. Patient had been on PO Clindamycin from wound care at nursing facility . The patient is noted to have a complicated history including rheumatoid arthritis, Methotrexate therapy and sepsis . CT scan on 5/31/23 shows sacrococcygeal decubitus ulcer with osteomyelitis of the coccyx. It also shows multifocal lower lobe bronchopneumonia which appears to be more prominent . On 6/1/23 review of hospital records indicate she had passed away from her complications. Interview on 8/10/23 at 10:40 a.m., with DON who said she started working at the nursing facility on 4/26/23 as the DON. She explained she had worked at the nursing facility as an agency nurse prior to her being hired as the DON. She said she had cared for CR #1 as an agency nurse and explained that the resident got COVID and then had a decline in her health. She said CR #1 had stopped eating and drinking. She explained in April and May 2023 the facility had to rely on agency staff quite a bit. She said that most of the nursing staff that worked at the facility then do not work at the facility anymore. Interview on 8/10/23 at 2:18 p.m. with DON provided a document indicating it was a wound care assessment completed by NP Wound Care. Record review of an untitled word Wound Care Assessment for date 5/2/23. DON reported that was the only wound care assessment she could find in CR #1's closed record. The report read in part . CR#1's active problems: Pressure ulcer of contiguous site of back, buttocks, and hip, Stage 3 . Recent isolation due to COVID is causing a delay in healing. Also changing soiled linens and dressings immediately after soiled . Moved patient back to normal room and is no longer on isolation. Continues to have loose stools and excessive moisture . Wound #2 is open . Treatment for 5 weeks . The wound is currently classified as a Category/ Stage IV wound with etiology of pressure ulcer and is located on the midline coccyx. Foul odor after cleansing wound bed . There is a large amount of necrotic tissue (dead tissue) . Wound progress unchanged . Wound #2 pre-procedure debridement includes eschar (dead tissue) and slough. Post procedure diagnosis wound #2: Stage IV pressure ulcer-fascia (muscle tissue) exposed. Wound #3 status is open. The date acquired was 4/27/23 with etiology of skin tear located on the superior thoracic spine . Small amount of drainage . Initial assessment . Wound #4 status is open. The date acquired was 4/27/23 with etiology of skin tear located on the inferior thoracic spine . Small amount of drainage . Record review of CR #1's progress notes dated 4/17/23 at 7:13 a.m., identified resident was started on isolation for 10 days due to COVID 19 positive. Record review of CR #1's progress notes dated 4/22/23 at 1:55 p.m., revealed wound with very foul, large amount of serosanguinous drainage (blood and liquid drainage). Approximately 40% slough (dead tissue that needs to be removed from the wound in order for it to heal) across width of wound. Record review of CR #1's progress note dated 4/22/23 at 10:01 p.m., revealed a PRN dressing change completed. Wound with 90% slough, mild drainage, with strong foul odor present. Record review of CR #1's progress note dated 4/23/23 at 1:50 p.m., revealed a dressing change to the pressure ulcer on coccyx. DON, Administrator and PCP notified of stage, condition and odor of wound. PCP was notified via text, waiting for reply. Wound care nurse to be notified of need to come see resident. Staff informed to keep CR #1 clean and dry. Licensed staff to change dressing as soon as it became soiled. Record review of CR #1's progress note dated 4/23/23 at 2:31 p.m., identified wound dressing changed second time that day. Wound bed tunneling. Continues with brownish- grey slough across the outer wound. Continues with large amount of drainage with very foul odor. Record review of CR #1's progress note on 4/24/23 at 5:24 a.m., revealed staff continues to await call back. Wound specialist anticipated in building 4/24/23. Wound with heavy exudate (drainage), 90% slough. Staff continue to push by mouth fluids and ensure resident has adequate diet to support wound healing. Resident COVID positive, remains on isolation precautions. Record review of CR #1's progress note on 4/24/23 at 9:04 a.m., revealed a call was placed to wound care NP consultant regarding the coccyx wound. NP stated she would come see CR #1 tomorrow afternoon and would call in oral antibiotics. Informed NP that the PCP had been notified regarding the wound. Record review of CR #1's progress note on 4/24/23 at 9:21 p.m., informed NP of the wound odor. She said she would attempt to call in oral medications and assess tomorrow. PCP notified yesterday of resident's worsening wound with odor. Another call will be placed to the PCP this morning. Record review of CR #1's progress note on 4/24/23 at 11:46 a.m., revealed air mattress applied to bed. Record review of CR #1's progress note on 4/24/23 at 6:09 p.m., by the DON revealed dressing removed and wound was evaluated by DON. Wound cleaned and wound cleanse spray and wiped clear of removable buildup and slough tissue. Record review of CR #1's progress notes identified as a late entry for 4/30/23 at 12:11 p.m., read in part . Coccyx wound with 10% scattered slough . Two new open areas to spine: 1) 2.8 x 1 x 0.1 cm, 100% epithelial (healing) tissue. 2) 3cm x 1 cm x 0.1 cm with only 10% epithelial tissue present . Record review of CR #1's progress notes revealed on 5/1/23 at 6:03 p.m., the wound to the coccyx had an increase in amount of drainage. Record review of CR #1's progress notes revealed on 5/3/34 at 3:01 p.m., identified CR #1's wound had slough and moderate drainage to the wound bed. Record review of progress notes dated 5/4/23 at 2:59 p.m., revealed CR #1 wound care completed. She had 2 previous developed wounds. Wound #1, superior spine presents with 50% slough, 50% slough, serous drainage. Wound #2 coccyx continues with slough to 75% of wound bed, foul odor, and previous dressing drainage present. New open area (wound #3) near posterior iliac crest, area presents with 100% epithelial tissue present. NP Wound Care Specialist notified of new areas new dressing change orders. Record review of CR #1's progress notes revealed on 5/5/23 at 9:40 a.m. read in part .Wound care completed, area continues to decline. NP wound care specialist notified . Record review of progress note dated 5/7/23 at 8:11 a.m. revealed CR #1 had not ate or drank x 3 days. Blood pressure was low. PCP notified and resident sent to hospital ER. Record review of CR #1's physician order start date of 3/25/23 identified order for: Stage 2 to coccyx: Cleanse with wound cleanser, pat dry apply dry dressing change daily and PRN for accidental removal of soiling every day[W(1] shift for wound care. Record review of a Dietary note dated 4/12/23 at 1:56 p.m. revealed CR #1 had a weight change: April 198#, BMI 33.0, Obese. Skin stage II/ III- coccyx. Plan: Continue diet recommend Prostat 30ml once a day. Weight had been 186-216 over past 6 months. Aim for weight maintenance over next quarter. Record review of Dietary note dated 4/26/23 at 3:15 p.m. revealed Skin change: wound was stageII. Per nursing notes read in part .On antibiotic for wound . Weight loss from monthly weight, but stable from last month . Meal intake varies, has been eating <50% most meals. Not on a scheduled supplements . Plan: Recommend begin liquid protein 30ml twice daily for additional 30 grams of protein/ day. Begin med pass 90ml twice daily for additional calories and protein, and address if appetite stimulant needed . Aim for weight maintenance with intact skin . Record review of an email dated 4/26/23 at 3:27 p.m. by Dietitian to the dietary manager and the DON. Per our conversation for the resident (CR #1), I recommend beginning liquid protein 30 ml bid (Prostat or Prosource). Also begin med pass 2.0- 90ml bid and address if appetite stimulant needed. Record review of CR #1's Treatment Administration Record (TAR) and Nurses Medication Administration Record reviewed for April 2023: Clindamycin HCL oral capsule 300mg, give by mouth 3 times a day for wound care for 6 days. Start date of 4/25/23. Stage 2 to coccyx: cleanse with wound cleanser, pat dry apply dry dressing change daily and PRN for accidental removal or soiling. Discontinued 4/24/23. Stage 3 Coccyx inferior open area: cleanse with wound cleanser, pat dry, apply calcium alginate and cover with alleyvn dressing. Change daily and PRN for soiling. Start date 4/1/23, discontinued 4/25/23. Dakins External Solution 0.25%. Apply to coccyx wound topically every day shift for wound care clean with normal saline, soak Dakins Solution in gauze, apply as wet to dry dressing, cover with foam dressing. Start date 4/25/23. No order for air mattress or pressure reducing mattress. No orders for Prostat 30ml once a day. No orders identified for liquid protein (Prostat or Prosource), med pass 2.0 or an appetite stimulant. On 8/10/23 at 1:25 p.m., 2:53 p.m. and 4:16 p.m. attempted to call previous DON, left a voicemail. On 8/28/23 at 1:42 p.m. attempted to call previous DON. Unable to leave a voicemail. An interview on 8/10/23 at 2:18 p.m., LVN A said she had cared for CR #1 occasionally. She explained that CR #1 was dependent on all ADL care because of her diagnosis of osteoarthritis and was in pain during any kind of transfer/ movement. She said she did not have to change the residents dressing when she worked with her, and she never saw CR #1's wounds. She explained that there was a NP Wound Care who came weekly to assess and prescribe orders for the residents who are followed for wound care. A telephone interview on 8/10/23 at 2:29 p.m., CR #1's PCP explained that the resident was on a medication (Methotrexate) for her rheumatoid arthritis that could have caused her to be in an immunocompromised state and could stop wound healing. The PCP explained CR #1 was also morbidly obese and had rheumatoid arthritis and was dependent on staff to reposition. She said she was not on call the weekend CR #1 had a change in condition, but a partner physician. She said she remembered she saw the resident while on isolation for COVID and she had no concerns at that time, the resident was stable. PCP said she had written a note regarding CR #1's wounds and health status and recommended surveyor to review the notation PCP wrote. A record review of PCP Physician Note dated 5/19/23 read in part .On 3/23/23 wound care documented 2 stage one wounds of the coccyx and orders for daily wound care were obtained on 3/24/23. On 4/22/23 foul odor from the wound was noted and on 4/24/23 antibiotics and air mattress were ordered. She started refusing meals and then medications. I saw the patient on 5/3/23 and noted brown substance in her teeth and swollen dry lips. Oral care and wet swabs and pushing fluids were ordered. On 5/7/23 she was sent to ER and hospitalized for dehydration and severe anemia. Decubitus ulcer to the coccyx was complicated by her bed immobility and then further decompensated by COVID infection. Methotrexate medication for severe rheumatoid arthritis limits healing. Decreased oral intake due to oral inflammation further complicated her condition due to protein malnutrition and dehydration . Signed by PCP on 5/19/23. A telephone interview on 8/10/23 at 2:47 p.m., with the On-Call Physician for the weekend of 4/22/23 said he was not familiar with CR #1's name. He explained he did not care for that resident. An interview on 8/10/23 at 1:38 p.m., with NP wound care said she was the wound care consultant that saw CR #1's wounds weekly. She said she first saw CR #1's wounds on 3/23/23. She explained that CR #1's wounds developed from moisture from her incontinence. She said she saw CR #1 on 3/23/23, 3/30/23, 4/13/23, 4/25/23 and 5/2/23. She explained she did not assess CR #1 on 4/6/23 because the resident was up in wheelchair in the dining room involved in activities. She said on 4/20/23 she was in the building, but the ADON at that time recommended not to assess CR #1 because she was on isolation for COVID. NP wound care said on 4/22/23 she was notified that CR #1's wound had a foul smell and she explained an antibiotic was started on 4/24/23. She said CR #1's wound was assessed on 4/25/23 and she had to debride 30 cm of the wound bed because of slough and necrotic tissue. She said she assessed the resident's wound on 5/2/23 and identified that it had dead tissue that needed to be debrided and she removed a total of 60 cm of necrotic tissue. She said the wound was quite large after she debride the coccyx wound. She explained CR #1 was sent to hospital for worsening wounds and poor nutritional intake. A follow-up interview on 8/15/23 at 4:28 p.m. with NP wound consultant explained that the DON notified her on 4/24/23 (Monday morning) that CR #1's wound had worsened and had a foul odor. She explained that she thought the staff had talked with the PCP over the weekend about CR #1's wound because the PCP gave orders for Clindamycin (antibiotic) and an air mattress. NP wound care said she did not remember ordering a culture of the wound and she was unsure why a culture was not done. She explained that any air mattress or any pressure reducing mattress would be beneficial if used correctly. She explained in the past she has done training with the staff on the correct settings of an air mattress because she has noted in the past that air mattresses were on firm setting and that would not be beneficial for wound healing. She said she typically ordered an air mattress after the first or second visit if they were at high risk of skin breakdown. NP wound care reviewed her 3/30/23 notes and said she ordered a pressure reducing mattress. She explained in April there was a transition of nursing staff and the communication was lacking. She explained that the DON at that time was upset because NP wound care did not see CR #1 on 4/20/23, but the ADON notified her and recommended not to assess the resident while on isolation for COVID-19. An interview by telephone on 8/15/23 at 3:12 p.m. with the Dietitian said she went to the nursing facility every month and reviewed all resident weights. She explained if a resident had dietary concerns then she would also review meal intakes. She said she communicated with the dietary manager and DON when she entered for a report about any concerns that they had or if there was any new skin breakdown on a resident. She said staff had reported CR #1 had developed wounds and that she was refusing to eat or drink. Record review with Dietitian of her progress notes for CR #1 was reviewed over the phone. She confirmed that she completed an annual Dietitian report dated 3/8/23 which she made no recommendations because at the time CR #1 had a weight loss between October - December 2023, but weight stabilized and within her weight range. She said because the resident was within her weight range and had no skin breakdown, she had no dietary recommendations during that visit. She did confirm that she did a couple assessments in April 2023 for CR #1 because of a newly developed wound and a recent change in weight. She said she made dietitian recommendations in April but could not remember what was completed or recommended for CR #1. She said she expected the nursing staff to notify her for any dietary concerns or weight loss or weight gain. A follow-up interview with DON on 8/29/23 at 10:38 a.m. explained facility staff should follow all policy and protocols for wound care or nutritional care to prevent resident decline. She explained that the charge nurse monitored and audited to make sure staff were repositioning residents. DON explained the ADON and DON provide in servicing to staff about repositioning and the importance of it. She explained interventions put in place for new or worsening wounds was notify the physician, NP wound care would assess weekly, turn and reposition frequently, use of air mattress and other equipment as needed. Also possible use of supplements like Prostat for as a protein supplement. She explained that the NP wound care should have saw CR #1 while on isolation. She explained it was not the best practice however in the past staff have done video calls with the NP wound care to assess the wound. She explained if a resident had a weight loss intervention of notifying the physician and the dietitian, obtain a weekly weight, possible use of stimulant to help increase appetite and possibly try to figure out the cause such as mouth pain or inability to chew or swallow. The DON said the facility process for dietitian recommendations was review the dietitian recommendations and discuss with the physician to get an order to make the changes. Review orders with pharmacy. She said she was aware that the Dietitian emailed recommendations to her and the dietary manager. She said she did not know why the dietary recommendations were missed for 4/26/23, but possibly because of a change in staff at that time. Record review of the facility Prevention of Pressure Ulcer dated 2001 MED-PASS, Inc, Revised July 2017 read in part . Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/ injury risk factors and interventions for specific risk factors. Risk Assessment # 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. Prevention: Nutrition: 1. Monitor the resident for weight loss and intake of food and fluids. 2. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring: Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility Pressure Ulcers/ Skin Breakdown- Clinical Protocol dated 2001 MED-PASS, Inc, Revised March 2014 read in part . Cause Identification: 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact or comorbid conditions on wound healing, ect . Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or nonhealing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions .

Based on interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one closed record (CR# 1) of 1 resident reviewed for weight loss. CR #1 had a significant weight loss of 57.7 pounds, a 14.7% body mass loss in less than 6 months, January 2023 to June 2023. The facility failed to develop and implement interventions to prevent weight loss and improve wound healing. This failure affected 1 discharged resident and placed other residents at risk for weight loss, wound healing and a decline in health. Findings included: Record review of CR's #1's Face Sheet indicated a [AGE] year-old female originally admitted to facility on 5/31/2012. CR #1 was transferred to the hospital on 5/7/23. Her primary diagnoses included primary generalized (osteo) arthritis (degenerative disease of the joints that worsens over time); major depressive disorder, moderate intellectual disabilities; muscle weakness; personal history of COVID 19, sickle cell trait (red blood cell disorder); iron deficiency (anemia); other chronic pain. Record review of CR #1's hospital record admitted [DATE] with diagnoses of sepsis (infection in blood), stage IV wound, anemia, renal failure and dehydration. The hospital record review read in part . Transferred with complaint of stage 4 decubitus ulcers to her coccyx . While recovering from COVID, her wound worsened . It was discovered she had developed oral ulcers from poor oral hygiene . Patient refused to eat or drink and stopped taking her medications. Patient had been on PO Clindamycin from wound care at nursing facility . The patient is noted to have a complicated history including rheumatoid arthritis, Methotrexate therapy and sepsis . CT scan on 5/31/23 shows sacrococcygeal decubitus ulcer with osteomyelitis of the coccyx. It also shows multifocal lower lobe bronchopneumonia which appears to be more prominent . On 6/1/23 review of hospital records indicate she had passed away from her complications. Record review of CR #1's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating mild cognitive impairment. CR #1's Functional Status revealed she was total dependence in ADL care with 2 staff assist. Her range of motion was impaired on both sides of her lower body. CR #1 was identified as total dependent on staff to eat with maximum assistance from staff. Weight: 185. No identified weight loss. No identified skin conditions. Record review of CR #1's Comprehensive MDS dated [DATE] revealed a BIMS score of 12. Mood identified no poor appetite. CR #1's Functional Status revealed she was total dependent of 2 staff with ADL care. Her range of motion was impaired on both sides of her upper and lower body. CR #1 was total dependent on staff to eat with maximum assistance. Nutritional Status revealed her weight was 192 pounds and identified as having a weight loss of 5% or more in the last month or 10% or more in the last 6 months without physician-prescribed weight loss regimen. CR #1 was identified at risk of pressure injuries and had one Stage 2 pressure injury and 1 Stage 3 facility acquired. Record review of CR #1's care plan dated 5/7/23: At risk for nutritional impairment. Regular diet. Feeding self-difficult. Interventions: Administer snacks/ supplements as ordered. Assist with eating, staff to feed if resident unable to feed self. Monitor food/ fluid intake and record. RD review of nutritional and hydration status upon admission, quarterly, and PRN. Weigh as ordered and PRN- report 5% loss/ gain to MD. Potential for oral/ dental problems such as mouth pain and infections related to history of cavities and poor condition of teeth. Interventions: Inspect mouth for lesions, redness, swelling or increased complaints of pain and report abnormal findings to MD. At risk for complications related to anemia. Interventions: Encourage to eat 75-100% of meals. Pressure ulcer to coccyx and have potential for additional pressure ulcer development. Interventions: I require supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Record review of CR #1's weights in the electronic health record on 8/10/23 revealed the following weights: 10/18/22- Weight 216.5 pounds, No weight documented for November 2022, 12/4/22- Weight 188.6 pounds (-7.5% and -10% change), 1/10/23- Weight 184.6 pounds (-7.5% change), 2/20/23- Weight 186.4 pounds (-10% change), 3/5/23- Weight 192.5 pounds (-10% change), 4/2/23- Weight 198.6 pounds (+7.5% change), and 5/2/23- Weight 158.8 pounds. Record review of Documentation Survey Report V2 dated March 2023 revealed: CR #1 refused 8 meals, 30 meals only consumed 25% or less, 27 meals consumed 50% or less, and 15 meals consumed 75% or less. There was a total of 11 meals. CR #1 did not consume 100% of a meal. 10 meals with no documentation of intake. Record review of Documentation Survey Report V2 dated April 2023 revealed: CR #1 refused 30 meals, 22 meals only consumed 25% or less, 6 meals consumed 50% or less and 7 meals consumed 75% or less. CR #1 did not have a meal of 100% consumption. CR #1 had 23 meals of no documentation. Record review of Documentation Survey Report V2 dated May 2023 from 5/1/23 to 5/7/23 revealed CR #1 refused all meals except one meal documented 25% or less. Record review of a Dietary note, progress note dated 3/8/23 revealed CR #1 had a weight change (March 192.5. Weight loss x 6 months. Weight has been in range of 184-192# over past quarter. BMI= 33.0= obese. Regular diet. Meal intake varies 25%- 100%. Needs total assistance with meals. Does accept snacks. Skin: No breakdown. Continue diet. Weight maintenance in usual range desired over next quarter. Record review of a Dietary note dated 4/12/23 at 1:56 p.m., revealed CR #1 had a weight change: April 198#, BMI 33.0, Obese. Skin stage II/ III- coccyx. Plan: Continue diet recommend Prostat 30ml once a day. Weight had been 186-216 over past 6 months. Aim for weight maintenance over next quarter. Record review of Dietary note dated 4/26/23 at 3:15 p.m., revealed Skin change: wound was Stage II. Per nursing notes read in part .On antibiotic for wound . Weight loss from monthly weight, but stable from last month . Meal intake varies, has been eating <50% most meals. Not on a scheduled supplements . Plan: Recommend begin liquid protein 30ml twice daily for additional 30 grams of protein/ day. Begin med pass 90ml twice daily for additional calories and protein, and address if appetite stimulant needed . Aim for weight maintenance with intact skin . An interview by phone on 8/15/23 at 3:12 p.m., the Dietitian said she went to the nursing facility every month and reviewed all resident weights. She explained if a resident had dietary concerns, she would also review meal intakes. She said she communicated with the dietary manager and DON when she entered for a report about any concerns that they had or if there was any new skin breakdown on a resident. She explained if a resident was having weight concerns such as weight gain or loss in a month then she would make a recommendation such as provide supplements or vitamin/minerals but depended on each resident's situation. She said she would look back in the resident's physician orders to make sure that the recommendations she previously made were ordered and initiated. She said she would recommend weekly weights or a possible tube feeding if the weight loss if the cause could not be explained. She said she could not give any details about CR #1's dietitian recommendations because she did not have her notes but explained that each of her dietitian recommendations for CR #1's was in her progress notes. She said staff had reported CR #1 had developed wounds and that she was refusing to eat or drink. She explained she did not remember if the NF staff notified her by phone or writing of CR #1's change in weight. Dietitian explained that when she made new recommendations, she would place them on her spread sheet and send an email to the dietary manager and DON. Dietitian recommendations for CR #1 were reviewed with dietitian over the phone by surveyor. She confirmed that she completed an annual Dietitian report dated 3/8/23 which she made no recommendations because at the time CR #1 had a weight loss between October - December 2023, but weight stabilized in her weight range. She said because the resident was within her weight range and had no skin breakdown, she had no dietary recommendations during that visit. She did confirm that she did a couple assessments in April 2023 for CR #1 because newly developed wound and a recent change in weight. She said she made dietitian recommendations in April for CR #1 but could not remember what the recommendations were. Record review of an email dated 4/26/23 at 3:27 p.m., by Dietitian to the dietary manager and the DON. Per our conversation for the resident (CR #1), I recommend beginning liquid protein 30 ml bid (Prostat or Prosource). Also begin med pass 2.0- 90ml bid and address if appetite stimulant needed. Record review of CR #1's Treatment Administration Record (TAR) and Nurses Medication Administration Record (MAR) reviewed for April 2023 and May 2023. No orders identified for liquid protein (Prostat or Prosource), med pass 2.0 or an appetite stimulant. Record review of CR #1's Physician Order dated 3/24/23 at 9:14 a.m. revealed a Stage 2 to coccyx: dressing treatment ordered daily and as needed. Record review of CR #1's Progress Note, late entry for 4/30/23 at 12:11 p.m. identified wound worsening. Record review of progress note for CR #1 on 5/2/23 at 12:26 p.m. revealed Patient refused to eat supper, stated her mouth hurt. CNA cleansed with mouth swab and stated patient was crying that her mouth was burning after oral care. This nurse assessed, patient with lips swollen and dry cracked skin inside bottom lip. Stated it hurts to eat or drink. Applied lip balm to patient's lips and educated to request to keep lips moisturized. Also reported to physician, who gave order for mouth to be rinsed with peroxide, swish and spit, and oral care to be done every shift. Record review of progress note for CR #1 dated 5/4/23 at 7:16 p.m. read in part .New order for peroxide swish and swallow not tolerated well, this nurse was able to get left over tobacco residue out with gums and lips bleeding mildly as a result . Refused lubricant x 3 attempts. MD notified. Record review of CR #1's progress note dated 5/7/23 at 8:11 a.m. revealed CR #1's had not ate or drank x 3 days. Blood pressure was low. PCP notified and resident sent to hospital ER. Interview on 8/10/23 at 10:40 a.m., the DON said she started working at the nursing facility on 4/26/23 as the DON. She explained she had worked at the nursing facility as an agency nurse occasionally prior to her being hired as the DON. She said she had cared for CR #1 as an agency nurse and explained that the resident got COVID and then had a decline in her health. She said CR #1 had stopped eating and drinking. She explained in April and May 2023 the facility had to rely on agency staff quite a bit and unsure if agency staff assisted her. She said that most of the nursing staff that worked at the facility then do not work at the facility anymore. An interview on 8/10/23 at 2:18 p.m., LVN A said she had cared for CR #1 occasionally. She explained that CR #1 was dependent on all ADL care including full assist with meal and fluid intake because of her diagnosis of arthritis. She explained that the resident did have a weight loss prior to her going to the hospital. She explained that CR #1 would chew tobacco and she had a history of sores in her mouth. A phone interview on 8/10/23 at 2:29 p.m., CR #1's PCP who explained that the resident was on a medication (Methotrexate) for her rheumatoid arthritis that could have caused her to be in an immunocompromised state and could stop wound healing. The PCP explained CR #1 was also morbidly obese and had rheumatoid arthritis and was dependent on staff to reposition. She said she was not on call the weekend CR #1 had a change in condition, but a partner physician. She said she remembered she saw the resident while on isolation for COVID and she had no concerns at that time, the resident was stable. PCP said she had written a note regarding the CR #1's wounds and health status and recommended surveyor to read it. A record review of PCP Physician Note dated 5/19/23 read in part . I saw the patient on 5/3/23 and noted brown substance in her teeth and swollen dry lips. Oral care and wet swabs and pushing fluids were ordered. On 5/7/23 she was sent to ER and hospitalized for dehydration and severe anemia . Decreased oral intake due to oral inflammation further complicated her condition due to protein malnutrition and dehydration . Signed by PCP on 5/19/23. An interview on 8/10/23 at 1:38 p.m., the NP wound care said she was the wound care consultant that saw CR #1's wounds weekly. She said that CR #1 had poor nutrition and had an order for supplements, but was refusing. Record review of the facility Weight Assessment and Intervention policy and procedure revised September 2008 read in part .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for out residents . Weight Assessment: 3. Any weight change of 5% or more nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing . 4. The Dietitian will respond within 24 hours of receipt of written notification. 5 . Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant, greater than 7.5% is severe. c. 6 months-10% weight loss is significant, greater than 10% is severe . Analysis: 2. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. cognitive or functional decline; b. chewing or swallowing abnormalities; c. pain .

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 8 of 40 residents (Residents #7, #11, #17, #20, #28, #29, #33 and #39) reviewed for abuse Resident #33 was the victim of sexual assault (as defined by Texas Penal Code Chapter 22) perpetrated by Resident #29 on 05/28/22. On 05/28/22 LVN B, LVN C, and CNA A heard Resident #33 in her room screaming, No Stop! LVN B, LVN C, and CNA A ran down the hall and into Resident #33's room. CNA A entered Resident #33's room first and witnessed Resident #29 holding both of Resident #33's legs in the air with one hand while using his other hand to penetrate Resident #33's vagina. Resident #7 was a victim of verbal/mental abuse Residents #7, #11, #17, and #28 were victims of mental abuse. Resident #39 was a victim of physical abuse. The facility failed to report allegations of abuse and neglect of Residents ##7, #11, #17, #20, #28, #29, #33 and #39 Due to the facility's lack of action after these occurrences, an Immediate Jeopardy (IJ) was identified on 07/25/22 at 04:40 PM. While the IJ was removed on 07/27/22 at 03:00 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility need to evaluate the effectiveness of their corrective systems. A second Immediate Jeopardy was identified on 8/11/2022 at 5:15pm. While the IJ was removed on 8/12/22 at 4:15pm, the facility remained out of compliance at a severity level of actual harm that is not immediate and scope of pattern due to the facility's need to evaluate the effectiveness of their corrective systems. The facility failed to take necessary action to ensure the safety of their 19 female residents. This failure could place any of the female residents in the facility in danger of sexual abuse. Findings include: Record review of Resident #29's Admission Record indicated the resident was an [AGE] year-old male with an original admitted [DATE], and a most recent admitted [DATE]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's MDS, dated [DATE] noted a BIMS of 8 indicating moderate cognitive impairment. The MDS recorded Resident #29 as independent in all activities of daily living. Record review of Resident #29's Care Plan dated 05/24/22 revealed an addition to the Care Plan dated 06/02/22 that indicted Resident #29's potential to demonstrate verbal/physical abusive behaviors related to dementia and poor impulse control. The intervention indicated, Any time resident enters other female resident's room redirect do not leave alone use call light if not easily redirected stay with resident and monitor. The Care Plan also noted Resident #29 was at risk of injury related to wandering, impaired cognition .independent locomotion and decrease [sic] safety awareness. Record review of Resident #29's progress notes revealed the following: On 05/28/22 at 12:26 PM Resident noted walking up and down A hall, stopping and looking into rooms. Female resident also complained of resident stopping at her door and staring at her. fell ow CN translated in Spanish to resident, asked res not to walk down hall or look into other rooms. Res understood. (Author: LVN B) On 05/28/22 at 04:52 PM Female resident heard yelling, 'No, stop' from A hall room [ROOM NUMBER]. This nurse, fell ow CN and CNA went to room when CNA entered room first and yelled out, 'No.' CNA and fell ow CN witnessed Resident #29 holding fell ow female penetrating her vagina with his fingers. fell ow CN immediately directed Resident #29 out of room, stated that he said in Spanish, 'I just wanted to see her.' ADM, DON, RN, and Doctor notified. Q 15-minute checks on resident initiated. Med aide assisted and notified wife in Spanish. (Author: LVN B) On 05/29/22 at 09:12 AM the DON interviewed Resident #29 regarding the incident on 05/28/22. Her notes stated, On arrival to room resident sitting in chair stated he was walking hall and heard lady yelling and saw her kicking off blankets and when he went in to help they all said he was doing something different he stated he was trying to secure her brief on and comfort her he denied doing anything and agreed not to go down that hall. (Author: DON) On 05/29/22 at 05:39 PM Resident cont's Q 15-minute checks, has stayed in room per choice. Resident would look out of room at nurses' station at times but would go back into room. (Author: LVN B) On 05/30/22 at 04:24 PM Resident remained in his room and other appropriate areas throughout the shift with no aggressive or inappropriate behaviors observed by nurse or reported by staff. (Author: Former Employee) On 06/01/22 at 01:27 PM LVN C wrote, Spoke with DON and ADM on Q 15-mins, on resident, states NO, only if we see him going into Female Residents room we are to call for help and redirect back to his hall and room will continue to monitor thru shift continue with POC. During an interview on 07/26/22 at 10:23 AM LVN C she said she was the person who signed the Q 15-minute checks on Resident #29 on 05/28/22 and 05/29/22. She said the DON told her to discontinue the Q 15-minute checks. She said she asked the ADM and the DON for permission to restart the Q 15-min checks on Resident #29 but they told her not to restart the checks and instead to redirect Resident #29 if he entered a female resident's room. Record review of Resident #29's progress notes revealed the following: 06/02/22 at 05:38 PM Resident stayed in room this shift per choice. This nurse and fell ow CN informed resident that he could come out of room, not to go into females rooms. (Author: LVN B) On 06/15/22 at 03:39 PM Resident noted walking down C hall stopped and looked into female room, saw CN's (Charge Nurses) were watching and left to dining room. (Author: LVN B) On 06/26/22 at 03:44 PM Resident redirected from standing in front of female door room [sic], and looking in to rooms this weekend several times, continue with POC (Plan of Care). (Author: LVN C) On 07/13/22 at 03:38 PM Resident observed touching female med aide on her side while she is passing medications then cont'd walking toward dining room. (Author: LVN B) During an interview on 07/27/22 at 10:24 AM with LVN B and LVN C they said Resident #29 was seen staring into Resident #32's room. Record review of resident #29's Progress Notes dated on 07/25/22 at 06:01 PM indicated resident was placed on one-to-one supervision. (Author: ADON) Record review of resident #29's Progress Notes dated on 07/25/22 at 09:56 PM indicated Resident #29 was picked up for transport to a behavioral hospital for evaluation and therapy. (Author: LVN V) Record review of the handwritten Q 15-minute checks on Resident #29 completed by LVN C following the incident on 05/28/22 cover a period of 12.25 hours total; spanning 05/28/22 and 05/29/22. Record review of Resident #33's Admission Record revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's MDS, dated [DATE] revealed a BIMS of 3 indicating severe cognitive impairment. Section G of the MDS indicated dependence upon staff for extensive assistance in all activities of daily living. Section D of the MDS indicated Resident #33 experienced little interest or pleasure in doing things, feeling or appearing to be down, depressed, or hopeless, trouble concentrating, and being short tempered or easily annoyed nearly every day. Record review of Resident #33's Care Plan, dated 06/20/22, noted dependence on staff for socialization and activities of daily living, a risk of fluctuation in mood related to depression, and a risk for falls. Record Review of document titled [Facility name] Incidents by Incident Type and dated 04/24/2022 to 07/24/2022 revealed the following entries related to Resident #33: Physical Aggression Received Incidents dated 05/28/22 at 03:31 PM. Alleged Abuse Incidents dated 05/28/22 at 03:30 PM but this entry had been electronically struck through with a thin black line. In an interview on 07/25/22 at 09:51 AM the DON was asked about the incident between Resident #33 and a male resident. She asked for the date of the incident. This surveyor stated the date was unknown. She searched through the electronic record and came up with the progress notes for Resident #33 on 05/28/22. Record review of Resident #33's Progress Notes dated May 2022 through July 2022 revealed the following in descending order: On 07/25/22 at 10:15 AM Resident #33 .was yelling, screaming, and crying . with .vivid hallucinations again about her spouse. (Author: SW G) On 07/14/22 at 10:23 AM Resident #33 had .increased agitation . and was .yelling at someone who was not in the room. (Author: LVN B) On 07/10/22 at 02:22 PM Resident #33 was .yelling and cursing at someone in the room that is not there. (Author: LVN B) On 06/12/22 at 02:24 PM Resident was reported to have .increased delusions regarding her husband, screaming and staff unable to calm resident multiple times this shift. (Author: LVN B) On 05/28/22 at 03:51 PM LVN B wrote that a male resident, Resident #29, was in Resident #33's room penetrating her vagina with his fingers and she was screaming No Stop. Two staff members ran in and saw him and redirected him out of the room. Resident #33 was crying and holding her brief. She was assessed by 3 staff witnesses and no apparent trauma was noted to her outer vaginal area. No other injuries were noted according to the progress notes and Resident #33 denied pain but was upset. Progress notes said ADM, DON, RN, Doctor, and Resident #33's family were all notified. (Author: LVN B) On 05/27/22 at 09:23 PM two CNA H and CNA I reported to the LVN J that when they were providing incontinent care and cleaning in the rectal area Resident #33 said, that hurts, that hurts, he got it three times. CNAs H and I reported the area was .redden [sic] more than usual. LVN J wrote, Resident (#33) is always yelling and screaming 'you hurt me, get out' all during shifts so I left it at she's just talking about her husband in the past. (Author: LVN J) In an observation and interview on 07/24/22 at 11:32 AM Resident #33 was observed lying in her bed on her right side with her left leg hanging halfway off the bed. Resident #33's room was at the end of A Hall. Her room was the furthest from the nurses' station. Her privacy curtain was drawn around her bed, therefore Resident #33 was not visible from the doorway. Resident #33 was wearing a hospital gown. Her blanket was pushed to the bottom of the bed. Her brief was between her legs but not fastened on and her gown was pushed up to her waist. Resident #33's left hip and the curve of her left buttock were visible. When asked if she had any concerns or complaints, Resident #33 shook her head indicating no concerns or complaints. This surveyor left the room and alerted staff that Resident #33 needed help with her brief. In an interview with Resident #33's family member on 07/24/22 at 07:05 PM the family member said, There was one incident with another resident. Staff put a stop to it immediately and called us right away. Another resident came in and was touching her inappropriately. She was screaming and staff came in and removed him from the room. When asked what the facility is doing to ensure this does not recur, Resident #33's granddaughter said, Keeping a closer eye on her. And I think they moved him further away from her. In an observation and interview on 07/25/22 at 08:40 AM Resident #33 was lying in bed under a fuzzy brown blanket with her knees bent at more than 90 degrees and up in the air, feet flat on the mattress, and head leaning off to the right. Small scab and bruising noted on her right forearm. Resident #33 could not recall how she got the scab and bruising. Privacy curtain drawn around the bed of Resident #33. During an interview on 07/25/22 at 11:06 AM the ADM was asked why this incident was not reported to law enforcement and as a Facility Reported Incident. The ADM asked this surveyor to step into the SW's office. The ADM said, the (DON) did a complete investigation and the outcome--let me get her in here. At this point the ADM walked out and retrieved the DON. They then entered SW's office together and this surveyor asked the question again. The DON stated, I checked right away and his (Resident #29's) BIMS was an 8. He was easily redirected, and we monitored him every 15 minutes. There were so many different stories (of what happened) I didn't know which way to go. I mean there were nurses saying he (Resident #29) had his whole hand in her (Resident #33) but there was no bruising, no redness or any irritation down there at all. This surveyor stated the notes made this point, but also stated Resident #33 was upset. The DON stated, And she does that anyway (Resident #33 gets upset). We never know what upsets her. Sometimes I tell them to turn off the TV because she gets way into the TV and she is always talking about her husband and I have yet to find out if he is alive or not. SW G interjected, He is dead. He was abusive. During a telephone interview on 07/25/22 at 01:23 PM LVN B stated the incident on 05/28/22 involving Resident #33 and Resident #29 was reported to her superiors and was never reported or acted upon further. She stated, I was frustrated and didn't know if I should call 911. LVN B said, They (administration) said he (Resident #29) has a BIMS 8 and dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B was asked who specifically said this to her, and she replied, Oh, I don't want to get anybody in trouble . (LVN B hesitated a few seconds and said the first name of DON). This surveyor clarified, The DON? She replied, Yes. LVN B further said, He (Resident #29) tries to go look in rooms. I think he knows when me and LVN C are there. She said when she and LVN C are on shift Resident #29 will peek out of his doorway and when she sees them watching from the nurses' station he will go back into his room. LVN B stated, He (Resident #29) touched my med aide last week; I wrote a note on that. LVN B was asked what is being done to ensure a similar incident does not happen, she replied, Just monitoring him (Resident #29), knowing where he is at all times. LVN B said the other charge nurse she refers to in her notes on the incident was LVN C. She said the CNA referred to in her notes about the incident was CNA A. She said when the three of them heard Resident #33 screaming No Stop from her room the three of them began to rush down the hall toward Resident #33's room. She said CNA A reached the room first and she (LVN B) heard CNA A shout, Stop it! LVN C reached the room second and LVN B thought LVN C saw the incident happening. LVN B said by the time she reached the room Resident #29 had stepped back from Resident #33 with both of his hands up. She said they redirected him from the room. During a telephone interview on 07/25/22 at 01:35 PM. CNA A said, We heard her (Resident #33) screaming. I ran in first. He (Resident #29) had her legs all the way up in the air in one hand and the other hand he had in and out of her really rough. This surveyor asked CNA A if it was Resident #29's whole hand going in and out of Resident #33's vagina or just his fingers. She replied, It looked like his whole hand was in and out. I yelled, 'What are you doing?! Stop it!' and he threw up both of his hands and backed away. During an observation and interview on 07/25/22 at 01:58 PM Resident #33 was lying her bed with her legs turned to the left and uncovered slightly. The privacy curtain was drawn around her bed. Resident #33 was wearing a hospital gown and her hair looked neatly combed. Resident #33 was asked if she remembered a man coming into her room and touching her. She stopped making eye contact, looked up and to the left, and did not answer. I then picked up a picture frame with an old black and white photo in it and asked her who the people in the photo were. She resumed eye contact, smiled and said, Me and my sisters. I asked if she had any brothers and she said, No just girls. During an interview on 07/25/22 at 02:36 PM The DON was asked why Resident #29's Care Plan, dated 05/24/22 mentioned him going into female resident's rooms and needing redirection when his progress notes showed no history of this type behavior until the incident with Resident #33 on 05/28/22. She replied, There was no history so on the day it happened I added it. I am encouraging all staff to read the care plans. During a telephone interview on 07/25/22 at 06:05 PM CNA A was asked what the facility has done to ensure Resident #29 does not sexually abuse female residents. She replied, Honestly, nothing. I mean the nurses on my shift and me, I mean, we watch him to make sure he doesn't go into anyone's room. Like, right now I believe he is targeting another patient (Resident #32). I've caught him looking into her room and I note it and other people have caught him looking in her room too. She said Resident #32 was unable to scream or make any sounds and he (Resident #29) knows that. CNA A was the CNA referred to in LVN B's notes who stayed in the room with Resident #33 after the incident to comfort her. CNA A said, Yeah it was hard to see and witness and to see her (Resident #33). CNA A said Resident #33 was holding onto her brief and was very upset for some time after the incident. CNA A stayed in the room with Resident #33 until she was calm. CNA A said, No one even asked me about it afterward. I wondered if it was reported and if state was going to look into it. During an interview on 07/26/22 at 10:25 AM the ADM was asked who is responsible for filing a Facility Reported Incident or launching an investigation into allegations of abuse? The ADM said, If it is anything that has to do with broken bones or everything like that it is discussed between the nurse and ADM, and I call it in. The ADM was asked if she meant the DON when she said nurse and she said she did. The ADM was asked why she did not call in the incident with Resident #33? She stated, When I got called on the weekend the DON immediately came to start investigating. At that point when she did all of her searching everything didn't appear that it had transpired like they--whoever saw it said. She said the DON came back to me, she was calling me, and said it didn't really happen. I saw documentation of what she investigated. The ADM was asked if she saw actual documents showing who the DON talked to, what they said, and what questions she asked them? She said she did. The ADM was asked to provide copies of these documents. She said, At that moment I felt like it (the incident between Resident #29 and Resident #33) did not happen. The ADM asked for copies of all investigations performed by the facility in the last 6 months. The ADM said there have not been any investigations performed in the facility in the last 6 months. Record review of the investigation paperwork provided by ADM on 07/26/22 at 11:14 AM revealed the investigation consisted of undated, handwritten nurses' accounts of what happened by LVN C and CNA A as well as documentation of Q every 15-minute checks on Resident #29 for less than 24 hours spanning the 28th and 29th of May, and an undated, handwritten statement by DON. Record review of LVN C's undated handwritten witness statement revealed LVN B, LVN C, and CNA A heard Resident #33 screaming no stop! and the three of them rushed down the hall to Resident #33's room. CNA A arrived first. When LVN C entered Resident #33's room she saw Resident #29 using his left hand to hold the leg of Resident #33 above her head. LVN C noted Resident #29 had .right hand fingers in her (Resident #33's) vagina. LVN C further documented that she asked Resident #29 in Spanish to leave the room and Resident #29 replied that .he just wanted to see her. LVN C wrote that she began Q 15-minute checks on Resident #29 and added, .with visual male resident seen at all time [sic]. Record review of CNA A's undated, handwritten witness statement regarding the incident on 05/28/22 indicated CNA A, LVN B, and LVN C heard Resident #33 screaming 'No, Stop!' and the three of them ran down the hall to Resident #33's room. CNA A said she got into the room first and saw Resident #29 holding Resident #33's legs up in the air with one hand and using his other hand to move in and out of Resident #33's vagina. She said when she saw what was happening she yelled, What are you doing? Stop it! She said at that point Resident #29 put both of his hands in the air and stepped back from Resident #33. CNA A stated they redirected Resident #29 out of the room. Record review of DON's handwritten, undated, witness statement revealed that upon being alerted to the incident involving Resident #29 penetrating the vagina of Resident #33 with his fingers the DON instructed LVN B to assess Resident #33 to be sure she is OK then call Dr. and family and Abuse Coordinator and follow what they say. The report went on to say, On 5/29 I came on in and f/u (followed up) on abuse and neglect reporting in-service and spoke with nurses and ask for their statement and when I ask Resident #33, she was asleep but later went back and she did not remember anything, so I left her alone. And was in no distress. When visiting with Resident #29 he said that he heard her screaming and kicking off the blankets and he was securing her brief and trying to comfort her. But he would never do what was being said by me and the nurses to an old lady sticking my finger-ooh he said. I then asked him not to ever please enter female rooms or go down A hall and he said OK. During an interview on 07/26/22 at 01:16 PM the DON was asked if the written statements by the nurses and her written statement were what she was referring to on 07/25/22 at 11:06 when she said there were .so many different stories . she did not know .which way to go? The DON said they were the stories she was talking about. She said, I mean the resident (Resident #29) was a BIMS 8 and the other resident (Resident #33) was a (BIMS of) 3 and when I was talking to the nurses . (the DON trailed off and stopped speaking) The DON was asked if the Abuse Coordinator in her report was the ADM, she said, Yes. During an interview on 07/26/22 at 02:11 PM The ADM was asked if the documents outlining the nurses' accounts of the incident with Resident #33 on 05/28/22 were the documents she reviewed when she decided the incident did not happen. The ADM said they were the documents she based her decision on. Record review of Resident #11's Admission Record revealed she was a [AGE] year-old female with an initial admitted [DATE] and a recent admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 06/20/22, noted Resident #11 was at risk for falls due to an unsteady gait and needed assistance with activities of daily living. The MDS, dated [DATE] noted a BIMS of 13 indicating intact cognition. Section G of the MDS revealed a need for supervision and one person to assist with activities of daily living. Record review of Resident #20's MDS, dated [DATE], reported a BIMS of 15 indicating intact cognition. Section G of the MDS indicated a need for extensive assistance by one or two staff members for all activities of daily living except eating which required only supervision. Section E of the MDS indicated verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred on 1 to 3 days of the 7-day period assessed. Record review of Resident #20's Progress Notes from October 2017 to July 2022 revealed the following: -On 10/11/17 at 05:54 PM written by LVN B, indicated Resident going into other female resident's room. Female resident states that he is watching her sleep. Resident stated that he does go in her room. ADON notified and Administrator notified. Resident was informed that he should not go into other residents' rooms without permission. -On 11/05/17 at 06:42 PM written by a former employee, indicated Resident was being hateful and rude to CNAs, told one CNA he was going to choke her. This nurse redirected resident, resident cursed at this nurse and told him to leave him along [sic]. Resident was then again redirected, and he replied ok im sorry. -On 10/21/21 at 04:05 PM written by the former DON, indicated This nurse and Administrator talked with resident in his room about a complaint that another female resident had reported to a staff member. (former ADM) gave resident the opportunity to voice his statement about what he said but resident became upset and defensive and started saying that we could kick him out of the facility because he didn't care. Resident then stated that he wanted to go back to [NAME]. (former ADM) stated to resident that he needed to not say inappropriate thigs to any females in the facility and that this was his last chance that she would give him before trying to find him an appropriate place to move him. Resident stated that we were trying to kick him out, but this nurse informed him that no one was trying to kick him out and that he needed to respect the other residents wished. I then informed resident that some of the female residents had voiced that they did not want him in their rooms, resident just looked. Resident stated, 'I don't give a damn, just move me.' (Former ADM) stated to resident that she wasn't just trying to move him, but she wanted him to treat other people with respect. Resident then replied, 'I already said what I had to say.' (former ADM) and I again stressed the importance of respecting others, but resident just looked at and started propelling himself out of his room. -On 10/25/21 at 05:07 PM written by a former LVN, indicated Resident visualized exiting another female residents room on A hall. Reiterated to resident that he is not to be in other female residents room. With resident voicing 'it's none of your business.' Went to female resident room and noted she was not in there at this time. -On 12/13/21 at 10:42 AM written by former SW, indicated Last Friday, 12-10, spoke to resident because received a grievance that he was going into a female room again. Told resident that if he wants to visit with a female resident (Resident #11) he must do so in the dining room, not in her room. He stated okay. -On 12/13/21 written by former SW, indicated Spoke to resident again today regarding him going into female rooms. It was reported last night that resident went into (Resident #17) room [ROOM NUMBER] times. She offered him crackers and hoped he would not return but he came back 2 more times. Told hm again how important it is to stay out of female rooms. He stated he only went in one time, not 3 times. Also spoke to female resident and she stated that he just wheels in and starts talking, he does not touch her. She doesn't want him in her room. Told him to stop going into female rooms and he said, 'yeah, yeah, I hear you.' -On 03/08/22 at 04:43 PM written by SW G, indicated Resident #20 became upset with SW G and began cursing at SW G, using racial slurs, telling SW G, 'You better get your white ass out of here! You don't tell me what to do! Resident #20 continued to curse at SW G and said, I'll knock the hell out of you if you don't get out of my face! At this point SW G informed Resident #20 that if he hit her, he would be arrested. He replied, I don't care, I've been to jail before! SW G filed a grievance against Resident #20 and gave it to ADM for resolution. -On 03/21/22 at 01:24 PM written by SW G noted, Grievance against resident is still being processed, ADM not on property today. -On 04/04/22 at 03:59 written by SW G noted, Continues to follow up on Grievance against resident, dated 03/08/22. Administrator (ADM first name) is compiling all documentation. DON (DON first name) made aware. -On 04/11/22 at 05:09 written by SW G noted, Per Administrator, (first name of ADM), the grievance against resident has been resolved, via medication review, and through therapy with (names of counselling centers). -On 05/27/22 at 05:17 PM written by LVN B, indicated Resident heard cursing from room. CNA reported that she was providing peri care for resident's room mate when (Resident #20's) opened the door asking another fell ow resident to come in room to look at his TV. CNA had informed res that she was providing care and to please wait. (Resident #20's) became angry, yelling for resident and this nurse to go to hell. Res asked to calm down, continued to yell and curse for about 5 minutes then calmed down and apologized. -On 06/06/22 at 02:22 PM written by LVN B, indicated Maintenance reported resident cursing at CNA. CNA states that resident asked her to braid his hair and she old him after his hair is washed she would. Res then became upset calling CNA names and yelling at her. This nurse asked res what happed, res refused. -On 06/19/22 at 01:23 PM LVN F wrote Resident continually going into females rooms on 'C' hall and 'A' hall. This nurse asked resident to not go into females rooms. The female residents on 'A' hall and 'C' hall very upset and asking that (Resident #20) stay out of their rooms. When this nurse asked resident to stay out of the female's rooms, he started yelling, cursing, and said if he had a knife, he would kill this nurse. This nurse allowed resident to calm down and wheel himself to the end of the hall. -On 06/20/22 at 12:26 PM written by DON, indicated spoke to (Resident #20) who stated he was wanting to move back to [NAME] and that he would stay out of other resident's room and not be verbally aggressive back to anyone and discussed of unacceptable behaviors, staff informed of plan and to redirect if going into other female's room and to notify me after redirection does not work and everyone safe. -On 07/09/22 at 10:17 AM written by LVN C, indicated Resident went to breakroom and began to say foul language to CNA's, tried to redirect and continued to use foul language to nurse also, will continue to monitor his behavior through shift. -On 07/11/22 at 04:25 PM written by DON, indicated Redirected (Resident #20) from going down a hall he did get upset but was easily redirected. During an interview on 07/26/22 at 09:17 AM, LVN F was asked where Resident #20's room was located. He pointed toward the room but said Resident #20 was out of the facility today for an appointment and would be back around 04:00 PM. During an interview on 07/26/22 at 09:22 AM, LVN F was asked if Resident #20 was the man who would wheel himself into the rooms of female residents and was inappropriate with them. He said, Yes, that's him. LVN F added, Just so you know, when you bring up this stuff (inappropriate behavior with female residents) to him he gets really angry and curses at you and he might even say he will get a knife from the kitchen and kill you. During an interview 07/27/22 at 10:50 AM, Resident #20 was asked if he ever went into female residents' rooms when they did not want him there. He was asked if he ever did sexually inappropriate things in front of female residents. He shook his head indicating he did not remember. This surveyor reiterated, You don't remember anything like that? He again shook his head. During an interview on 07/26/22 at 10:10 AM the DON was asked why no incidents or grievances were filed regarding Reside [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 7 of 15 residents (#3, 7, 13, 17, 18 20 and 30), in that: a)The facility failed to maintain resident use hot water at safe temperatures. Resident-use hot water was not reliably controlled, reaching temperatures as high as 136 degrees F. Seven of 15 resident rooms (B101, B102, B103, B104, B106, B108 and B112) and Hall B bath/shower room had water temperatures that had the potential to cause 3rd degree (full thickness injury) burns. These problems resulted in an Immediate Jeopardy (IJ) on 6-14-16. While the immediacy was removed on 6-15-16, the facility remained out of compliance at a pattern with the potential for more than minimal harm as the facility had not had time to fully monitor and evaluate the effectiveness of their Plan of Removal. These deficient practices have the potential to cause 3rd degree burns and pain to all 11 residents who resided on B Hall and especially 9 residents that were identified as independently ambulatory or with minimal assistance of these 11 residents. Of these 9 residents, 5 were identified as confused. The findings include: ~ The following observations were made on 6-14-16 at handsinks in the below mentioned Hall B rooms and Hall B bath: 1.At 3:00p.m. on 6-14-16, the hot water at the Hall B bath was 118 degrees. The bath was checked again at 3:02 p.m. with witness CNA #1 and the water temperature was 125.7 degrees F. At that time CNA #1 stated that she knew the water in the bath was hot, stating Yes I know. It ' s hot here (Hall B bath) the last 2 months. I do showers, but I use the one (bath) on Hall A and C. CNA #1 further stated, I can never get it to adjust, it ' s just me. She confirmed that other staff give resident showers in the Hall B shower and had given showers in the Hall B bath today. CNA #1 also stated, They said they were going to fix it; the Maintenance Supervisor. She added that when she was first employed in the facility, the Maintenance Supervisor said he was going to fix it and just had not got to it. She further stated that this was said approximately 2 months ago. During another interview with CNA #1 on 6-15-16 at 12:50 p.m., she was asked why she felt the water temperature was difficult to adjust in the Hall B bath. She stated, When I tried to adjust it, it was really really hot or really really cold. I could not get it to be stable. She added that while she tried to adjust the shower temperature, the residents were sitting in the shower naked and cold and wanted to leave. She stated that was the reason she started to use other showers. CNA #1 was also asked if she had directly heard from the Maintenance Supervisor that he was aware of the hot water temperatures 2 months prior to the current hot water problems. She stated that she had heard this comment from another staff member. Room B108 on 6-14-16 at 3:05 p.m. - 119.2 degrees F. Room B103 on 6-14-16 at 3:07 p.m. - 124.5 degrees F. Room B102 on 6-14-16 at 3:11 p.m. - 116.7 degrees F. Room B 112 on 6-14-16 at 3:12 p.m. - 129.8 ° F. On 6-14-16 at 3:23 p.m. Surveyor notified the Maintenance Supervisor of high water temperatures on Hall B. He said he would go turn the thermostat down for Hall B. Room B106 on 6-14-16 at 3:30 p.m. - 117.9° F. On 6-14-16 at 4:05 p.m., the Maintenance Supervisor was observed working on/repairing the main entrance door. He was again informed of elevated hot water temperatures on Hall B by another surveyor. He responded, Yes, I ' m turning it down. The Hall B bath hot water was checked again at 4:15 p.m. on 6-14-16. The surveyor ' s digital thermometer registered 136 degrees F and the facility ' s digital thermometer (gun type) read 135 degrees F. At this time, the Maintenance Supervisor went to adjust the Hall B hot water temperature. The Administrator was informed of the elevated temperatures on Hall B on 6-14-16 at 4:17 p.m. Room B108 on 6-14-16 at 4:18 p.m. - 131 degrees F. MA #1 witnessed this temperature. MA #1 stated at this time, This room is always hot (water). She stated that the room ' s hot water had been elevated for a couple of months, approximately 2. She added that she could tell the water temperature was elevated in the room by touching the water. MA #1 was asked if she had ever mentioned the elevated hot water temperatures in this room to anyone. She stated, I never really mentioned it to anyone. Room B103 on 6-14-16 at 4:20 p.m. - 117.1 degrees F. Hall B bath on 6-14-16 at 4:22 p.m. - 125.4 degrees F. Room B104 on 6-14-16 at 4:25 p.m. - 135.1 degrees F. Room B101 on 6-14-16 at 4:30 p.m. - 117.8 degrees F. Room B112 on 6-14-16 at 4:33 p.m. - 120 degrees F. The Administrator was informed of the hot water issues at 4:17 p.m. on 6-14-16 and she contacted the Maintenance Supervisor. After this, staff and some residents were immediately alerted to the hot water and water temperatures were reduced. Three of 4 residents confidentially interviewed on Hall B (Residents D, G and H) and 1 of 2 family members confidentially interviewed on Hall B (Family member A)) were not informed of the hot water issues on Hall B. The DON stated on 6-15-16 at 10:20 a.m. that most of the residents on Hall B were ambulatory. At this time, DON presented a list of residents on Hall B that were independently ambulatory. Review of this listing revealed that there were 9 of 11 residents on hall B that were identified as independently ambulatory. Of these 9 residents, 5 were identified as confused. The listing identified the following resident ambulation and cognitive capabilities: Room B101 occupied by Resident #13 - independently ambulatory with a walker Room B102 occupied by Resident #17 - independently ambulatory with a wheelchair Room B103 occupied by Resident #18 - not independently ambulatory Room B104 occupied by Resident #30 - independently ambulatory with a wheelchair and confused Room B106 occupied by Resident #7 - independently ambulatory with a wheelchair Room B108 occupied by Resident #13 - not independently ambulatory Room B112 occupied by Resident #13 - independently ambulatory with a wheelchair and confused ~ Maintenance Supervisor Interview/Water Heater Observations: 2. The water heater for Hall B was observed on 6-14-16 at 4:50 p.m. with the Maintenance Supervisor. It was noted that a red colored pump was unplugged in the water heater closet. The Maintenance Supervisor stated that this pump was the one that pumped water from the water heater to the facility. Observation of the water heater at this time (6-14-16 at 4:50 p.m.) revealed that the temperature dial was set past 130 degrees F. and into the red colored zone of the dial towards 160 degrees F. When the Maintenance Supervisor was asked why the water heater was set at this temperature, he stated, This has to stay set like this to kill Lyme disease in the water heater; any bacteria. On 6-14-16 at 4:50 p.m., the Maintenance Supervisor identified the silver colored knob plumbed near the top level of the water heater as the mixing valve and stated, This is where you set and mix hot and cold water. Turn it clockwise to add cold water and counterclockwise to increase the water temperature. At this time the Maintenance Supervisor was asked what caused the water temperature on Hall B to elevate. He stated, (the mixing valve) had 2 turns back toward hot, so now I did 2 turns to the right for more cold water. The Maintenance Supervisor also stated that he looks for the temperature of 104 or 105 degrees F. as the correct temperature for resident use hot water, with a maximum of 110 degrees F. The water heater for Hall B was observed on 6-14-16 at 6:05 p.m. with the Maintenance Supervisor. The Maintenance Supervisor was asked at this time what type of training he had received related to the water heaters. He stated that he had received 2 days of orientation and that the director came 2 or 3 days to train and orient him the to the facility maintenance duties. The Maintenance Supervisor was asked what caused the water temperature on Hall B to elevate. He stated, I had a failed pump (water heater) and I fixed it. I keep it (water heater) at 140 degrees F to kill Lyme disease. The (red) pump went out today. A wire was loose on the recirculating pump. With the wire loose, the water was not recirculating properly. I check water heater closets once a week on no particular day. The (pump ' s) loose wire was discovered today. The water heater for Hall B was observed on 6-15-16 at 4:55 p.m. with the Maintenance Supervisor. It was noted that the top of the mixing valve was marked hot and cold on top with a maker. The word cold had an arrow pointing to the right and the word hot had arrows pointing both left and right. There was also an instruction tag on the back of the mixing valve that had a portion of the tag ' s wording missing. The Maintenance Supervisor stated at this time that he had reduced the temperature dial on the water heater lower, stating, I set it at 140 degrees F, a notch above 130 degrees F. Observation of the temperature control dial on the water heater on 6-15-16 at 5:02 p.m. revealed that the dial was set between 120 degrees F and 130 degrees F and in the yellow zone of the dial. On 6-14-16 at 5:47 p.m., the Administrator was asked what caused the hot water to be elevated on Hall B. She stated, He (Maintenance Supervisor) probably turned it up because someone said it (hot water) was too cold. On 6-16-16 at 12:55 p.m., the Administrator was asked how she thought the IJ came about. She stated, He (Maintenance Supervisor) admitted me that he turned it up because a resident on the hall said it was too cold; maybe (Resident #17) or (Resident #24). He got pulled away to do something and didn ' t get back to turn it down. On 6-14-16 at 4:43 p.m., the Administrator also stated that she had not been told about the hot water being elevated on Hall B prior to 6-14-16. ~ Thermometer Accuracy: 3. At 7:00 p.m. on 6-14-16, the Administrator was observed using a dial thermometer to check water temperatures in the facility. Closer observation of the thermometer revealed that it read 70 degrees F. while on the counter at the nurse ' s station. The thermometer was placed in ice water to check the calibration. The facility dial thermometer registered 25 degrees F and the surveyor ' s digital thermometer registered 32 degrees F. The Administrator stated on 6-14-16 at 7:02 p.m. that the dial thermometer was the only one she had. ~ Water Temperature Logs and Maintenance Duties Scheduling System: 4. Review of the Maintenance Manual, dated February 2012, revealed the following documentation, Critical Systems Inspection and Preventative Maintenance Planning Schedule .Water heaters .Note: Water temperatures are to be taken daily per instructions in maintenance manual . Review of the Tels (maintenance duties scheduling/monitoring system) Logbook Documentation of water temperature testing in the facility revealed that from 4-08-16 thru 6-09-16 (most recent) that water temperatures were taken in the facility at intervals ranging from 3 to 11 days once during the week. It was further noted that the only documentation of the Hall B bath temperatures was on 4-11-16 and 6-02-16. It was also noted that the only documentation of the Hall B resident rooms being checked was on 6-02-16 in this 2 month period. The last time resident rooms on Hall B were tested prior to 6-02-16 was on 3-30-16. The temperatures for Hall B resident rooms at this time on 6-02-16 ranged from 105 to 108 degrees F. Of the 10 weeks reviewed during this time period, temperatures were taken during the morning hours 9 of the 10 weeks; mainly between 9:00 a.m. and 10:00 a.m. On 6-14-16 at 4:05 p.m., the Maintenance Supervisor stated that he checked resident use hot water in the facility one time a week on every hallway. He stated that he checked random areas at different times. He also denied any knowledge of a hot water problem on B hall prior to today, stating No one told me about water being too hot. During another interview with the Maintenance Supervisor on 6-15-16 at 5:06 p.m., he stated that the facility ' s online maintenance scheduling system, Tels, sets up maintenance duties on a weekly basis. He stated that he could insert comments in the system also. The Maintenance Supervisor was asked why he checked water temperatures on a weekly basis instead of daily as stated in the facility policy. He stated that he thought that water temperature checks were conducted on a weekly instead of daily basis since the Tels system documented it as weekly. He added, I misunderstood. During an interview with the Administrator on 6-15-16 at 11:30 a.m., the Administrator was asked about the water temperature checks reports/documentation in the Tels online maintenance scheduling/monitoring system. She stated that she goes into the Tels system and looks at the water temperature documentation and prints it. She stated that no one brought the concern of hot water to her. She added that she usually checks the water temperature logs weekly. She stated that the Tels system sends out weekly alerts on Mondays if temperature checks were not done. She stated that the system alerted once recently and the Maintenance Supervisor told her that he had written down the temperatures but had not entered them in the system. She added that when the Tels system maintenance duties pop up, she prints them and gives them to the Maintenance Supervisor. She further stated that the system sends alerts labeled last week when duties were not completed. Review of the Tels system Work Schedule Tasks for this week (5/8/2016 - 5/14/2016) documented the following, Last Week - Water Temps: Test and log the hot water temperatures. On 6-14-16 at 4:50 p.m., the Maintenance Supervisor was asked what system the facility used to inform the maintenance department of maintenance issues. He stated that staff placed work orders in a Maintenance Book. Review of the Maintenance Log book from December 2015 thru June 13, 2016 revealed no documentation of reports of elevated hot water from staff. ~ Background Information on Hot Water and Burns: 5. Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. ~ Facility Water Temperature Policy: 6. Review of the Maintenance Manual policy labeled Control and Water Temperatures, dated February 2012 revealed the following documentation, Mixing Valves. All mixing valves that are currently in place in any resident use water year must be cleaned at least every 30 days. If you find that the mixing valve is giving you temperatures on a daily basis and vary from 3 to 6°, the valve is typically indicating that it needs to be cleaned. A schedule of regular cleaning will ensure proper water temperatures on a consistent basis. Document mixing valve cleaning and repairs on water temperature log . Standards for water temperatures for resident usage areas: 100°F minimum; 110°F maximum. An upper limit deviation of 5° is allowed at the tank for fluctuation in supply water temperature, temperature variance due to distance between water heater in the fixture, as well as the volume and timing of hot water usage. NOTE: Consistent water temperatures of 115° to maintain acceptable temperatures throughout the loop is an indication that the system requires evaluation for a more satisfactory means of providing hot water. Water temperatures will be taken Daily in the following manner .2. Take water temperatures in resident rooms at the beginning, middle and the end of each water heater loop. (Take temperatures in different rooms every day.) 3. Check each shower and whirlpool area. This should include both the sink and the bathing fixture . Hand washing sinks must be tempered to 100°F to 110°F. During an interview with the Administrator on 6-15-16 at 11:30 a.m., she stated that she had inserviced the Maintenance Supervisor on the facility ' s water check policy. She stated that water temperatures should be checked on a front, middle and end of hall room and a bath on the corridor. The facility Administrator was notified on 6-14-16 at 5:47 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. 7. The final facility Plan to Remove Immediate Jeopardy was submitted to the survey team on 6-15-16 at 12:39 p.m. It stated: Plan of removal for IJ regarding hot water on Hall B. 1) The hot water to Hall B the offending Hall was terminated. a. Done immediately following the IJ determination at approximately 5:47 PM. i. Done by the Facility Maintenance Director ii. Verified or monitored by the Facility Administrator at 5:49PM. 2) All residents/Staff on Hall B were notified of increased water temperature by the Facility Administrator. i. Staff were in-serviced to check water comfort level and safety by touch and report any indication of water being too hot. 3) Using the appropriate thermometer, the water temperature was checked on all walls, checking rooms on both sides of the hall at the beginning, middle and end of the hall and the shower rooms. a. Started at 5:49 PM and completed at 7:00 AM. i. Done by the facility administrator. 1. No other areas of hot water were identified. ii. Monitoring will be done by the facility administrator. 4. The hot water on the offending hall once restarted will not be used for resident care until the water is consistently between 100 and 110 and degrees. a. Daily temperature checks will be performed on 4 - 6 rooms per hall and shower rooms. i. Done by the Facility Maintenance Director using the appropriate thermometer. ii. These temperatures will be logged. iii. Monitoring will be done by the Facility Administrator during morning stand up meeting. iv. Administrator notified medical director at 6:17 PM. 5. Going forward water temperatures will be checked daily per policy by the maintenance man/administrator/designee. On the weekend the administrator will designate weekend RN with housekeeper being backup. All temperatures will be logged and turn into administrator weekly. 6. New hires/Hospice aide/agency will be in-serviced prior performing their duties. PLAN OF ACTION WHEN WATER TEMPS ARE ABOVE 110°. When water temp or too hot maintenance will adjust the water temps to bring water temp back in line (100 - 110°). Maintenance will monitor water temps daily and as reported by staff on water temp are too hot to the touch. The staff will report it to the administrator/maintenance supervisor/charge nurse if the water feels too hot. The administrator/charge nurse will immediately notify the maintenance supervisor to get the water temperature adjusted and administrator will also check water temps to ensure the safety of the resident. Administrator/Designee will notify all residents on the Hall of the water temp that is too hot to not use the water because water is too hot. Signs will be put in all resident ' s bathrooms that the hot water is too hot to ensure resident ' s safety and will remove when water temp are safe per policy. The maintenance supervisor has labeled the hot water tank showing which direction to turn the valve to adjust the water heater to lower or raise the temp to ensure water temp are adjusted correctly. The maintenance supervisor will notify administrator of progress/concerns. If the problem persists the Regional Maintenance Supervisor will be notified. 8. On 6-14-16 between 4:40 p.m. and 6:14 p.m., surveyor verified the hot waters remained within safe limits and facility staff began receiving training related to the facility policy on actions to take if hot water is discovered at elevated temperatures. On 6-15-16 staff members were interviewed on this policy. In-service records were reviewed related to this training. Facility water temperature logs were reviewed. ~ The following were temperatures taken in the facility on 6-14-16: 9. Hall B bath at 4:40 p.m. - 103 degrees F. Hall B bath at 6:02 p.m. - 105.8 degrees F. Room B108 at 6:12 p.m. - 107.5 degrees F. Room B104 at 6:14 p.m. - 100.5 degrees F. On 6-15-16: Room B112 at 11:52 a.m. - 93°F. Hall B bath at 3:32 p.m. - 95.9 degrees F. The hot and cold water fixtures were checked in the Hall B bath shower stall. There were no sharp fluctuations in water temperatures while mixing hot and cold water. Review of the facility Water Temperature Logs dated June 2016 revealed (hot water temperatures, taken by facility staff, on Hall B on 6-14-16 (night) and 6-15-16 (early morning)) that temperatures ranged from 100.9 degrees F to 121 degrees F. on Hall B. The Administrator was alerted when temperatures reached 113 degrees F or above. The Administrator was informed the immediacy was removed on 6-15-16 at 5:50 p.m. However, the facility remained out of compliance at a severity of potential for harm with scope identified as a pattern. The facility was continuing to monitor water temperature safety for all residents. ~Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 6-15-16 confirmed a census of 45. The DON stated on 6-15-16 at 10:20 a.m. that most of the residents on Hall B were ambulatory. At this time, DON presented a list of residents on Hall B that were independently ambulatory. Review of this listing revealed that there were 9 of 11 residents on hall B that were identified as independently ambulatory. Of these 9 residents, 5 were identified as confused

Based on observation, interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in that; a)The Administrator failed to follow policies and procedures to ensure that resident use hot water was maintained at safe temperatures. Resident-use hot water was not reliably controlled, reaching temperatures as high as 136 degrees F. Seven of 15 resident rooms (B101, B102, B103, B104, B106, B108 and B112 affecting 7 of 15 residents respectively - #13, 17, 18, 30, 7, 20 and 3) and Hall B bath had water temperatures that had the potential to cause 3rd degree (full thickness injury) burns, b) The Administrator failed to adequately monitor staff that had water temperature monitoring related duties to ensure resident use hot water was monitored and tested according to facility policy. The Maintenance Supervisor checked resident use hot water once a week instead of daily as per the facility policy. The Administrator monitored the water temperature logs and failed to correct this situation. These logs also documented that water temperatures were not documented as checked in Hall B resident rooms for 63 days between 3-30-16 and 6-02-16, c) The Administrator failed to ensure that information related to elevated/unsafe water temperatures was effectively disseminated to residents and staff, and d) The Administrator did not use accurate equipment when testing water temperatures These problems resulted in an Immediate Jeopardy (IJ) on 6-14-16. While the immediacy was removed on 6-15-16, the facility remained out of compliance at a pattern with the potential for more than minimal harm as the facility had not had time to fully monitor and evaluate the effectiveness of their Plan of Removal. These deficient practices had the potential to cause hot [MEDICAL CONDITION] pain to all 11 residents who resided on B Hall and especially 9 residents that were identified as independently ambulatory or with minimal assistance of these 11 residents. Of these 9 residents, 5 were identified as confused. The facility had a census of 45. These problems could have resulted in residents receiving 3rd [MEDICAL CONDITION] using resident-use/resident accessible water. The findings include: ~ The following observations were made on 6-14-16 at handsinks in the below mentioned Hall B rooms and bath: 1.At 3:00p.m. on 6-14-16, the hot water at the Hall B bath was 118 degrees. The bath was checked again at 3:02 p.m. with witness CNA #1 and the water temperature was 125.7 degrees F. At that time CNA #1 stated that she knew the water in the bath was hot, stating Yes I know. It ' s hot here (Hall B bath) the last 2 months. I do showers, but I use the one (bath) on Hall A and C. CNA #1 further stated, I can never get it to adjust, it ' s just me. She confirmed that other staff give resident showers in the Hall B shower and had given showers in the Hall B bath today. CNA #1 also stated, They said they were going to fix it; the Maintenance Supervisor. She added that when she was first employed in the facility, the Maintenance Supervisor said he was going to fix it and just had not got to it. She further stated that this was said approximately 2 months ago. During another interview with CNA #1 on 6-15-16 at 12:50 p.m., she was asked why she felt the water temperature was difficult to adjust in the Hall B bath. She stated, When I tried to adjust it, it was really really hot or really really cold. I could not get it to be stable. She added that while she tried to adjust the shower temperature, the residents were sitting in the shower naked and cold and wanted to leave. She stated that was the reason she started to use other showers. CNA #1 was also asked if she had directly heard from the Maintenance Supervisor that he was aware of the hot water temperatures 2 months prior to the current hot water problems. She stated that she had heard this comment from another staff member. Room B108 on 6-14-16 at 3:05 p.m. - 119.2 degrees F Room B103 on 6-14-16 at 3:07 p.m. - 124.5 degrees F. Room B102 on 6-14-16 at 3:11 p.m. - 116.7 degrees F. Room B 112 on 6-14-16 at 3:12 p.m. - 129.8 ° F. On 6-14-16 at 3:23 p.m. Surveyor notified the Maintenance Supervisor of high water temperatures on Hall B. He said he would go turn the thermostat down for Hall B. Room B106 on 6-14-16 at 3:30 p.m. - 117.9° F. On 6-14-16 on 6-14-16 at 4:05 p.m., the Maintenance Supervisor was observed working on/repairing the main entrance door. He was again informed of elevated hot water temperatures on Hall B by another surveyor. He responded, Yes, I ' m turning it down. The Hall B bath hot water was checked again at 4:15 p.m. on 6-14-16. The surveyor ' s digital thermometer registered 136 degrees F and the facility ' s digital thermometer (gun type) read 135 degrees F. At this time, the Maintenance Supervisor went to adjust the Hall B hot water temperature. The Administrator was informed of the elevated temperatures on Hall B on 6-14-16 at 4:17 p.m. and was informed that immediate action needed to be taken to reduce the hot water temperatures and protect the residents. Room B108 on 6-14-16 at 4:18 p.m. - 131 degrees F. MA #1 witnessed this temperature. MA #1 stated at this time, This room is always hot (water). She stated that the room ' s hot water had been elevated for a couple of months, approximately 2. She added that she could tell the water temperature was elevated in the room by toughing the water. MA #1 was asked if she had ever mentioned the elevated hot water temperatures in this room to anyone. She stated, I never really mentioned it to anyone. Room B103 on 6-14-16 at 4:20 p.m. - 117.1 degrees F. Hall B bath on 6-14-16 at 4:22 p.m. - 125.4 degrees F. Room B104 on 6-14-16 at 4:25 p.m. - 135.1 degrees F. Room B101 on 6-14-16 at 4:30 p.m. - 117.8 degrees F. Room B112 on 6-14-16 at 4:33 p.m. - 120 degrees F. The Administrator was informed of the hot water issues at 4:17 p.m. on 6-14-16 and she contacted the Maintenance Supervisor. After this, staff and some residents were immediately alerted to the hot water and water temperatures were reduced. The DON stated on 6-15-16 at 10:20 a.m. that most of the residents on Hall B were ambulatory. At this time, DON presented a list of residents on Hall B that were independently ambulatory. Review of this listing revealed that there were 9 of 11 residents on hall B that were identified as independently ambulatory. Of these 9 residents, 5 were identified as confused. The listing identified the following resident ambulation and cognitive capabilities: Room B101 occupied by Resident #13 - independently ambulatory with a walker Room B102 occupied by Resident #17 - independently ambulatory with a wheelchair Room B103 occupied by Resident #18 - not independently ambulatory Room B104 occupied by Resident #30 - independently ambulatory with a wheelchair and confused Room B106 occupied by Resident #7 - independently ambulatory with a wheelchair Room B108 occupied by Resident #13 - not independently ambulatory Room B112 occupied by Resident #13 - independently ambulatory with a wheelchair and confused ~ Maintenance Supervisor Interview/Water Heater Observations: 2. The water heater for Hall B was observed on 6-14-16 at 4:50 p.m. with the Maintenance Supervisor. It was noted that a red colored pump was unplugged in the water heater closet. The Maintenance Supervisor stated that this pump was the one that pumped water from the water heater to the facility. Observation of the water heater on 6-14-16 at 4:50 p.m. revealed that the temperature dial was set past 130 degrees F. and into the red colored zone of the dial towards 160 degrees F. When the Maintenance Supervisor was asked why the water heater was set at this temperature, he stated, This has to stay set like this to kill Lyme disease in the water heater; any bacteria. On 6-14-16 at 4:50 p.m., the Maintenance Supervisor identified the silver colored knob plumbed near the top level of the water heater as the mixing valve and stated, This is where you set and mix hot and cold water. Turn it clockwise to add cold water and counterclockwise to increase the water temperature. At this time the Maintenance Supervisor was asked what caused the water temperature on Hall B to elevate. He stated, (the mixing valve) had 2 turns back toward hot, so now I did 2 turns to the right for more cold water. The Maintenance Supervisor also stated that he looks for the temperature of 104 or 105 degrees F as the correct resident use hot water, with a maximum of 110 degrees F. The water heater for Hall B was observed on 6-14-16 at 6:05 p.m. with the Maintenance Supervisor. The maintenance Supervisor was asked at this time what type of training he had received related to the water heaters. He stated that he had received 2 days of orientation and that the director came 2 or 3 days to train and orient him the to the facility maintenance duties. The Maintenance Supervisor was asked what caused the water temperature on Hall B to elevate. He stated, I had a failed pump (water heater) and I fixed it. I keep it (water heater) at 140 degrees F to kill Lyme disease. The (red) pump went out today. A wire was loose on the recirculating pump. With the wire loose, the water was not recirculating properly. I check water heater closets once a week on no particular day. The (pump ' s) loose wire was discovered today. The water heater for Hall B was observed on 6-15-16 at 4:55 p.m. with the Maintenance Supervisor. It was noted that the top of the mixing valve was marked hot and cold on top with a maker. The word cold had an arrow pointing to the right and the word hot had arrows pointing both left and right. There was also an instruction tag on the back of the mixing valve that had a portion of the tag ' s wording missing. The Maintenance Supervisor stated at this time that he had reduced the temperature dial on the water heater lower, stating, I set it at 140 degrees F, a notch above 130 degrees F. Observation of the temperature control dial on the water heater on 6-15-16 at 5:02 p.m. revealed that the dial was set between 120 degrees F and 130 degrees F and in the yellow zone of the dial. On 6-14-16 at 5:47 p.m., the Administrator was asked what caused the hot water to be elevated on Hall B. She stated, He (Maintenance Supervisor) probably turned it up because someone said it (hot water) was too cold. On 6-16-16 at 12:55 p.m., the Administrator was asked how she thought the IJ came about. She stated, He (Maintenance Supervisor) admitted me that he turned it up because a resident on the hall said it was too cold; maybe (Resident #17) or (Resident #24). He got pulled away to do something and didn ' t get back to turn it down. On 6-14-16 at 4:43 p.m., the Administrator also stated that she had not been told about the hot water being elevated on Hall B prior to 6-14-16. ~ Thermometer Accuracy: 3. At 7:00 p.m. on 6-14-16, the Administrator was observed using a dial thermometer to check water temperatures in the facility. Closer observation of the thermometer revealed that it read 70 degrees F. while on the counter at the nurse ' s station. The thermometer was placed in ice water to check the calibration. The facility dial thermometer registered 25 degrees F and the surveyor ' s digital thermometer registered 32 degrees F. The Administrator stated on 6-14-16 at 7:02 p.m. that the dial thermometer was the only one she had. During an interview with the Administrator on 6-15-16 at 11:30 a.m., she stated that she had gotten a new thermometer today. ~ Water Temperature Logs and Maintenance Duties Scheduling System: 4. Review of the Maintenance Manual, dated February 2012, revealed the following documentation, Critical Systems Inspection and Preventative Maintenance Planning Schedule .Water heaters .Note: Water temperatures are to be taken daily per instructions in maintenance manual . Review of the Tels (maintenance duties scheduling/monitoring system) Logbook Documentation of water temperature testing in the facility revealed that from 4-08-16 thru 6-09-16 (most recent) that water temperatures were taken in the facility at intervals ranging from 3 to 11 days once during the week. It was further noted that the only documentation of the Hall B bath temperatures was on 4-11-16 and 6-02-16. It was also noted that the only documentation of the Hall B resident rooms being checked was on 6-02-16 in this 2 month period. The last time resident rooms on Hall B were tested prior to 6-02-16 was on 3-30-16. The temperatures for Hall B resident rooms at this time on 6-02-16 ranged from 105 to 108 degrees F. Of the 10 weeks reviewed during this time period, temperatures were taken during the morning hours 9 of the 10 weeks; mainly between 9:00 a.m. and 10:00 a.m. On 6-14-16 at 4:05 p.m., the Maintenance Supervisor stated that he checked resident use hot water in the facility one time a week on every hallway. He stated that he checked random areas at different times. He also denied any knowledge of a hot water problem on B hall prior to today, stating No one told me about water being too hot. During another interview with the Maintenance Supervisor on 6-15-16 at 5:06 p.m., he stated that the facility ' s online maintenance scheduling system, Tels, sets up maintenance duties on a weekly basis. He stated that he could insert comments in the system also. The Maintenance Supervisor was asked why he checked water temperatures on a weekly basis instead of daily as stated in the facility policy. He stated that he thought that water temperature checks were conducted on a weekly instead of daily basis since the Tels system documented it as weekly. He added, I misunderstood. During an interview with the Administrator on 6-15-16 at 11:30 a.m., the Administrator was asked about the water temperature checks reports/documentation in the Tels online maintenance scheduling/monitoring system. She stated that she goes into the Tels system and looks at the water temperature documentation and prints it. She stated that no one brought the concern of hot water to her. She added that she usually checks the water temperature logs weekly. She stated that the Tels system sends out weekly alerts on Mondays if temperature checks were not done. She stated that the system alerted once recently and the Maintenance Supervisor told her that he had written down the temperatures but had not entered them in the system. She added that when the Tels system maintenance duties pop up, she prints them and gives them to the Maintenance Supervisor. She further stated that the system sends alerts labeled last week when duties were not completed. Review of the Tels system Work Schedule Tasks for this week (5/8/2016 - 5/14/2016) documented the following, Last Week - Water Temps: Test and log the hot water temperatures. On 6-14-16 at 4:50 p.m., the Maintenance Supervisor was asked what system the facility used to inform the maintenance department of maintenance issues. He stated that staff placed work orders in a Maintenance Book. Review of the Maintenance Log book from December 2015 thru June 13, 2016 revealed no documentation of reports of elevated hot water from staff. ~ Background Information on Hot Water and Burns: 5. Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: .although [MEDICAL CONDITION] happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third [MEDICAL CONDITION] 1 minute and water at 133 degrees F. caused third [MEDICAL CONDITION] 15 seconds. Water temperatures at 140 degrees F. caused third [MEDICAL CONDITION] 5 seconds. ~ Facility Water Temperature Policy: 6. Review of the Maintenance Manual policy labeled Control and Water Temperatures, dated February 2012 revealed the following documentation, Mixing Valves. All mixing valves that are currently in place in any resident use water year must be cleaned at least every 30 days. If you find that the mixing valve is giving you temperatures on a daily basis and vary from 3 to 6°, the valve is typically indicating that it needs to be cleaned. A schedule of regular cleaning will ensure proper water temperatures on a consistent basis. Document mixing valve cleaning and repairs on water temperature log . Standards for water temperatures for resident usage areas: 100°F minimum; 110°F maximum. An upper limit deviation of 5° is allowed at the tank for fluctuation in supply water temperature, temperature variance due to distance between water heater in the fixture, as well as the volume and timing of hot water usage. NOTE: Consistent water temperatures of 115° to maintain acceptable temperatures throughout the loop is an indication that the system requires evaluation for a more satisfactory means of providing hot water. Water temperatures will be taken Daily in the following manner .2. Take water temperatures in resident rooms at the beginning, middle and the end of each water heater loop. (Take temperatures in different rooms every day.) 3. Check each shower and whirlpool area. This should include both the sink and the bathing fixture . Hand washing sinks must be tempered to 100°F to 110°F. During an interview with the Administrator on 6-15-16 at 11:30 a.m., she stated that she had inserviced the Maintenance Supervisor on the facility ' s water check policy. She stated that water temperatures should be checked on a front, middle and end of hall room and a bath on the corridor. The facility Administrator was notified on 6-14-16 at 5:47 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. 7. The final facility Plan to Remove Immediate Jeopardy was submitted to the survey team on 6-15-16 at 12:39 p.m. It stated: Plan of removal for I J regarding hot water on Hall B. 1) The hot water to Hall B the offending Hall was terminated. a. Done immediately following the IJ determination at approximately 5:47 PM. i. Done by the Facility Maintenance Director ii. Verified or monitored by the Facility Administrator at 5:49PM. 2) All residents/Staff on Hall B were notified of increased water temperature by the Facility Administrator. i. Staff were in-serviced to check water comfort level and safety by touch and report any indication of water being too hot. 3) Using the appropriate thermometer, the water temperature was checked on all walls, checking rooms on both sides of the hall at the beginning, middle and end of the hall and the shower rooms. a. Started at 5:49 PM and completed at 7:00 AM. i. Done by the facility administrator. 1. No other areas of hot water were identified. ii. Monitoring will be done by the facility administrator. 4. The hot water on the offending hall once restarted will not be used for resident care until the water is consistently between 100 and 110 and degrees. a. Daily temperature checks will be performed on 4 - 6 rooms per hall and shower rooms. i. Done by the Facility Maintenance Director using the appropriate thermometer. ii. These temperatures will be logged. iii. Monitoring will be done by the Facility Administrator during morning stand up meeting. iv. Administrator notified medical director at 6:17 PM. 5. Going forward water temperatures will be checked daily per policy by the maintenance man/administrator/designee. On the weekend the administrator will designate weekend RN with housekeeper being backup. All temperatures will be logged and turn into administrator weekly. 6. New hires/Hospice aide/agency will be in-serviced prior performing their duties. PLAN OF ACTION WHEN WATER TEMPS ARE ABOVE 110°. When water temp or too hot maintenance will adjust the water temps to bring water temp back in line (100 - 110°). Maintenance will monitor water temps daily and as reported by staff on water temp are too hot to the touch. The staff will report it to the administrator/maintenance supervisor/charge nurse if the water feels too hot. The administrator/charge nurse will immediately notify the maintenance supervisor to get the water temperature adjusted and administrator will also check water temps to ensure the safety of the resident. Administrator/Designee will notify all residents on the Hall of the water temp that is too hot to not use the water because water is too hot. Signs will be put in all resident ' s bathrooms that the hot water is too hot to ensure resident ' s safety and will remove when water temp are safe per policy. The maintenance supervisor has labeled the hot water tank showing which direction to turn the valve to adjust the water heater to lower or raise the temp to ensure water temp are adjusted correctly. The maintenance supervisor will notify administrator of progress/concerns. If the problem persists the Regional Maintenance Supervisor will be notified. ~ Ineffective Notification of Unsafe Water Temperatures: 8. The Administrator was informed of the hot water issues at 4:17 p.m. on 6-14-16 and she contacted the Maintenance Supervisor. After this, staff and some residents were immediately alerted to the hot water and water temperatures were reduced. Three of 4 residents confidentially interviewed on Hall B (Residents D, G and H) and 1 of 2 family members confidentially interviewed on Hall B (Family Member A)) were not informed of the hot water issues on Hall B. On 6-14-16 at 4:27 p.m. Resident H and Family Member A were in the resident ' s room on Hall B. They were asked if they had been informed of the hot water on Hall B being elevated where the resident resided. Resident H stated that nothing had been mentioned to her. Family Member A agreed and stated, I guess it ' s (water temperature) fine. On 6-14-16 at 4:30 p.m. Resident D and her roommate were in their room on Hall B. Resident D was asked if they had been informed of the hot water on Hall B being elevated where the residents resided. Resident D stated that nothing had been mentioned to her. On 6-14-16 at 4:35 p.m. MA #2 was observed on Hall B with the medication cart. She stated at this time that she had been made aware of the elevated hot water on Hall B by the Administrator. On 6-14-16 at 4:30 p.m. Resident G was in her room on Hall B. Resident G was asked if she had been informed of the hot water on Hall B being elevated. Resident G stated that nothing had been mentioned to her. On 6-14-16 at 5:47 p.m., the Administrator was told that the surveyor had talked to residents on Hall B and that some were not told about the water being too hot. The Administrator stated, I told the Med Aide (on Hall B - MA #2) about it. 9. During an interview with the Administrator on 6-15-16 at 11:30 a.m., she was asked if staff were using the B Hall bath for showers today. She stated, One lady from hospice used it and I didn ' t know, but I had checked it (hot water) before she used it. 10. On 6-15-16 at 11:03 a.m., Contract Therapist #1 stated that he had not been told by facility staff any actions to take if he discovered that resident use hot water was elevated. The Administrator was asked if she had included the contract therapists in the facility training related to actions taken when hot water was discovered in the facility. She stated that she had not. She added that she had not informed hospice agencies that visit the facility about the facility training related to actions taken when hot water was discovered in the facility. On 6-14-16 between 4:40 p.m. and 6:14 p.m., surveyor verified the hot waters remained within safe limits and facility staff began receiving training related to the facility policy on actions to take if hot water is discovered at elevated temperatures. On 6-15-16 staff members were interviewed on this policy. In-service records were reviewed related to this training. Facility water temperature logs were reviewed. ~ The following were temperatures taken in the facility on 6-14-16: 11. Hall B bath at 4:40 p.m. - 103 degrees F. Hall B bath at 6:02 p.m. - 105.8 degrees F. Room B108 at 6:12 p.m. - 107.5 degrees F. Room B104 at 6:14 p.m. - 100.5 degrees F. On 6-15-16: Room B112 at 11:52 a.m. - 93°F. Hall B bath at 3:32 p.m. - 95.9 degrees F. The hot and cold water fixtures were checked in the Hall B bath shower stall. There were no sharp fluctuations in water temperatures while mixing hot and cold water. Review of the facility Water Temperature Logs dated June 2016 revealed (hot water temperatures, taken by facility staff, on Hall B on 6-14-16 (night) and 6-15-16 (early morning)) that temperatures ranged from 100.9 degrees F to 121 degrees F. on Hall B. The Administrator was alerted when temperatures reached 113 degrees F or above. The Administrator was informed the immediacy was removed on 6-15-16 at 5:50 p.m. However, the facility remained out of compliance at a severity of potential for harm with scope identified as a pattern. The facility was continuing to monitor water temperature safety for all residents. ~ Administrator Process Interview: 12. During an interview with the Administrator on 6-16-16 at 12:55 p.m., she was asked: What type of procedure was there to ensure the Maintenance needs of residents are being met? She stated, There is a book at the nurse ' s station they are supposed to put issues in. We have Ambassadors program and they report to me each day. When employees talk to them (residents) they say all is fine. I ' m finding out that ' s not true recently. She stated that she has found that staff bypass her and report issues to staff above her. I ' m always accessible. We have to know (issues) or we can ' t fix it. The Administrator was then asked: How do you monitor staff to ensure the systems they monitor are being done sufficiently? She stated, I walk around and watch them and assure it ' s done. He (Maintenance Supervisor) did not know what I proposed as back up for the hot water. I think he was working on the air conditioner. He was not a part of our conversation. He came back and asked me. She added that she ensures the competency of staff by monitoring, training and retraining. She stated that facility policy and procedures reviewed yearly or as an incident occurs. The Administrator further stated that she ensured the effectiveness of facility processes by putting a plan into practice place and then reassess the process. The Administrator was also asked: How do you think the IJ came about? Were you aware of the situation? If so, did you investigate and/or implement corrective measures? She stated, Somebody probably told him it (hot water) was too cold and he (Maintenance Supervisor) turned it (up) and did not go back and check; this is my thought. He should adjust and check for 20 minutes if it is high. He admitted me that he turned it up because a resident on the hall said it was too cold; maybe (Resident #17) or (Resident #24). He got pulled away to do something and didn ' t get back to turn it down. She added that she was not aware of hot water issues on Hall B prior to 6-14-16. She stated, I wasn ' t aware. (Resident #17) and (Resident #2) complain more that it ' s cold. This was the first I heard of this problem on Hall B. The Administrator was then asked: What resources were available to her and her staff? She stated, Corporate Maintenance staff, the Regional Director of Operations gives me anything (I need) and I have access to repairmen (local). 13. The Administrator was unable to locate a facility policy related to the Administration of the facility, but was able to locate the facility Job description for the Administrator prior to exit on 6-17-16. Review of the facility job description labeled Administrator, date revised 7/2011 revealed the following documentation, position summary: the overall purpose of the administrator position is to ensure the provision of the best available quality of care for facility resident. Incumbents plan, develop, direct, and control facility operations within the bounds of established policies, procedures, programs, and budgets ~Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 6-15-16 confirmed a census of 45.