Every finding on record at The Center at Grande

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one of seven residents (Resident #88) reviewed for misappropriation. The facility failed to report Resident #88's allegation of misappropriation reported on 04/06/2026 within 24 hours and did not report to the State Agency until approximately 54 hours after the incident was reported. The facility failed to submit the Provider Investigation report of an investigation of misappropriation within 5 working days as required until 7 working days after the incident was reported. This failure could place residents at risk of not receiving timely investigation into allegations of misappropriation. The findings included: A record review of TULIP case details on 5/18/2026 at 9:00 AM indicated the report of misappropriation alleged by Resident #88 was received by HHSC on 04/08/2026 at 2:29 PM. The PIR Submission Date was received 04/15/2026. A record review of Resident #88's face sheet dated 05/20/2026 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #88 had diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition characterized by the buildup of plaque in the coronary arteries, which supply blood to the heart) and acute on chronic systolic heart failure (a situation where a person with a history of chronic heart failure experiences a sudden worsening of symptoms). A record review of Resident #88's Discharge MDS dated [DATE] indicated a BIMS of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #88 did not present inattention, disorganized thinking, or an altered level of consciousness. During a telephone interview on 05/19/2026 at 1:00 PM Resident #88 stated he was missing money during his stay and he originally thought it to be in the sum of $1500, but then believed it to be $1800. Resident #88 was unable to give a timeframe in which the event occurred or when he reported it. Resident #88 stated the BOM and a case manager assisted him in searching for the money and filing a police report. A record review of a witness statement by the BOM dated 04/08/2026 in the facility's PIR indicated on 04/06/2026 Resident #88 reported to her he was missing $1500 from his bedside drawer. The BOM indicated she immediately notified the case manager and they assisted him in investigating the alleged misappropriation on 04/06/2026 and 04/07/2026. An interview with the BOM on 05/20/2026 at 11:50 AM stated Resident #88 reported to her on 04/06/2026 he was missing $1500. The BOM stated Case Manager A assisted her in investigating the alleged misappropriation. The BOM stated that an allegation of misappropriation was to be reported to the State Survey Agency within 24 hours of the report being made. The BOM stated she mentioned the report of alleged misappropriation to the ADM on 04/06/2026 and notified the ADM of the findings she had obtained on 04/07/2026. During an interview on 05/20/2026 at 1:27 PM, Case Manager A stated she could not recall specific dates, but knew Resident #88 reported to the BOM he was missing a lump sum of money and she had assisted in the investigation. Case Manager A stated she and the BOM reported the alleged misappropriation to the ADM as soon as they were aware of it. Case Manager A stated she believed the timeframe for reporting misappropriation to the State Survey Agency to be less than a week. During an interview on 05/20/2026, the ADM stated she was aware she did not report the alleged misappropriation or the results of the investigation within the required timeframes. The ADM stated she was responsible for reporting the allegation as she was the Abuse Coordinator. The ADM stated she did not report the alleged misappropriation within the required timeframes due to other priorities arising. The ADM stated she did not feel there was a risk to Resident #88 as it was not an issue of abuse or neglect and the facility was thoroughly investigating the alleged misappropriation. A record review of facility policy dated January 2018 titled Abuse and Neglect Prohibition indicated the following: PolicyEach resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.Abuse Prevention CoordinatorThe facility administrator is the Abuse Prevention Coordinator.Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Reporting and ResponseState Reporting Obligations: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services (where state law provides for jurisdiction in long-term care facilities) in accordance with Federal and State law through established procedures. Timeline for reporting is as follows:If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation; or If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a need to alter treatment for 1 of 4 residents reviewed for physician notification. (Resident #1) The facility failed to immediately notify the physician on 9/24/25 when they were unable to draw the blood successfully on Resident #1 for labs. This failure could place residents at risk for delayed diagnosis or altered medical management.Findings included: Record review of an admission record, dated 9/30/25, indicated Resident #1 was a 68 year female who admitted on [DATE] and discharged home with home health services on 9/28/25 with diagnoses including acute kidney failure (when the kidneys suddenly stop functioning, leading to a build-up of waste products in the blood), arthropathic psoriasis (a form of inflammatory arthritis that can affect people with psoriasis, causing joint pain, swelling, stiffness, and fatigue), congestive heart failure (a condition where the heart muscle is damaged and cannot pump blood efficiently to meet the body's needs), anemia (a condition where the body lacks enough healthy red blood cells or hemoglobin, which can cause symptoms like fatigue, weakness, and shortness of breath), hypertension (or high blood pressure, a condition where the force of blood against artery walls is consistently too high), and hypothyroidism (a common condition where the thyroid gland in your neck does not make enough hormones). Record review of an active orders summary report, dated 9/16/25, indicated Resident #1 had admission Labs CBC, CMP, TSH, Vit.D one time only for one week post admission for two days follow up with results with an order date of 9/16/25, start date of 9/23/25, and end date of 9/25/25. Record review of Physician order detail report, dated 9/16/25, and completed by LVN B, indicated Resident #1 had verbal orders for admission labs: CBC, CMP on admission and one week post admission: CBC, CMP, TSH, Vit.D. This order was signed by Resident #1's Physician and dated 9/17/25. Record review of admission MDS assessment, dated 9/20/25, indicated Resident #1 had clear speech, was able to make her self-understood by expressing ideas and wants; had clear comprehension. She had a BIMS score of 12 out of 15 indicating she had moderate cognitive impairment with thinking and memory. She required supervision or moderate assistance with most ADLs. Record review of Resident #1's undated revised care plan indicated the following:-Focus (initiated 9/16/25): [Resident #1] respiratory risk related to respiratory conditions. Goal: Respiratory risks related to pulmonary conditions/function will be minimized with interventions. Intervention (initiated 9/24/25): Notify physician of change in status. -Focus (initiated 9/24/25): [Resident #1] was at risk for cardiac complications due to Hypertension. Goal: will have no cardiac complications through review date. Interventions: and monitor lab work as ordered by physician and report results.-Focus (initiated 9/24/25): [Resident #1] had potential for complications from chronic kidney disease. Goal: [Resident #1] will have minimized risk for progression of comorbidities due to CKD. Intervention: Monitor lab values per physician's orders.-Focus (initiated 9/24/25): [Resident #1] at risk for complications r/t Hypothyroidism (under active thyroid). Goal: No complications related to hypothyroidism over the next 90 days. Interventions: Monitor lab results per physician's orders and report results to physicians.-Focus (initiated 9/24/25) [Resident #1] had blood pressure. Goal: No complications related to high blood pressure over the next 90 days. Interventions: Obtain and monitor lab work as ordered by physician. Notify physician of any change in condition. Record review of Resident #1's clinical records from 9/16/25 to 9/28/25 reflected no one week post admission: CBC, CMP, TSH, Vit.D. documentation or results. Record review of a handwritten statement, dated 9/29/25, provided by the facility, completed by Staff C indicated the following: On September 24, 2025, I [Staff C] attempted to draw blood from [Resident #1] for her one-week labs. Unfortunately, [Staff C] was unsuccessful after two attempts. So, on the next day [Staff C] went to [LVN D] that worked on the 2nd floor who had helped [Staff C] before on several occasions. However, [LVN D] was also unable to draw the blood successfully. At the next attempt to draw blood [Resident #1] refused because of so many failed attempts. Record review of education/in-service record, date 9/29/25, and signed by the DON and Staff C, indicated the following: If [Staff C] was unable to obtain blood from the patient, [Staff C] must immediately notify the charge nurse and either DON. During an interview on 11/16/25 at 4:00 p.m. the DON said the one-week post admission labs for CBC, CMP, TSH, and Vit.D. were a mistake made by the staff when entering the order. During an interview on 11/16/25 at 5:23 p.m. the DON said Resident #1's one week post admission CBC, CMP, TSH, Vit.D labs were not done. The DON said she was not aware of what [Staff C] did until after [Resident #1] discharged . The DON said Staff C and LVN D should have told her or the resident's doctor. The DON said they did not have a system in place to verify labs were done because that was not an issue before, to her knowledge. The DON said the facility used its own staff to draw blood because everything was in-house and not contracted. She said Staff C was good, no complaints, and DON trained Staff C had been trained on how to draw laboratory specimens. On 11/21/25 at 12:55 p.m., attempted to interview LVN B, the staff who entered the orders, the telephone number provided by facility was not a working number and no interview was obtained. On a telephone interview was attempted with Staff C, regarding the unsuccessful lab attempts for Resident #1. Staff C did not answer, and although a message with a call back telephone number was left, the interview was not obtained. During a telephone interview on 11/21/25 at 12:57 p.m., Resident #1's physician who wrote the order for one-week post-admission laboratory tests said he had not been made aware that the labs ordered were not completed. He said he had not been notified of Staff C's unsuccessful attempts to collect the lab specimen. Resident #1's Physician stated he would have expected Staff C to inform her nurse manager or for the facility to contact him directly, so the matter could have been addressed. He further stated that not doing the lab would never be an option and expressed that he wished he had been notified. Record review of revised facility laboratory services policy, dated 4/2/24, indicated, The facility stall: 1. Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. 2.Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Based on interview and record review the facility failed to ensure within 14 days after a facility completed a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System including a subset of items upon a resident's transfer, reentry, discharge, and death for 2 of 2 residents (Residents #16 and #115) reviewed for MDS assessments. 1. The facility failed to transmit to the CMS system Resident #16 's discharge MDS assessment, dated 01/10/25. 2. The facility failed to transmit to the CMS system Resident #115 's discharge MDS assessment, dated 11/16/24. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted. Findings include: 1. Record review of Resident #16's face sheet, dated 03/13/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Resident #16 had diagnoses which included right femur fracture (a break in the thigh bone), multiple sclerosis (numbness, weakness, trouble walking, and vision changes caused by a breakdown of the nerves protective covering), and hypertension (high blood pressure). Record review of Resident #16's electronic health records, under the MDS tab, indicated the discharge MDS was dated 11/19/24. The discharge MDS status indicated the assessment was transmitted and accepted on 03/12/25. 2. Record review of Resident #115's face sheet, dated 03/13/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Resident #115 had diagnoses which included surgery on the digestive system, ileus (slowing of the digestive tract that can prevent the passage of food), sepsis (blood infection), and dementia (loss of cognitive function that affects memory, thinking and social abilities). Record review of Resident #115's electronic health records, under the MDS tab, indicated the discharge MDS was dated 11/06/24. The discharge MDS status indicated the assessment was transmitted and accepted on 03/12/25. During an interview on 03/12/25 at 2:04 p.m., MDS Nurse A said she and MDS Nurse B were responsible for ensuring the MDS assessments were completed and transmitted within a 14-day timeframe. MDS Nurse A said the discharge MDS status for Residents #16 and #115 were listed as Ready to Export, which meant they were completed but were not transmitted. MDS Nurse A said she and MDS Nurse B were unable to submit Residents #16 and #115 MDS within the 14 day timeframe because they were both out sick . MDS Nurse A said the discharge MDS for Residents #16 and #115 were not transmitted by the 14th day but will submit them today. MDS Nurse A said it was important to complete and transmit the MDS assessments timely because they affected quality of care measures and payments. MDS Nurse A said they did not have a policy and followed the RAI guidelines . During an interview on 03/12/25 at 2:34 p.m., the Administrator said she was not aware Residents #16 and #115's MDS were not transmitted. The Administrator said it was the responsibility of the MDS nurses to complete and transmit the MDS timely. Record Review of the CMS RAI Version 3.0 Manual, dated October 2024, indicated, in Chapter 2, page 2-39 .09. Discharge Assessment-Return Not Anticipated (A0310F) . Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B +14 calendar days) .

Based on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 4 of 10 residents reviewed for misappropriation of resident property. (Resident #'s 1, 2, 3, and 4) CNA B stole money from Resident #1, #2, and #4 during the night shifts of 2/11/25 to 2/12/25 and 2/13/25 to 2/14/25. CNA B stole money and credit card information from Resident #3 during the night shifts of 2/11/25 to 2/12/25 and 2/13/25 to 2/14/25. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of Resident #1's face sheet dated 3/6/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included, heart failure. Record review of Resident #1's admission MDS assessment, dated 2/11/25, indicated Resident #1 had adequate vision. The MDS indicated Resident #1 made himself understood and was understood by others. The MDS (BIMS of 15) indicated Resident #1 had no cognitive impairment. Record review of Resident #1's care plan dated 2/7/25 did not address the right to be free from misappropriation. The care plan indicated Resident #1 was to be assisted with ADLS including repositioning as needed. Record review of the facility investigation summary dated 2/18/25 stated, On Friday February 14, 2025, it was brought to the attention of the ADON, that (Resident #1) had money missing. The ADON went to visit with (Resident #1) . and was told that he had $500 stolen from his wallet on Tuesday 2/11/25 at night . During a phone interview on 3/6/25 at Resident #1 said he had taken a sleeping pill to go to sleep on Tuesday night (2/11/25). Resident #1 said he had four 100-dollar bills in his wallet which initially remained in his pants when he started to fall asleep. He described the CNA as taking care of that night as having red tinted hair maybe in her upper 30's and kinda heavy set. Resident #1 said regarding the CNA he described she was not regular staff and did not know her name. Resident #1 said he got up and laid his pants (with his wallet in the pants) in the bottom drawer in the nightstand. Resident #1 said he didn't realize the money was missing until he went to pay his water bill. Record review of Resident #2's face sheet dated 3/6/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, aftercare following joint replacement surgery. Record review of Resident #2's admission MDS assessment, dated 1/17/25, indicated Resident #2 had adequate vision. The MDS indicated Resident #2 made herself understood and was understood by others. The MDS (BIMS of 15) indicated Resident #2 had no cognitive impairment Record review of Resident #2's care plan dated 1/16/25 did not address the right to be free from misappropriation. The care plan indicated Resident #2 was to receive assistance with ADLs including toileting, grooming, transferring and eating as needed. Record review of the facility investigation summary dated 2/18/25 stated, . Later that morning (2/14/25) (the ADON) was informed that (Resident #2) . had money missing as well. Upon interview (Resident #2) advised the ADON that she had $200 missing. (Resident #2) said she had a fall earlier and the suspect, CNA B with .staffing agency was in her room assisting with fall and rummaging through her belongings. After she was assisted to bed, the aid asked to borrow her key to the locked drawer where she had her money stored. She gave CNA B her key because she told her she was cleaning up. She asked for her key back when CNA B started to leave the room. She did not realize that the money was missing until the next morning when she went to get out money . Resident #2 described the suspect as having red curly hair that worked on Thursday night . During a phone interview on 3/6/25 at 11:03 a.m., Resident #2 said she had a little over 200 dollars stolen while at the facility. Resident #2 said she did not know the name of the CNA but described her as having red curly hair a little shorter than shoulder length. Resident #2 said the ends of her hair were a little lighter in color than the rest of her hair. Resident #2 described the CNA as having a medium build. Resident #2 described herself as being a little bit out of it as she got up during the night to use the restroom. Resident #2 said while in the bathroom she kinda slid down the wall and reached over and pulled the call light in the bathroom. Resident #2 said her nurse came and the CNA she described also came in the room. Resident #2 said the nurse helped her up and as she was assisting her into the bed she looked into the mirror and saw the CNA she described (CNA B) going through her makeup bag. Resident #2 said she said to CNA B put that down , that's not yours. Resident #2 said CNA B responded, I was just making sure everything was standing up straight. Resident #2 said she thought that was a weird response. Resident #2 said she got back in bed and was dosing back off to sleep. Resident #2 said she always kept the key to her locked drawer (each resident room has a lock drawer in the bedside table for which they are provided a key ) on a band on her wrist. Resident #2 said she had fallen back asleep, and something woke her. Resident #2 said she saw CNA B standing over the bedside table with the key in her hand. Resident #2 said she said to CNA B What are you doing? Give me that band and I'll lock the drawer. Resident #2 said she did not actually see CNA B take anything from the drawer. Resident #2 said all she kept in the drawer was a small wallet with a little cash. Resident #2 said CNA B handed her the band with the key and Resident #2 placed it back on her wrist. Resident #2 said she tried to go back to sleep. Resident #2 said CNA B then went over to her closet. Resident #2 explained she had not really unpacked anything since arriving to the facility and had bags in the closet. Resident #2 said CNA B began to look through the items in the closet. Resident #2 said she said, What are you doing? to CNA B. Resident #2 said CNA B responded, I'm just making sure everything is ok. Resident #2 said she eventually fell back to sleep and at one point CNA B was back in the room and placed her hand on my right arm and gently squeezed. Resident #2 said she just opened her eyes and looked at her. Resident #2 said she didn't realize there was actually any money missing until the next day. Resident #2 said she opened her wallet and there was nothing in it. Resident #2 said she questioned herself for a moment and said to herself I know I brought around 200 hundred dollars in cash with me. Resident #2 said she had some receipts and things as well in the wallet and it was all gone. Resident #2 said at that point she immediately suspected CNA B. Record review of Resident #3's face sheet dated 3/6/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, compression fracture of the T9-T10 vertebra. Record review of Resident #3's admission MDS assessment, dated 1/17/25, indicated Resident #3 had adequate vision. The MDS indicated Resident #3 made herself understood and was understood by others. The MDS (BIMS of 15) indicated Resident #3 had no cognitive impairment. Record review of Resident #3's care plan dated 1/16/25 did not address the right to be free from misappropriation. The care plan indicated Resident #3 was to receive assistance with ADLs including grooming, bathing and personal hygiene. Record review of the facility investigation summary dated 2/18/25 stated, .(Resident #3) in room [ROOM NUMBER] also reported that the aid matching the same description was going through her makeup bag and purse. (CNA B) said to (Resident #3) that she really liked that makeup brand when (Resident #3) caught her going through her things. CNA B proceeded to chat with (Resident #3) telling her that she lived .and where she was originally from . in an attempt make small talk. (Resident #3) reported that the day after the pilfering (stealing) occurred, she received a text notification of a fraud alert for someone trying to purchase an item through Amazon on her missing card. She did not even realize the card was missing until she received this notification and went to locate her card. (Resident #3) also realized that she was missing $60 cash . During an interview and observation 2/20/25 on at 11:00 a.m., Resident #3 sat in her bed. Resident #3 said everything had been great at the facility other than having some money taken. Resident #3 said she knew the police had been called. Resident #3 said it was sad to think someone would steal 60 dollars of cash. Resident #3 said she also had a card taken from her wallet and didn't realize it until she had received a fraud alert. During a phone interview on 3/6/25 at 11:20 a.m., Resident #3 said the CNA taken care of here the night before she received the fraud alert and realized the money was missing, the aide was about 5'7 brownish dyed red hair and had the faint smell of smoke. Resident #3 said the CNA was thicker in the midsection but would not describe the woman as fat. Resident #3 said the CNA described (CNA B), had helped her to the toilet. Resident #3 said she got up from the toilet on her own and as she came into the room, she saw CNA B going through her makeup bag. Resident #3 said she stared at her and when CNA B noticed her, she responded I'm just going through your makeup. I have some of the same brand. Resident #3 said she thought to herself well, ok whatever. Resident #3 said CNA B then went over to the chair where her purse was and saw her (CNA B) bent over my purse. Resident #3 said she asked CNA B what she was doing, and she (CNA B) responded she was looking for something. Resident #3 said she had not realized that CNA B had taken anything form her purse until the next day. Resident #3 said she got a fraud alert the following morning on her Target card when someone tried to make a purchase through Amazon. Resident #3 said she got her purse and wallet and saw that the card was still in her wallet but her $60.00 dollars cash was missing. Resident #3 said I guess she wrote the card information down, but she was so quick. Record review of Resident #4's face sheet dated 3/6/25, indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included, COPD (Chronic Obstructive Pulmonary Disease is a group of lung diseases that cause long-term breathing problems). Record review of Resident #4's admission MDS assessment, dated 2/15/25, indicated Resident #4 had adequate vision. The MDS indicated Resident #4 made herself understood and was understood by others. The MDS indicated Resident #4 had no cognitive impairment (BIMS of 13). Record review of Resident #4's care plan dated 1/16/25 did not address the right to be free from misappropriation. The care plan indicated Resident #4 was to receive assistance with ADLs including grooming, bathing and personal hygiene. Record review of the facility investigation summary dated 2/18/25 stated, .Later that day the ADON overheard a patient talking to a therapist regarding missing money. She approached (Resident #4) . who was out of room when she did previous interviews. She went and discussed with (Resident #4) the situation and was advised that he also had $400 cash missing from his room. He did not realize his money was missing until he went to get some to give to his brother to purchase him some snacks. (Resident #4) did not see anyone going through his things in his room but also resided in the section CNA B worked . During an interview and observation on 3/3/25 at 2:40 p.m., Resident #4 sat in his recliner. Resident #4 said he had 400 dollars stolen from his room. Resident #4 said he had the money in his locked bedside drawer. Resident #4 said he had laid the key on his bedside table. Resident #4 said he did not realize the money was missing until the next day when he attempted to give his brother some money. Resident #4 said 4, 100-dollar bills had been taken from his wallet and 4 single dollar bills were left in the wallet. Resident #4 said he didn't see anyone going through his things but suspected it had been taken by the CNA that had cared for him the night before the money went missing. Resident #4 described her as having red hair and a piercing in her nose. Record review of the facility investigation summary dated 2/18/25 indicated the police department had been notified and the facility provided the responding officers with the full name of CNA B, her social security number, copy of her driver's license, phone number, CNA certificate number which was obtained through the staffing agency she had been hired from. During an interview on 3/6/25 at 10:57 a.m., Resident #5 also reported she saw a CNA matching the description of CNA B going through her personal items but had nothing missing. During an interview on 3/6/25 at 10:57 a.m., Resident #6 also reported he saw a CNA matching the description of CNA B going through his personal items but had nothing missing. During an interview on 3/6/25 at 10:30 a.m., the investigating officer with the police department said the investigation was ongoing. The officer said the investigation was supporting that CNA B had stolen various amounts of money and card information from residents at the facility. The officer stated he was still working to build a solid criminal case. During an interview on 3/6/25 at 1:50 pm the ADON said video footage showed the CNA B going in out of the victimized residents' rooms throughout the shifts on 2/11/25 to 2/12/25 on the night shift and 2/13/25 to 2/14/25 on the night shift. The ADON said the video footage doesn't actually show her taking anything as there are no cameras in the resident rooms but in the hallways. The ADON said we received a text message from CNA B asking if she offended someone (she explained this was when they had notified the staffing agency of the situation and she was removed from coming back to work her additional scheduled shifts). The ADON said we interviewed all the residents that were assigned to her care and notified the police and reported to the state agency. During an interview on 3/6/25 at 1:51 pm the DON said she to, saw the footage that showed CNA B going in out of the victimized residents' rooms throughout the shifts on 2/11/25 to 2/12/25 on the night shift and 2/13/25 to 2/14/25 on the night shift. The DON said the staffing agency was notified we did not allow her to return to the facility. During an interview on 3/6/25 at 1:52 the Administrator was not able to share the video footage they had. The Administrator said the maintenance man was working to get the footage to supply it to the police department but was unable to do so. The Administrator said she did not know what else she could do to keep residents from being victims of misappropriation other than not using agency staff at all. The Administrator said when she hires staff she goes beyond convictions barring employment and will not hire anyone with a history of theft. The Administrator with shift key they (we the facility) can be picky about who they hire and had do so only taking CNAs with high star ratings (she explained star ratings came from other facilities) and that CNA B had a 4- or 5-star rating). The Administrator said CNA B also had a high reliability rating (indicating her attendance to scheduled shifts). The Administrator said the facility did everything correctly in response to allegations of misappropriation, including conducting a prompt investigation, not allowing CNA B to return to the facility, notifying the staffing agency of the allegations, reporting to the state agency, reporting local police department and in servicing the facility staff. Record review of the facility policy and procedure titled Abuse Neglect and Misappropriation, dated February of 2021, stated each resident had the right to be free from .misappropriation of resident property .

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for Resident#197 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one of one resident (Resident #197) reviewed for baseline care plan. The facility failed to ensure Resident #197's baseline care plan included information related to Resident #197's respiratory needs. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admitted [DATE] with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis (long-term inflammation of the bronchi, It is common among smokers. People with chronic bronchitis tend to get lung infections more easily. They also have episodes of acute bronchitis, when symptoms are worse, anxiety, and chronic obstructive pulmonary disease (COPD) refers to a group of diseases that cause airflow blockage and breathing-related problems. Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggested moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had shortness of breath with exertion and when lying flat. Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures (p) other indicated no other devices and Treatment. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024, revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once on 2/4/2024 at 0325A.M. During an observation and interview on 02/05/2024 and 02/06/2024 resident #197 was observed with handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as needed. During an observation and interview on 02/07/2024 at 10:30 am resident #197 was observed with a vial of Albuterol to instill in her nebulizer, the resident said she always has done this. In an interview with the MDS Coordinator and the Administrator on 02/06/2024 at 11:30 a.m., the MDS Coordinator confirmed Resident #197's respiratory orders had not been addressed on the baseline care plan. The MDS Coordinator revealed the care plan was created from the initial nursing assessment and updated when the MDS assessment was completed. The MDS Coordinator added that respiratory orders and therapy orders were given on admission and should have been in Resident #197's care plan. The MDS Coordinator stated it was the responsibility of the MDS Coordinators to review orders to ensure all resident needs were captured on the care plan , that the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being The care plan must be based on the assessment. Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; and .any specialized services or specialized rehabilitative services .

Based on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plan for one of one residents (Resident #197) reviewed for care plans. The facility failed to ensure Resident #197's care plan included information related to Resident #197's respiratory needs was developed within 7 days of the comprehensive assessment and included that the resident was receiving Albuterol for (chronic obstructive pulmonary disease) COPD and shortness of breath. This failure could place residents at risk of not receiving medication as ordered to meet their current Respiratory needs. The findings were: Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admitted [DATE] with diagnoses that included: Closes left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggest moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had shortness of breath with exertion and when lying flat. Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures (p) other indicated no other devices and Treatment. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024, revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once on 2/4/2024 at 0325A.M. During an observation and interview on 02/05/24 and 02/06/2024 Resident #197 was observed with handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as she wills. During an observation and interview on 02/07/2024 at 10:30 am Resident #197 was observed with a vial of Albuterol to instill in her nebulizer, the resident said she always has done this. During an interview with the MDS Coordinator and Administrator on 02/06/2024 at 11:30 a.m., the MDS Coordinator confirmed Resident #197's respiratory orders had not been addressed on the care plan. The MDS Coordinator revealed the care plan was created from the initial nursing assessment and updated when the MDS was completed. The MDS Coordinator added that respiratory orders and therapy orders were given on admission and should have been in Resident #197's care plan. The MDS Coordinator stated it was the responsibility of the MDS Coordinators to review orders to ensure all resident needs were captured on the care plan. Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; and .any specialized services or specialized rehabilitative services .

Based on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for (Resident #197) reviewed for Nebulizer therapy. Resident #197's Nebulizer therapy ordered by the physician dated 1/17/2024 Albuterol Sulfate inhalation Nebulization solution, 0.083%, to Inhale orally four times a day for COPD for 30 days administer for 15 minutes. Order date 1/17/2024, there was no order for self-administration. This failure could place residents who receive Nebulization therapy at risk for respiratory distress. The findings were: Record review of Resident #197's electronic face sheet, dated 01/17/2024, revealed an admitted [DATE] with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Review of resident #197's MDS dated [DATE] had not been completed. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. A review of Resident #197's physicians orders for January 17,2024 did not indicate any orders for self-administration of medication. It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During observations Resident #197 was Inhalation Nebulization on the following dates and times: 02/05/2024 at 10:24AM with no staff observation and with her own personal hand-held nebulizer 02/06/2024 at 10 AM opening the Albuterol vial on her own and instilling medication into her personal hand-held nebulizer. 02/07/2024 at 10:30 am with no staff observation as she had been to therapy and returning to room. During an interview on 02/05/2024 at 10:24AM Resident #197 said she can use her personal nebulizer as she needs it, her husband was at the bedside and agreed. During an interview with LVN A on 02/05/2024 at 11:30 am she said that she was to monitor and make sure residents with Nebulizer therapy get their entire treatment, but she knew that resident #197 has her own personal nebulizer and carries it around . During an interview on 02/05/2024 at 04:07 pm with DON, she said, residents are to be assessed before and after any inhalation treatment, nurses are to follow the physicians' orders, and no medication is to be left at bedside for residents to administer themselves . During an interview on 02/07/2024 at 4:00pm with the ADON, she said that none of the nurses on staff have had skills training to administer respiratory therapy . A review of the facility's policy on Respiratory Therapy Program dated 1/15/2023: #4 The Services are required and provided by qualified personnel. Nurses administered respiratory therapy will have respiratory therapy training and competency evaluation will reflect proficiency in providing respiratory modalities. A review of the facility's Nebulizer Policy dated 8/16/2022 indicated the following: Purpose: Nebulizer therapy may be provider through various types of supply and delivery systems. Equipment may include the provision of trans-tracheal nebulizer, mask, or handheld. Procedure: For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. Patient's door is recommended to be closed during nebulizer treatment. Nurse must rinse the mouthpiece or face mask when completed.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #197) reviewed for pharmacy services. LVN A failed to ensure Resident # 197's medications were secure and left physician ordered medications at the bedside. LVN A failed to ensure Resident #197 inhaled her medications. These failures placed Resident #197 at risk of not receiving full dosage and treatment of medication as ordered. Findings included: Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a[AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's Medication Administration Record for 02/05/2024 reflected LVN A had administered the medications ordered to be given between 08:00, 12:00, and 16:00 over a 15-minute period. Record review of Resident #197's physician orders dated January/February 2024 did not reflect an order for the resident to self-administer medications. Record review of Resident #197s medical records did not reflect an assessment of the residents' ability to self-administer medications safely was completed. Review of Resident #197's Care Plan for January/February 2024 did not reflect Resident #197's was to be allowed to self-administer her own medications. During an observation and interview on 02/05/2024 at 10:24 AM, Resident #197 was noted to be sitting in a wheelchair in her room with an over-the-bed table in front of her. No staff were in the room. The resident's husband was sitting in the room in a bedside chair. The residents' personal hand-held nebulizer was in her hand with medication in the chamber. In an observation and interview on 01/06/2024 at 10 AM, the resident had a vial of Albuterol in her hand ready to open and instill in her personal hand-held nebulizer. The resident and her husband said they didn't want to get anyone in trouble, but this is what they do all the time with the Albuterol treatment. Resident #197 said Nurses will give her the vial to put in her nebulizer and maybe check later to see if she needs anything else, but they trust me to take on her own. During an interview with LVN A on 02/05/2024 at 11:30AM, she said she left Resident #197's medications on the over-the-bed table for the resident to take. LVN A said she was supposed to stay/or return within 15minutes with the resident until she had taken all her medications. LVN A said the policy for administering medications was for the nurse to stay with the resident to ensure the medications are taken. LVN A did not respond to being asked if there was a reason for leaving the medications at bedside and not ensuring the resident took her medications , It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During an interview with the DON on 02/05/2024 at 11:05 AM, she said she expected the nurses to stay with the residents when giving medications and ensure they took them. She said residents who did not take their medications were at risk for not receiving the intended therapeutic effect of their medications. She said residents could hoard their untaken medications and risk overdosing themselves and residents who wander may take unattended medications if it was left sitting out. She said that she had done an employee disciplinary review with LVN A, and the nurse should be following policy . It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. LVN B said nurses were required to stay with each resident until medications were taken and swallowed . Record review of the facility's general policy titled Medication Administration dated 3/31/2023, including the following: It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment.

Based on interviews and record reviews the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for (Resident #197) resident reviewed for resident records. The facility failed to ensure Resident #197's Medication Administration Record (MAR) reflected documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine in her Electronic Health Record (EHR). This failure could place all residents who receive nebulizer treatment at risk of having errors in care and treatment. The findings included: Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's Medication Administration Record revealed documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine every shift, in her Electronic Health Record (EHR) had never been done but was being signed as done from 1/17/2024 - 2/6/2024. During an interview with LVN A on 02/06/2024 at 12:30 pm, she stated she never cleaned nebulizer machine on her shift because the resident had her own hand-held nebulizer, she said she just signed the Electronic Health Record (EHR ) Which can Compromised Patient Safety: Missing information can lead to treatment errors, posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can delay care as medical professionals. Each Nurse is responsible to make sure the Electronic Health Record is correct and when signing the task is complete. During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. She stated she never cleaned nebulizer machine on her shift because the resident had her own hand-held nebulizer, she said she just signed the Electronic Health Record (EHR) Which can Compromised Patient Safety: Missing information can lead to treatment errors, posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can delay care as medical professionals. Each Nurse is responsible to make sure the Electronic Health Record is correct and when signing the task is complete. During an interview with resident on 02/07/2024 at 12:30 pm, she said her, or her husband would clean the nebulizer machine and alternate with her second machine, she said that's what she did at home, and they followed the manufacturer instructions on cleaning. Staff was just signing the Electronic Health Record and not doing the task of cleaning. During an interview with ADON on 02/07/2024 at 2:30 pm, who said she would review orders for the Nebulizer, call the physician and make sure staff and resident have respiratory therapy training and competency evaluation that will reflect proficiency in providing respiratory modalities as stated in the centers policy & Procedure. The facility could not produce a policy on resident use of own equipment or policy of staff signage of orders that were not being done.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings were held at least quarterly, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure their QAA and QAPI meetings were held quarterly since the last recertification survey in October 2021 through October 2022. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months October 2021 through October 2022 indicated, meetings were not conducted each quarter during that period. There was one attendance sheet indicating a meeting was held in August 2022. During an interview on 12/07/22 at 11:15 AM, the administrator said no QA meetings had been held prior to her coming to the facility on [DATE]. She said she had a meeting on November 22, 2022, when she realized meetings had not been held. She said one of the medical directors had asked about QA meetings and wanted to begin having them monthly and had some topics for the committee to look into. She said the facility had to have the meetings at least once every quarter. During an interview on 12/07/22 at 11:30 AM, the DON said she started at the facility in July 2022, and they had one meeting in August 2022 and she found an attendance sheet for that meeting. Review of the facility's policy Quality Assurance and Performance Development (revised 2.8.2021) indicated, The Center committee with appropriate membership will meet (at least) quarterly to identify issues with respect to quality assessment, assurance and improvement activities that are deemed necessary, or deemed to be in pursuit of improved care/services.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 6 residents reviewed for misappropriation of property. (Resident #1) The facility did not ensure Resident #1's narcotic pain medication was sent with him to the facility he transferred to. Three months later, the facility was notified the medication did not arrive at the receiving facility. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of Resident #1's face sheet, with a print date of 7/15/22, indicated he was [AGE] years old, admitted on [DATE] and discharged on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's orders as of 4/1/22, indicated he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Internal Investigation on RN A 7/1/22 indicated on 7/1/22 the facility was notified by the OIG (Office of the Inspector General) and the local police department that RN A had controlled medications in her car that were taken from the facility. RN A had been terminated from the facility on 4/25/22 for reasons unrelated to her misappropriation of resident medications. Record review of a complaint form filed by the facility with the Texas Board of Nursing indicated RN A worked in the facility for 11 months. She was terminated on 4/25/22 for reasons unrelated to the misappropriation of resident property. On 7/1/22 the facility was notified by the OIG that RN A was arrested on 4/20/22 and was found with Resident #1's medication in her possession. Record review of RN A's employee file indicated RN A was trained on job duties and signed that she been trained. Abuse, Neglect and Exploitation was included in the training. A signed abuse education on 9/15/21 was found and included the definition of misappropriation, as well as what to do in the event it was was witnessed or known of. Disciplinary reviews on 3/21/22 and 4/19/22 indicated she was missing documentation on her shifts, not completing skills, failing to meet patient needs, leaving the floor for long periods of time to go outside, and using her cellphone during patient care and while on the floor. She was terminated from the facility on 4/25/22. During an interview on 7/8/22 at 1:30 p.m., the ADON said RN A was pulled over by officers and was found to have Resident #1's medication and information in her car. She said the administrator had not yet completed his report on the misappropriation because he was waiting on the authorities to provide proof, such as the narcotic card and other evidence they found in RN A's car. She said RN A stole the medication from a resident who was discharged in possibly April 2022 and no longer lived there. She said staff were unaware of how the RN obtained the medication or the resident information. She said she did not know how the nurse would have gotten her hands on them. She said the facility did not know the medication was missing until the police came to the facility and notified them they had found the medication in RN A's car. She said she did not know how they didn't realize the medication was missing before now . During an interview on 7/8/22 at 2:00 p.m., LVN B said he helped RN A discharge Resident #1 from the facility. He said RN A was never in his medication cart to his knowledge, and he would never give her his keys because he knew she had a history. He said he worked with her at another facility and 2 cards of [MEDICATION(S)] 10s (a pain relieving medication that contains 10mg [MEDICATION(S)] and 300mg tylenol) went missing while in her possession. He said RN A had been told by the DON at that facility that she would have to provide a urine sample, which to his knowledge did come back positive. He said he saw her maybe 2 more times at work after that instance and then she left that facility. He said he then saw her working at the current facility and knew not to allow her on his cart or have his keys. He said he believed the only way she could have gotten Resident #1's medication was if she had stolen them when she took the resident down to his transportation for his transfer. He said he was not familiar with the resident and could not say with certainty which medications he sent with the resident, but he knew he had the resident sign that he was being transferred with his medications. The form would also include the names and amounts of those medications and the hard copy of the form would have been filed in medical records. During an interview on 7/8/22 at 4:00 p.m., the DON said she and the ADON were unable to locate the hard copy of the medication form that would have been sent with Resident #1. She said they were having to assume RN A took the form out of the medical records box so that it could not be filed. During a phone interview on 7/11/22 at 12:00 p.m., Resident #1's family member said he was sent with his medications from one facility to the other so he could resume his treatment. She said she was not sure if his Norcos arrived with him to the receiving facility or not, but she did have to take medication to the new facility. She did not recall what medication it was she had to provide the facility. During an interview on 7/12/22 at 5:30 p.m., the administrator from the receiving facility said he had done a record review on Resident #1 and saw a brief note about the resident's family member needing to bring him medications from home. He said he was not sure what medications needed to be brought in, but that the resident's Norcos were in a pill bottle. He said medications brought in from a facility should be in a blister pack since that was how they would be delivered from the pharmacy. He said he believed the Norcos in the pill bottle would have been brought to them from the resident's home, but he could not be sure. During an interview on 7/14/22 at 11:30 a.m., the DON said she went to the police station asking when the facility could expect the documents for the investigation into RN A. She said the staff at the police station told her they had up to 10 days to get her the paperwork. She said she asked how many pills RN A had been in possession of and all they could tell her was 28 grams. During a phone interview on 7/16/22 at 9:27 a.m., LVN C said she was the admitting nurse at the receiving facility for Resident #1. She said she no longer worked there, but she had spoken to the administrator about the vague note she had made in the resident's chart about requesting medications being brought from home. She said she was fairly sure it was the Norcos that were needed. She said she remembered the Norcos being brought into the facility in a pill bottle, and she believed those came from home since his other medications came in blister packs. She said the facility would have been given the count sheets for the narcotics brought into the facility, but she remembered having to count the Norcos and make a count sheet for them. She said she did not remember having any other medications brought into the facility by his family member. She said she did not ever remember him being in obvious pain or having signs and symptoms of pain, but he also had other pain medication available until they received the Norcos. Record review of a Drug Diversion in-service was completed with staff on 7/1/22 and indicated the facility would be implementing random checks and verifications of controlled substances by the DON/ADON/Pharmacist. Record review of the facility Abuse and Neglect Prohibition policy with a release date of January 2018, indicated Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .

Based on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property for 1 of 1 employees reviewed for pre-employment screening. (RN A) The facility failed to maintain reference checks for RN A who re-hired in September 2021 and then misappropriated medications in April 2022. This failure placed residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of RN A's employee file indicated she had a hire date of 9/15/22, with no reference checks completed. During an interview on 7/11/22 at 1:00 p.m., the HR coordinator said she did not do any reference checks on RN A because she looked at her file and saw the employee was a rehire. She said she saw the employee had several write ups during her last employment with the facility. She said she was apprehensive to hire her back, but the old DON was very adamant that they hire her back and told her they were desperate for staff. She said the employee was apologetic for her behavior in the past and she was in a better place in her life. She said because the employee was a rehire, she didn't even think to run references, but she did run the EMR, background checks and nursing license. She said she knew she was supposed to run the employee's references. She said she was unsure if there was a policy for running references, but she was pretty sure it was in her job description and she could provide that. She said she should run references because if she were to contact another HR person that was willing to give information on an employee, they could be able to avoid situations like these by choosing not to hire someone. During an interview on 7/12/22 at 1:13 p.m., the DON said she knows the HR coordinator should have run references on RN A because it could have given them information on her to keep her from being rehired. Record review of the facility's Director of Human Resources job description signed 5/10/21 indicated .Check applications and references of prospective employees and arrange for interview with department directors as required or requested . Record review of the facility's Abuse and Neglect Prohibition policy with a release date of January 2018, indicated .Procedure Screening 1. The facility will screen for employees with a history of abusive behavior, or who may be at risk for being abusive. 2. The facility will ensure that prospective temporary or agency staff will be screened . The policy did not address reference checks.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals reviewed for menus and nutritional adequacy. (Lunch meal 10/05/21) (Resident #s 12, 54, 104, and 315) Dietary staff did not serve bread during the noon meal on 10/05/21 to Resident #s 54, 104, and 315 who received pureed diets. Dietary staff did not serve a requested cheeseburger during the noon meal on 10/05/21 to Resident #12 who received a mechanical soft diet. This failure could place residents who eat mechanically altered foods from the kitchen at risk of not having their nutritional needs met. Findings included: The planned menu dated 10/05/21 for the noon meal was beef and broccoli stir fry, steamed rice, oriental vegetable mix, bread slice, and Mandarin orange cake for dessert. The diet spreadsheet for the noon meal indicated residents on pureed diets received a #20 dip (2 oz.) of puree bread. The diet spreadsheet for the noon meal indicated residents on mechanical soft diets received 1 slice of unaltered bread with their meal. During an observation of the steam table on 10/05/21 at 11:57 AM there was no pureed bread prepared and placed for service. During an observation on 10/05/21 at 11:20 AM, tray line service began and continued until 12:35 PM. Resident #s 54, 104, and 315 received pureed diet trays and did not receive a serving of bread. Resident #12 had requested a cheeseburger instead of the main offering for lunch. A cheeseburger was listed as one of many items a resident may request anytime they do not want the main menu. During an observation on 10/05/21 at 12:10 PM, During tray service, Resident #12 was on a mechanical soft diet and had ordered a cheeseburger for his noon meal instead of the prepared meal. He was told he could not have the bun from the cheeseburger because he was on a mechanical soft diet and had not been approved by speech therapy. He was very angry and insisted he could chew a hamburger bun. He was told he had to be screened by speech therapy before he could have a hamburger, cheeseburger or any sandwich. He ordered fried chicken strips and French fries which he received. During an interview on 10/05/21 at 12:42 PM the DM said the cook was responsible for preparing the pureed bread. She said she had been told when she came to work at the facility over a year ago that all residents on mechanical soft or puree diet could not receive bread, they had to have a referral from speech therapy first. She said apparently a resident in the past must have choked on pureed bread because it was too sticky, so they have to get a referral before they can serve bread to any mechanically altered diet. She said they did not have approval yet from speech therapy for the 3 residents on pureed diets to receive bread. The DM said she had been at the facility a little over a year and that had been done since before she came. She said the RD had not altered any menu items to replace those lost calories. During an interview on 10/05/21 at 12:45 PM the RD said speech therapy had to approve residents to receive pureed bread because it was too sticky. She said she had not altered any diets to replace the lost caloric value of the bread products served at all meals. She said she and the DM had discussed using the packaged puree bread mix, but had not done so because they couldn't see a difference between using it or preparing their own. When asked if she had modified any of the diet plans to reflect the approximately 300 calories lost per day from bread products not being served (breakfast-toast, pancakes, waffles, muffins, biscuits; lunch/supper-rolls, cornbread, sliced bread) she said she had not. During an interview on 05/06/2021 at 02:55 PM the DM said all residents that admit to the facility on a mechanical soft or puree diet must be evaluated by speech therapy and have a swallow study and evaluation done before receiving bread products. She said she and the RD did not agree totally with speech therapy's fear of choking on bread as an overall blanket statement for all residents on modified diets. She said if foods are prepared to the appropriate consistency of pudding or mashed potatoes the residents should not choke if they are approved to eat food products. She said the speech therapists were not present in the facility all day or every day. She said they come usually later in the afternoon or evening and not every day so it may take a little while to get an evaluation. She said the residents may discharge before they get evaluated. She said dietary meets with each resident within 3 days of admission to see if they have any issues with chewing or swallowing. She said she has had many residents admit to the facility on a mechanical soft diet and tell her they had no issues with chewing or swallowing and it was the diet the hospital put them on. She said all she can do is fill out a request form for the evaluation and place it in the therapy communication box. During an interview on 10/06/21 at 04:20 PM the DON said she had never heard that residents on mechanically altered diets must be evaluated by speech therapy before they can receive bread products. She said a sandwich or hamburger could be cut into small pieces so the residents could chew and swallow it easily when they are on a mechanically soft diet. She said almost any food product could be pureed so residents can easily swallow the food. She said residents would be observed by nursing service to determine if they had an issue with chewing or swallowing and make the appropriate request from speech therapy for evaluation. She said to her knowledge there was no policy requiring speech therapy's evaluation prior to allowing bread for mechanically altered diets. She said she would look to see if they had one. During an interview on 10/06/21 at 4:40 PM the DON said apparently a resident a long time ago choked on a Brussels sprout and needed to be evaluated by speech therapy. She did not know how that turned into bread being denied on the diets since it was before she came to the facility. She said the facility did not have a policy regarding all residents on mechanically altered diets being required to have a swallow study and evaluation by speech therapy prior to receiving bread products with their meals. A facility Diet Roster dated 10/04/2021 indicated 3 residents (Resident #s 54, 104, and 315) received pureed diets and 14 residents, including Resident #12, received mechanical soft diets.

Based on observation, interview and record review, the facility failed to provide services in accordance with the written plan of care for 2 of 7 residents reviewed for physician orders. (Resident #'s 313 and 320) The facility failed to implement Resident #313's 1500 cc fluid restriction as ordered by the physician. The facility failed to ensure Resident #320 received daily weights as ordered by the physician. These failures could place residents at risk for not receiving appropriate treatment and services to meet their needs. Findings included: 1) Physician orders dated October 01, 2021 indicated Resident #313 was an [AGE] year-old male who admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #313's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident #313 had severely impaired cognition and required supervision of one staff for eating. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #313's care plans initiated since admission on 09/20/2021 did not document or identify his fluid restriction as ordered. During an observation on 10/04/2021 at 1:09 PM, Resident #313 was sitting up in his recliner chair in his room eating lunch. He was well hydrated and fed himself and had a 32-ounce personal mug of water and drank 8 ounces of tea. During an observation and interview on 10/05/2021 at 1:00 PM, Resident #313 was sitting up in his recliner in his room. He had half a personal mug of water on his overbed table and said he ate and drank well at lunch. He said he did not know if staff measured how much he drank and denied knowing of any restrictions on his fluid intake. He said no one had told him anything about it and did not know why he would be on a fluid restriction. During an interview on 10/05/2021 at 01:20 PM, LVN A said she did not know why Resident 313's fluid restriction was ordered and was not recording his intake other than meal percentages. LVN A said there was no intake or output record that she could find. LVN A said she would call her boss, the DON, to see what she should do. During an interview on 10/05/2021 at 2:12 PM, Resident #313's primary physician said he ordered Resident #313's fluid restriction because the resident had [CONDITION(S)]. He said he did not recall reviewing lab dated 09/21/2021 that indicated, Resident #313's sodium and chloride levels were within normal levels During an interview on 10/06/2021 at 9:07 AM, the DON said Resident #313 had a physician ordered fluid restriction for [CONDITION(S)], but the order was over looked. She said the charge nurses should have documented the quantities in the progress notes because there was not a separate intake or output document. She said Resident #313's fluid restriction should have been entered on his nutrition card as well, but it was missed. The DON said the charge nurse was responsible to enter the order and transcribe it onto the treatment administration record, but it was missed. She said she was not notified about it until yesterday and she should have been. The DON said she was responsible to oversee that orders but was not notified by the charge nurses about the missed issues. The more routine consequences of missed orders can include delayed or omitted medications or treatments; complications such as atelectasis, congested heart failure. During an interview on 10/06/2021 at 12:28 PM, the administrator said he was not aware Resident #313 fluid restriction was not implemented and did not know this surveyor was still harping on that. The administrator said the DON was responsible to oversee nursing orders and implementation. The administrator said physician orders should always be implemented. A weight summary printed on 10/06/2021 indicated Resident #320's weight on 10/01/2021 and 10/02/2021 was 197.2 pounds. No other weights were documented. Resident #320's hospital records dated 10/01/2021 indicated his weight was 170 pounds. A physician ordered dated 10/01/2021 indicated Resident #320 was on [MEDICATION(S)] (a diuretic) 50 mg tablet by mouth every morning for fluid retention. A physician ordered dated 10/02/2021 indicated Resident #320 was on trospium chloride (used to treat overactive bladder) 20 mg tablet by mouth every bedtime for fluid retention. Resident #320's treatment administration record dated 10/01/2021-10/6/2021 did not document his daily weight was obtained. Resident #320's care plans initiated since admission on 10/01/2021 did not document or identify daily weights as ordered. During an observation and interview at 10/04/2021 at 12:59 PM, Resident #320 was sitting up in bed watching tv in his room. He ate 50% of his lunch, and said he had poor appetite and did not want any more. He did not have [CONDITION(S)]. During an interview on 10/04/2021 at 2:30 PM, CNA B said she had not weighed Resident #320. She said there was not a weight scale on the Covid ward at all. During an observation and interview on 10/05/2021 at 1:16 PM, Resident #320 was resting in his bed. He said nobody had weighed him and he did not know what he weighed. He did not have [CONDITION(S)]. During an interview on 10/05/2021 at 1:20 PM, LVN A said staff were not able to weigh residents regardless of their diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she would call her boss, the DON, to see what she should do. During an interview on 10/05/2021 at 2:12 PM, Resident #320's primary physician said he did not recall specifically ordering Resident #320's daily weights but they were usually indicated with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/06/2021 at 9:07 AM, the DON said the charge nurse was responsible to enter Resident #320's orders, including the daily weight, and transcribe it onto the treatment administration record, but it was missed. The DON said she was not notified about it until yesterday and she should have been. She said Resident #320 had congestive heart failure and required daily weights as ordered but the order should have been discontinued when he transferred to the Covid ward, but it was missed. She said she was responsible to oversee that orders were correctly implemented but was not notified by the charge nurses about these missed issues. She said there was not a weight scale dedicated to the Covid ward, so residents are not weighed while a resident in the Covid ward. The more routine consequences of missed orders can include delayed or omitted medications or treatments; complications such as atelectasis, congested heart failure. During an interview on 10/06/2021 at 12:28 PM, the administrator said he was not aware Resident 320's daily weights were not obtained as ordered. The administrator said the DON was responsible to oversee nursing orders and implementation. The administrator said weights could be obtained in the Covid ward with available scales and disinfected after ordered weights were obtained. The administrator said physician orders should always be implemented. A Physicians Orders policy and procedure revised 02/08/2021 stated The Center will transcribe Physicians orders for medications and treatments and will be consistent with principles of safe and effective order writing.

Based on observation, interview, and record review, the facility failed to assess for the appropriate use of a urinary catheter for 1 of 2 residents reviewed with a urinary catheter. (Resident #320) The facility did not have an appropriate medical indication and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place 2 residents with indwelling catheters at risk for infections, discomfort, and [CONDITION(S)] with inappropriate urinary catheter use. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #320's treatment administration record dated 10/01/2021-10/31/2021 did not document he had a urinary catheter. Resident #320's care plans initiated since admission on 10/01/2021 did not document or identify his urinary catheter. Admission Summary indicates this resident having a urinary catheter, During an observation and interview at 10/04/2021 at 12:59 PM, Resident #320 was sitting up in bed watching tv in his room. He had a urinary catheter in place. During an interview on 10/04/2021 at 2:36 PM, LVN A said she thought Resident #320 admitted from the hospital with the urinary catheter but did not know why he required it. She said she did not find the documentation or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 10/05/2021 at 1:16 PM, Resident #320 was resting in his bed. He said staff removed his catheter that had been inserted in the hospital and told him he needed to pee in a bottle but he was unable to yet but denied discomfort. During an interview on 10/05/2021 at 1:20 PM, LVN A said Resident #320 did not have an intake or output record that she could find. LVN A said she removed Resident #320's catheter about 20 minutes ago and he had not urinated yet. LVN A said there should have been a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A said the DON was responsible to make sure the orders were properly transcribed and implemented but the DON did not notify her there was not an order or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/05/2021 at 2:12 PM, Resident #320's primary physician said he did not recall specifically ordering Resident #320's urinary catheter but recalled Resident #320 had difficulty urinating. During an interview on 10/06/2021 at 9:07 AM, the DON said the charge nurse was responsible to enter Resident #320's orders, including the urinary catheter, and transcribe it onto the treatment administration record, but it was missed. The DON said Resident #320 did not admit with a catheter, but it was placed after he had issues urinating. She said the charge nurse was responsible to enter the order and transcribe it onto the treatment administration record, but it was missed. She said she was responsible to oversee that orders were correctly implemented but was not notified by the charge nurses about these missed issues. During an interview on 10/06/2021 at 12:28 PM, the administrator said he was not aware Resident #320's catheter did not have an order or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator said physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Foley Catheter Care policy and procedure revised 02/08/2021 stated, when possible, all foley catheters should be removed prior to admission unless an appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, and record review, the facility failed to ensure the physician was consulted regarding the need to alter treatment for 1 of 1 resident reviewed for medications. (Residents #1) The facility did not notify Resident #1's physician when the resident's blood pressure medications were held for 6 of 10 days due to blood pressure being outside of the physician ordered parameters. This failure could place residents who received medication at risk of a delay in medical evaluation and treatment. Findings included: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was no longer in the facility at the time of this investigation, he was sent to the hospital on 01/10/21 and did not return. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Losartan-Potassium- HCTZ for high blood pressure, hold until blood pressure is back up over 130 systolic to restart. The initial MDS assessment indicated Resident #1 was cognitively impaired and needed total assist with ADLs and transfers and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan for Resident #1 dated 1/12/21 indicated he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions were to administer medications per physician orders. The care plan did not address the parameters for the blood pressure written by the physician. During an interview on 2/05/21,LVN A said she came on shift at 6 PM, she does her rounds about 7 PM. She said Resident #1 took all of his night time medications at that time and he went to sleep. He had no complaints on my first rounds. I checked on him about 9:30 PM and he was sleeping, he was ok. Between 11-12 PM he had a change of condition, I called his physician, his pulse was faint, order was given to send him to the ER. The EMARS (electronic medication administration record) dated January 2021 indicated Resident #1's blood pressure medications were held due to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] 15 mg in the morning for high blood pressure (hypertension) hold for systolic blood pressure (SBP) under 100 and diastolic blood pressure (DBP) under 60, and pulse under 60 bpm (beats per minute). 01/01/21 Resident #1's blood pressure was documented as 100/58, pulse 89, medication held. 01/02/21 Resident #1's blood pressure was documented as 100/58, pulse 70, medication held. 01/03/21 Resident #1;s blood pressure was documented as 104/58, pulse 71, medication held. 01/06/21 Resident #1' s blood pressure was documented as 100/49, pulse 89, medication held. 01/07/21 Resident #1' s blood pressure was documented as 100/57, pulse 79, medication held. 01/10/21 Resident #1' s blood pressure was documented as 94/40, pulse 73, medication held. *[MEDICATION(S)] 50 mg in the morning for high blood pressure (hypertension) hold for systolic blood pressure (SBP) under 100 and diastolic blood pressure (DBP) under 60, and pulse under 60 bpm (beats per minute). 01/01/21 Resident #1's blood pressure was documented as 100/58, pulse 89, medication held. 01/02/21 Resident #1's blood pressure was documented as 100/58, pulse 70, medication held. 01/03/21 Resident #1;s blood pressure was documented as 104/58, pulse 71, medication held. 01/06/21 Resident #1' s blood pressure was documented as 100/49, pulse 89, medication held. 01/07/21 Resident #1' s blood pressure was documented as 100/57, pulse 79, medication held. 01/10/21 Resident #1' s blood pressure was documented as 94/40, pulse 73, medication held. *Losartan-Potassium- HCTZ 50-12.5 mg one tablet in the morning for high blood presssure, hold until blood pressure is back up over 130 systolic to restart. 01/01/21 Resident #1's blood pressure was documented as 100/58, pulse 89, medication held. 01/02/21 Resident #1's blood pressure was documented as 100/58, pulse 70, medication held. 01/03/21 Resident #1;s blood pressure was documented as 104/58, pulse 71, medication held. 01/06/21 Resident #1' s blood pressure was documented as 100/49, pulse 89, medication held. 01/07/21 Resident #1' s blood pressure was documented as 100/57, pulse 79, medication held. 01/10/21 Resident #1' s blood pressure was documented as 94/40, pulse 73, medication held. Nurse notes dated January 1,2,3,6,7,and 10, 2021 indicated blood pressure medications had been held for Resident #1 due to low blood pressure. No documentation was made about notifying the physician of medication being held, or blood pressures. During an interview on 02/05/21 at 5:50 PM, LVN A said she does not remember notifying the physician for low blood pressures and holding his blood pressure medications for Resident #1. During an interview on 02/05/21 at 6:50 PM, the DON said if blood pressures are outside of the parameters set by the physician they are to call the physician to inform him/her of holding the medications and what the blood pressure was. They are to document the notification in the progress notes. She said she does chart audits every Friday, and she has seen the change of condition documented, but the physician notification of the blood pressure was not documented that he/she was notified. Policy for blood pressure parameters notification to physician was not given by facility.

Based on observation, interview, and record review, the facility failed to ensure treatment and care, in accordance with the comprehensive care plan and professional standards of practice was provided for 3 of 6 residents reviewed for follow up physician appointments. (Resident #s 1, 2, and 3) Resident #1 required a follow up appointment with her neurologist and the appointment was cancelled. Resident #2 required a follow up with her cardiologist and it was not scheduled. Resident #3 required an appointment with a cardiologist and it was not scheduled. This failure could place residents with a follow up physician visit at risk for not receiving care and services to meet their needs. Findings included: 1. During a phone interview on 12/09/20 at 03:35 p.m., Resident #1's family member said they were informed when she was admitted the facility would take her to her doctor appointments and the family did not need to take her. They said she was not taken to her neurologist appointment that was scheduled 09/28/20. They said they were informed by the neurologist office she was a no show for the appointment. A face sheet dated 11/10/20 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her primary admitting [DIAGNOSES REDACTED]. Hospital discharge orders dated 07/22/20 indicated Resident #1's admitting [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, usually made herself understood, and understood others. The MDS further indicated she was cognitively intact and had active [DIAGNOSES REDACTED]. During an interview on 12/10/20` at 11:25 a.m. the administrator said Resident #1 had [MEDICAL CONDITION] but admitted to the facility for meningitis. He said she had an appointment in September 2020 with her neurologist, but the facility cancelled the appointment due to COVID. He said it was the facility's policy since it was not related to her admission it was not needed for her to keep. He said residents were transported to their physician visits by the facility if it was related to their admitting condition. A nurse practitioner note dated 07/24/20 indicated Resident #1 was admitted to the facility status [REDACTED]. Daily Skilled Nurse's Notes dated 07/24/20 through11/16/20 indicated Resident #1's admitting [DIAGNOSES REDACTED]. A physician history and physical dated 07/29/20 indicated Resident #1 was status [REDACTED]. The Treatment Plan on the history and physical indicated for the meningitis she was on medication with the Infectious Disease physician following and she was being treated per their recommendations. The Treatment Plan on the history and physical also indicated for the [MEDICAL CONDITION] she was to continue aggressive therapy, continue prescribed medication, and continue with neurology. During a record review and interview on 12/11/20 at 05:05 p.m. CM B's hand-written notes indicated on 11/04/20 at 10:28 a.m. she spoke with Resident #1's family. The family member indicated Resident #1 had an appointment with the neurologist on 09/28/20 and was told by the neurologist office the resident was a no show. She said she had been working at the facility about a month. She said she had been working with Resident #1's family prior to her discharge to the hospital. 2. A face sheet dated 12/11/20 indicated Resident #2 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Hospital discharge orders dated 11/10/20 indicated Resident #2 had a [DIAGNOSES REDACTED]. Hospital Discharge Instructions dated 11/10/20 indicated Resident #2 was to follow up with her cardiologist in 1 week. An MDS dated [DATE] indicated Resident #2 had adequate hearing, clear speech, could make herself understood, and could understand others. The MDS further indicated the staff assessment of her mental status she had modified independence for making decisions regarding tasks of daily life. Daily Skilled Nurse's Notes dated 11/10/20 through 12/10/20 indicated Resident #2's admitting [DIAGNOSES REDACTED]. There was no documentation of a cardiology appointment being made or resident seen by a cardiologist. During an observation and interview on 12/11/20 at 03:25 p.m. Resident #2 was clean and neat. She said she did not recall having an appointment with the cardiologist since she had been at the facility. During an interview on 12/11/20 at 03:55 p.m. LVN A said she could not find where Resident #2 had a cardiology appointment scheduled on the transportation schedule and in the clinical record. She said when a resident had a physician appointment a transportation slip was filled out for transportation to put on their schedule. She said the nurses or the CMs could schedule an appointment. During an interview on 12/11/20 at 05:15 p.m. CM B said she did not see where Resident #2's cardiology appointment was scheduled on the transportation schedule and in the clinical record. She said if a referral or an appointment was needed she could get one set up. 3. A face sheet dated 12/11/20 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #3 had moderate difficulty hearing, had clear speech, was usually understood, and usually understood others. The MDS further indicated she had severely impaired cognition and an active [DIAGNOSES REDACTED]. An Interdisciplinary Care Conference Summary dated 10/12/20 in Resident #3's clinical record indicated in the Discharge Goals/Planning section she needed a cardiac referral. Daily Skilled Nurse's Notes dated 10/13/20 through 12/10/20 had no indication Resident #3 had a cardiology referral obtained. During an interview on 12/11/20 at 03:00 p.m. LVN C said she could not find where Resident #3 had a cardiology appointment scheduled on the transportation schedule and in the clinical record. During an observation and interview on 12/11/20 at 03:15 p.m. Resident #3 was clean, neat and had no lingering odors. She said she saw the doctor about her broken hip but did not think she saw a heart doctor. During an interview on 12/11/20 at 03:30 p.m. CM D said she did not see where Resident #3 a cardiology referral had been done by the previous CM on the transportation schedule and in the clinical record. She said she could get the referral done. During an interview on 12/11/20 at 05:32 p.m. the administrator said the facility had a cardiologist who comes to the facility. He said the cardiologist would also see residents without a primary [DIAGNOSES REDACTED]. He said he did not know why Resident #2 and 3 did not see him. He said the nurses or the CMs could get an appointment set up. An undated Admission Agreement indicated IV. Facility Policies: C. Transportation Policy: The (facility) provides limited transportation services for appointments directly related to patient's stay

Based on interview and record review, the facility failed to inform the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 6 residents reviewed for change of condition. (Resident #1) The facility failed to notify and update Resident #1's family when she had significant changes in her condition and care. This this failure could place resident/representatives at risk of not being aware of changes in condition to make needed decisions. Findings included: During a phone interview on 12/09/20 at 03:35 p.m., Resident #1's family member said they sad none of the family members listed on her facesheet were notified of changes with her or given updates on her during most of her stay at the facility from 7/22/20. A face sheet dated 11/10/20 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her primary admitting [DIAGNOSES REDACTED]. Family members were listed on the face sheet as emergency/HIPAA contacts. A care plan initiated 07/22/20 indicated Resident #1 wanted to establish goals for herself and be involved in her discharge planning process with interventions including communicate with resident and/or family as needed related to progress, goals, and plans. A Social History note dated 07/23/20 indicated Resident #1 resided at home, lived at home alone, planned to discharge back home, and had family members who watched over her care at home. An admission MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, usually made herself understood, and understood others. The MDS further indicated she was cognitively intact. Nursing documentation for Resident #1 indicated the following: * on 08/03/20 at 03:56 a.m., she refused her gastrostomy tube ([DEVICE]) (a tube going into the stomach to provide nutrition) feeding due to complaint of gas and bloating. There was no indication the family was notified; * on 08/03/20 at 03:49 p.m., the [DEVICE] feeding was discontinued. There was no indication the family was notified; * on 08/09/20 at 12:22 p.m., she refused the oral nutritional supplement and the NP discontinued it. There was no indication the family was notified; * on 08/14/20 at 10:43 a.m., she complained on burning with urination. There was no indication the family was notified; * on 08/30/20 at 04:09 p.m., the NP was notified of a 7.2 pound weight gain in 24 hours. There was no indication the family was notified; and * on 09/08/20 at 05:57 p.m., she was put on an antibiotic for urinary tract infection. There was no indication the family was notified. The clinical records from 07/23/20 through 09/29/20 for Resident #1 had no documentation by previous CM of updates being discussed with the family members. The previous CM was not available for an interview. The Social Worker's notes dated 09/04/20, 10/09/20, and 10/13/20 for Resident #1 had no indication of updates being discussed with the family members. During an interview on 12/11/20 at 03:00 p.m. LVN C said nurses were to report any resident changes in condition to the physician and their family. During an interview on 12/11/20 at 03:45 p.m., RN E said when a resident had any change in condition she would notify the physician and resident Responsible Party/family. During an interview on 12/11/20 at 03:55 p.m. LVN A said physician was to be notified when resident had a change in condition by the charge nurse. She said if a resident was their own Responsible Party then family was not notified unless the family was known to be involved in their care at home. During an interview on 12/11/20 at 05:15 p.m. CM B said she would contact families weekly to update them on their resident. She said with the facility not doing visitation it seemed to help the families. She said she was the current CM assigned to Resident #1 since she started working at the facility. She said she kept notes of when she contacted Resident #1's family member. She said the family told her the previous CM did not keep them informed of any updates on how she was doing. She said the nurses were to contact the physician of changes and would notify the family. She said she also would talk with the family to give them updates on the resident. An undated Change of Condition policy and procedure indicated Change of Condition: Procedure: As part of the evaluation the nurse will help identify individuals for having any changes of condition during their stay. In addition, the nurse shall evaluate and document/report the following: a) vital signs, b) difficulty speaking, c) neurological abnormalities, e) recent labs, f) all active diagnoses, g) cognitive and emotional status, h) change in mental status. Direct care staff to notify nurse if they notice subtle, but significant changes in the patient: for example a) decrease in food intake, b) increase in confusion/agitation, c) change in vital signs etc, d) change in balance. The nursing will notify the physician if any of the above signs and symptoms are identified. The physician will indicate if patient requires evaluation/treatment at the facility or if patient needs to be sent out to the hospital. There was no indication the resident representative was to be notified of a change in condition.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided according to the care plan and consistent with professional standards of practice for 1 of 3 residents reviewed for pain management. (Resident #36) The facility did not administer [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg for pain for 3 days as ordered for Resident #36. Resident #36 was in tears from the pain and reported he did not sleep well. This failure could place residents on pain management at risk for unnecessary pain, discomfort, and a decreased quality of life. Findings included: The consolidated physician orders [REDACTED].#36 was a [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. An order dated 12/19/19 indicated Resident #36 was to receive [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg 2 tablets every 6 hours as needed for pain level of 6 to 10. A care plan initiated on 12/01/19 indicated Resident #36 had acute/chronic pain related to motor vehicle collision with interventions including administer pain medications per physician orders [REDACTED]. An admission MDS dated [DATE] indicated Resident #36 could understand, made himself understood, was cognitively intact, received as needed pain medication, pain occasionally, surgical wounds, and received an opioid (pain) medication for 7 of the 7-day lookback period. During an interview on 01/07/20 at 09:50 a.m., Resident #36's wife indicated the resident had not received pain medication yesterday or today. She said they were told they were waiting for the medication to come from the pharmacy. During an observation and interview on 1/7/20 at 9:53 a.m., Resident #36 was in tears, he indicated he had a pain level of 10 on a scale of 1 to 10. He said he did not sleep well last night because of the pain. Resident #36 said he was last given his pain pill ([MEDICATION NAME]/[MEDICATION NAME]) for pain on Saturday, he said they told him they were waiting for the medication to come from the pharmacy. He said they were giving him regular Tylenol and it was not getting rid of the pain. He said when he tried to go to therapy on Monday (01/06/20)it hurt. During an interview on 01/07/20 at 10:00 a.m., LVN N indicated Resident #36 was out of his [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg pain medication. She said they were trying to get some from the pharmacy. LVN N indicated she was agency staff and did not know how to access the emergency medication unit. During an interview on 01/07/20 at 10:14 a.m., RN C said Resident #36 was out of his [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg pain medication, she said they had given him over the counter Tylenol. RN C said they were trying to get his medicine from the pharmacy. She said the pain medication was in the emergency medication unit, she said a code had to be obtained from the pharmacy to access it. She said if a resident did not have a triplicate at the pharmacy for the medication it could not be obtained from the emergency medication unit. She said she did not know why the medication was not obtained sooner, she said she was trying to locate the narcotic count sheet for his [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg. A Narcotic Administration Record (NAR) dated 12/23/19 for Resident #36 indicated he received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg on Thursday 01/02/20 at 8:55 a.m. there were 8 tablets, on Thursday 01/02/20 at 8:30 p.m. there were 6 tablets, on Friday 01/03/20 at 9:00 p.m. there were 4 tablets, on Saturday 01/04/20 at 10:21 a.m. there were 2 tablets left, and on Saturday 01/04/19 at 7:00 p.m. the last 2 pills were given. During an interview on 01/07/20 at 11:55 a.m., RN C said the day nurse faxed the triplicate to the pharmacy on 01/06/20 for Resident #36. She said the evening nurse called yesterday evening and was told by the pharmacy the resident did not have a triplicate therefore the nurse could not access the emergency medication unit to obtain pain medication for Resident #36. She said she called a few minutes ago and they said the resident did have 14 tablets of the pain medication remaining, they gave her a code at that time to access the emergency medication unit and obtain a dose of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325mg to administer to Resident #36. During an interview on 01/07/20 at 12:22 p.m., Resident #36 said he had finally received his pain medication and was much better. He no longer had tears in his eyes. A Controlled Medication Administration policy dated 07/01/17 indicated Policy: It is the policy of this facility that medications are to be administered as prescribed by the attending physician An Electronic Interim Box (emergency medication unit) policy revised 03/18 indicated Purpose: To provide an interim supply of medications to be used for emergency or nonemergency dosing administration for nursing facility residents until the Provide Pharmacy (pharmacy) is able to provide a regular supply of medication to the nursing facility resident During an interview on 01/09/20 at 4:15 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs for 4 of 25 residents reviewed for medications (Resident #s 36, 381, 382, and 233) and for 1 of 3 medication carts reviewed (2nd floor A Hall nurse cart). * The facility did not provide [MEDICATION NAME]/[MEDICATION NAME] (pain medication) for 3 days to Resident #36. * The facility did not provide 8 doses of dofetilide (([MEDICATION NAME])heart medication) as ordered for Resident #381. * The facility did not provide eztimibe for lipids, [MEDICATION NAME] for hypertension, ropinirole for restless legs, [MEDICATION NAME] for gout, Eliquis for anticoagulant, or any [MEDICATION NAME]/[MEDICATION NAME] (pain medication) when admitted for Resident #382. * The 2nd floor A hall nurse cart contained expired Andrographis 300 mg (natural immunity herb). *The facility did not initiate administration of Keflex (antibiotic) in a timely manner for Resident #233. This failure could place residents at risk of not receiving necessary medications, not receiving the intended therapeutic benefits of their medications, and a decline in health. Findings included: 1. The consolidated physician orders [REDACTED].#36 was a [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. An order dated [DATE] indicated Resident #36 was to receive [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg 2 tablets every 6 hours as needed for pain level of 6 to 10. A care plan initiated on [DATE] indicated Resident #36 had acute/chronic pain related to motor vehicle collision with interventions including administer pain medications per physician orders [REDACTED]. An admission MDS dated [DATE] indicated Resident #36 could understand, make himself understood, was cognitively intact, received as needed pain medication; he had pain occasionally; he had surgical wounds, and received an opioid (pain) medication for 7 of the 7-day look back period. During an interview on [DATE] at 09:50 a.m., Resident #36's wife indicated the resident had not received pain medication yesterday or today. She said they were told they were waiting for the medication to come from the pharmacy. During and observation and interview on [DATE] at 9:53 a.m., Resident #36 indicated he had a pain level of 10 and was in tears, he said he did not sleep well last night because of the pain. Resident #36 said he was last given Tylenol for pain on Saturday, he said they told him they were waiting for the medication to come from the pharmacy. During an interview on [DATE] at 10:00 a.m., LVN N indicated Resident #36 was out of his [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg pain medication. She said they were trying to get some from the pharmacy. LVN N indicated she was agency staff and did not know how to access the emergency medication unit. During an interview on [DATE] at 10:14 a.m., RN C said Resident #36 was out of his [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg pain medication, she said they had given him over the counter Tylenol. RN C said they were trying to get his medicine from the pharmacy. She said the pain medication was in the emergency medication unit, she said a code had to be obtained from the pharmacy to access it. She said if a resident did not have a triplicate at the pharmacy for the medication it could not be obtained from the emergency medication unit. RN C said she had contacted the pharmacy and received the code to get the medication from the emergency medication unit, she said he had received a dose of the medication a few minutes ago. She said she did not know why the medication was not obtained sooner, she said she was trying to locate the narcotic count sheet for his [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg. A narcotic administration record dated [DATE] for Resident #36 indicated he received [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg on Thursday [DATE] at 8:55 a.m. there were 8 tablets, on Thursday [DATE] at 8:30 p.m. there were 6 tablets, on Friday [DATE] at 9:00 p.m. there were 4 tablets, on Saturday [DATE] at 10:21 a.m. there were 2 tablets left, and on Saturday [DATE] at 7:00 p.m. During an interview on [DATE] at 11:55 a.m., RN C said the nurse faxed the triplicate to the pharmacy on [DATE] for Resident #36. She said the nurse called yesterday evening and was told by the pharmacy the resident did not have a triplicate therefore the nurse could not access the emergency medication unit to obtain pain medication for Resident #36. She said she called this morning and they said the resident did have 14 tablets of the [MEDICATION NAME]/[MEDICATION NAME] 7XXX,[DATE]mg pain medication remaining and they gave her a code to access the emergency medication unit. During an interview on [DATE] at 12:22 p.m., Resident #36 said he had finally received his pain medication and was much better. 2. The consolidated physician orders [REDACTED].#381 was an [AGE] year-old female admitted [DATE] with [DIAGNOSES REDACTED]. ventricle), and [DIAGNOSES REDACTED] (disease of the heart muscle that makes it harder for your heart to pump blood to the rest of your body). During an interview on [DATE] at 10:45 a.m., Resident #381's family said the resident did not receive her heart medication for several doses when she first admitted to the facility because the facility did not have it from the pharmacy. An order dated [DATE] indicated Resident #381 was to receive dofetilide 125 mcg every morning and at bedtime for [MEDICAL CONDITION]. A MAR indicated [REDACTED]. The nursing notes either said not available or did not say anything regarding the missed dose. A MAR indicated [REDACTED]. The nursing notes either said not available or did not say anything regarding the missed dose. During an interview on [DATE] at 04:28 p.m., RN C said the nursing notes indicated nothing documented or medication not available. She said she did not know why there was no follow up when the medication was not received. She said the medication was not a common medication and was not in the emergency medication unit. 3. The consolidated physician orders [REDACTED].#382 was a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] that affects pumping action of the heart muscles), and hypertension (high blood pressure). Physician orders [REDACTED].#382 was to receive eztimibe at bedtime for lipids, [MEDICATION NAME] at bedtime for hypertension, ropinirole in the evening and at bedtime for restless legs, [MEDICATION NAME] at bedtime for gout, Eliquis at bedtime for anticoagulant, [MEDICATION NAME]/[MEDICATION NAME] 1 tablet every 4 or 6 hours as needed for pain, [MEDICATION NAME]/[MEDICATION NAME] 2 tablets every 4 hours as needed for severe pain, [MEDICATION NAME] every 6 hours as needed for pain, and for staff to record the number of hours the resident slept every shift for [MEDICAL CONDITION]. During an interview on [DATE] at 10:18 a.m., Resident #382 said he did not have medications when he admitted on [DATE], he said he was in pain that night and did not sleep. Resident #382 said he was told his medication did not come in from the pharmacy. A MAR indicated [REDACTED]. The number of hours the resident slept on night shift for [DATE] was 0. A packing slip from the pharmacy dated [DATE] indicated eztimibe, [MEDICATION NAME], ropinirole, [MEDICATION NAME], Eliquis, and [MEDICATION NAME]/[MEDICATION NAME] were received for Resident #382. During an interview on [DATE] at 04:28 p.m., RN C said Resident #382 admitted in the early afternoon and she did not know why the resident's medication did not arrive for his evening doses. She said she did not know why the emergency medication unit was not checked to see if any of the medications were in there. An Electronic Interim Box (emergency medication unit) policy revised ,[DATE] indicated Purpose: To provide an interim supply of medications to be used for emergency or nonemergency dosing administration for nursing facility residents until the Provide Pharmacy (pharmacy) is able to provide a regular supply of medication to the nursing facility resident 4. During an observation of the 2nd floor A hall nurse medication cart on [DATE] at 9:55 a.m. contained Andrographis 300 mg (natural immunity herb) expired in ,[DATE]. During an interview on [DATE] at 10:04 a.m., LPN K said she picked that medication up in a resident's room and put it on the medication cart because you cannot have medications in the resident room. 5. A face sheet dated [DATE] indicated Resident #233 was an [AGE] year-old male who admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 02:15 p.m., Resident #233's daughter said the resident had received a new order for [MEDICATION NAME] (Keflex) on [DATE] at his doctor appointment. She said the prescription had been given to the facility staff around 4:00 p.m. on [DATE], she said at this time the resident still had not received his first dose of [MEDICATION NAME] (Keflex). A progress note dated [DATE] entry at 10:03 p.m., indicated RN L was aware Resident #233 returned from a doctor appointment on [DATE] with a new order to start [MEDICATION NAME] (Keflex) 250mg three times for a day for 10 days and his doctor would be notified. A physician order [REDACTED].#233's [MEDICATION NAME] (Keflex) order was not entered into the EMR until [DATE] at 02:13 p.m A MAR printed on [DATE] at 02:49 p.m. indicated Resident #233 had not yet received an initial dose of [MEDICATION NAME] (Keflex). During an interview on [DATE] at 02:35 p.m., the RCD said the pharmacy runs to this facility are at 11:30 a.m. and 08:30 p.m., she said immediate (stat) medications take 2 hours. She said Resident #233 should have received his first dose of [MEDICATION NAME] (Keflex) yesterday evening, she said the medication should have arrived on the 08:30 p.m. pharmacy run. The RCD said otherwise nursing could have called the doctor to obtain clearance for the medication to be removed from the emergency medication unit. During an interview on [DATE] at 03:00 p.m., the RCD said the doctor had been called to clarify any possible medication allergy that the system alerted, she said the doctor had ordered to proceed with the medication. She said Keflex could be found in the emergency medication kit and was being administered to Resident #233 at this time. During an interview on [DATE] at 4:15 p.m., the facility was asked for additional information at exit, no additional information or policies was provided.

Based on observation, interview, and record review, the facility failed to ensure the written plan of care was followed for 1 of 4 residents reviewed for wound care orders. (Resident #1) The facility did not provide daily wound care as ordered for 6 weeks for Resident #1. Resident #1 developed a stage 2 pressure injury to his right trochanter (hip) wound that worsened into an unstageable pressure injury. This failure could place residents at risk of not receiving care and services to meet their needs Findings included: A face sheet dated 06/28/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged home on[DATE]. His [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had intact cognition, made himself understood, and understood others. He required extensive assistance with most ADLs. Resident #1 had a [MEDICAL CONDITION], urinary catheter and admitted with 2 stage 4 pressure injuries. The hospital discharge orders dated 02/27/19 for Resident #1 included traditional wound vac (negative-pressure wound therapy) at 125 mm/hg pressure to left trochanter and sacral wounds. Wound vac to be changed on Monday, Wednesday, and Friday. Physician orders [REDACTED].#1 included a low air loss mattress and to clean left hip and coccyx with normal saline/wound cleanser, pat dry, skin prep, and apply negative pressure dressing at 125 mm/hg pressure every Monday, Wednesday, and Friday. A skin assessment dated [DATE] indicated Resident #1 admitted with pressure injuries to his coccyx (sacrum) and left trochanter (hip). Resident #1 had a [MEDICAL CONDITION] to his abdomen and a suprapubic catheter to his groin area with no abnormalities. Resident #1 had scattered bruising/discoloration to both his upper arms. A care plan last revised on 03/19/19 indicated Resident #1 required extensive assistance with ADLs. He had pressure injuries and was at risk for further skin breakdown. Interventions included weekly treatment documentation of each skin breakdown's width, length, depth, type of tissue, and exudate, apply negative pressure dressing to coccyx and left hip, obtain/monitor laboratory services as ordered, weekly skin documentation, a low air loss mattress while in bed, and a wheelchair cushion while in wheelchair. The care plan did not address Resident #1's wound to his right trochanter. A Braden scale evaluation for predicting pressure injuries dated 03/16/19 indicated Resident #1 was at low risk for developing pressure injuries. Wound care clinic notes dated 03/26/19 indicated Resident #1 had a new pressure injury to his right trochanter that was dressed with Allevyn and left in place for a week. The right trochanter wound measured 4.0x5.0x0.1cm, there was no tunneling or undermining. The wound had a medium amount of serosanguineous (both blood and the liquid part of blood serum) drainage, a small amount of red/pink granulation tissue within the wound bed, a small amount of necrotic (non-viable tissue due to reduced blood supply) tissue within the wound bed including adherent slough (dead tissue, usually cream or yellow in color). The wound was debrided (removal of unhealthy tissue from a wound to promote healing), post debridement measurements were 4.0x5.0x0.2cm and noted as a stage 2 wound. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. A skin assessment dated [DATE] indicated Resident #1had a shear/trauma wound (slide board injury) to his right trochanter that measured 5.0x3.5x0.1 cm with a small amount of serosanguineous drainage and healing well. A nursing note dated 03/29/19 indicated Resident #1 and his wife complained about dressing changes to right hip not being performed daily per wound care center recommendations. Educated resident that per RN assessment, it was not beneficial to change daily and could cause more injury to area when repeatedly removing and reapplying the dressing. There was no indication to change dressing daily unless there was excessive drainage. Collagen can be left on wound up to 5 days per protocol. Treatment nurse spoke to facility NP and she agreed with every other day dressing changes. A skin assessment dated [DATE] indicated Resident #1 admitted with pressure injuries to his coccyx (sacrum) and left trochanter (hip). Resident #1 had a [MEDICAL CONDITION] to his lower left abdomen and a suprapubic catheter to his groin area that was slightly pink at insertion site. Resident #1 had faded scattered bruising/discoloration to his bilateral upper extremities. He had a shear/trauma wound to his right trochanter that measured 4.8x3.0x0.1 cm with a small amount of serosanguineous drainage and healing well A treatment administration record (TAR) for (MONTH) 2019 indicated Resident #1 received wound care and wound vac changes every Monday, Wednesday, and Friday to his left trochanter and sacral wounds from 03/01/19 to 03/31/19. The TAR did not include wound care for Resident #1's right trochanter wound. Wound care clinic notes dated 04/02/19 indicated Resident #1 and his family reported the facility's treatment nurse wanted to stop wound vac and refused to perform daily wound care as ordered. The facility was called, and a message was left for the treatment nurse to please follow physician orders. Resident #1's wound to his right trochanter measured 3.6x3.0x0.1 cm, there was no tunneling or undermining. The wound had a medium amount of serosanguineous drainage and a small amount of necrotic tissue within the wound bed including adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. A wound care evaluation form did not address the right trochanter wound for the following dates: -3/22/19, 3/29/19, 4/5/19, 4/12/19, 4/19/19, 4/26/19, 5/3/19, or 5/10/19. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 4.8x3.0x0.1 cm with a small amount of serosanguineous drainage and was healing well. Wound care clinic notes dated 04/09/19 indicated Resident #1 and his family reported that the facility's treatment nurse was still not following wound care orders. Resident #1's wound to his right trochanter measured 4.0x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] for Resident #1 was not available. Wound care clinic notes dated 04/16/19 indicated Resident #1 and his family reported they were still concerned about the care being received at the facility. Resident #1's wound to his right trochanter measured 4.0x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.3x2.6x0.1 cm with a small amount of serosanguineous drainage and healing well. Wound care clinic notes dated 04/23/19 indicated Resident #1's wound to his right trochanter measured 3.3x2.6x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A wound care evaluation dated 04/26/19 did not address Resident #1's right trochanter wound. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.5x2.2x0.1 cm with a small amount of serosanguineous drainage and was healing well. Wound care clinic notes dated 04/30/19 indicated Resident #1's wound to his right trochanter measured 3.3x2.4x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A TAR dated (MONTH) 2019 for Resident #1 indicated he received wound care to his right hip every Monday, Wednesday, and Friday from 04/17/19 to 04/30/19. The record did not indicate the resident received care daily. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.5x2.2x0.1 cm with a small amount of serosanguineous drainage. A wound care evaluation dated 05/03/19 did not address Resident #1's right trochanter wound. Wound care clinic notes dated 05/07/19 indicated Resident #1's wound to his right trochanter measured 3.5x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.3x2.2x0.1 cm with a small amount of serosanguineous drainage and wound bed was slightly yellow with pink surrounding tissue. A wound care evaluation dated 05/10/19 did not address Resident #1's right trochanter wound. A treatment administration record dated (MONTH) 2019 for Resident #1 indicated he received wound care to his right hip, left hip, and coccyx every Monday, Wednesday, and Friday from 05/01/19 to 05/10/19. Wound care clinic notes dated 05/14/19 indicated Resident #1's wound to his right trochanter measured 3.2x2.4x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Resident #1 was at home from the nursing facility for at least 2 days where he was confused and running fever. Resident #1 was transported from the wound care clinic to the emergency department. A hospital operative note dated 05/16/19 indicated Resident #1 had surgical debridement performed to his left trochanteric wound, right trochanteric wound, and sacral wound. During an interview on 07/01/19 at 11:20 a.m., Resident #1 said he discharged from the facility on 05/10/19 and was admitted to the hospital on [DATE]. He said he had surgery on his left and right hip wounds on 05/16/19. He said he admitted to the facility with wounds to his left hip and sacrum. He said he had a wound vac during his stay at the facility and received wound care treatments on Monday, Wednesday, and Friday. He said he thought he tried to transfer himself and bumped into the sliding board, causing the wound to his right hip. He said the wound care physician ordered daily wound care to his right hip and they hand delivered the orders to the treatment nurse when they returned to the facility. He said the treatment nurse refused to perform daily wound care but acknowledged he received the wound care orders. Resident #1 said the treatment nurse performed wound care to his right hip on the same days when he changed the dressing for the wound vac. During an interview on 06/28/19 at 12:41 p.m., the treatment nurse said Resident #1 admitted to the facility with stage 4 pressure injuries to his left hip and coccyx area and a wound vac was in place on admission. The treatment nurse said Resident #1 admitted with orders to change the wound vac 3 times a week. He said Resident #1's surgeon debrided his wounds before admission and wanted Resident #1 to go to the wound care center once a week instead of seeing the wound care physician that came to the facility. The treatment nurse said Resident #1 attempted to transfer himself with a slide board and bumped his right hip. He said the area first looked bruised but eventually opened. He said the wound to Resident #1's right hip was not caused by pressure. He said he notified the NP and received an order for [REDACTED].#1's left hip, right hip, and coccyx wounds. The treatment nurse said Resident #1's wife would hand him the wound care physician orders [REDACTED]. He said the orders were vague. He said Resident #1's wife asked him why he was not performing daily wound care to Resident #1's wounds. He said he attempted to educate the wife that performing daily wound care could cause more harm than good. He said he called the wound care center once and spoke to the front office. He said they acted like they were offended when he questioned the daily wound care orders. He said he did not contact the wound care physician that ordered the daily wound care. He said all the wounds improved while the resident was at the facility. He said Resident #1 was non-compliant with meals and ate cereal for breakfast, wound not eat lunch, and his wife would bring him fast food for dinner. He said the resident's [MEDICATION NAME] kept dropping but the resident refused to eat the meals at the facility. He said Resident #1 was ordered Prostat 3 times a day, protein shakes, and vitamins. The treatment nurse said he documented Resident #1's left hip and coccyx wounds on the wound care log. He said he documented Resident #1's right hip wound on the weekly skin assessment. During an interview on 06/28/19 at 11:13 a.m., the NP said she saw Resident #1 at least once a week while he was at the facility. She said she saw Resident #1's wound a few times and they were improving. She said Resident #1 went out weekly for wound care, but the treatment nurse was good about contacting her about order clarifications. She said she occasionally clarified orders regarding Resident #1's wound care. During an interview on 06/28/19 at 2:04 p.m., the wound care center RN said Resident #1 saw the wound physician once a week at the clinic. She said Resident #1 had pressure injuries to his left trochanter and sacrum. She said the wound care physician ordered negative pressure therapy (wound vac) at 125 mm/hg pressure. She said the wound vac was ordered to be changed on Monday, Wednesday, and Friday. The wound care center RN said Resident #1 came in on 03/26/19 and a new wound was on his right hip. She said the wound care physician classified the wound as a stage 2 pressure injury. She said the wound care physician ordered daily wound care to the right hip. She said Resident #1 and his wife voiced concerns about the facility treatment nurse was not performing daily wound care to the right hip wound. She said they left messages for the treatment nurse at the facility to please carry out the physician orders. She said she assisted the wound care physician with Resident #1's wounds and his right hip wound eventually was unstageable. She said Resident #1 came to the wound care center on 05/14/19, after he was discharged from the facility, and was transported to the emergency department for confusion and fever. During an interview on 06/28/19 at 10:05 a.m., the DON said Resident #1 admitted to the facility with orders to change his wound vac every Monday, Wednesday, and Friday. She said there were no orders to send the resident out for wound care when he admitted . She said Resident #1's family complained that the surgeon that performed surgery on Resident #1's wounds wanted the resident to be sent out for wound care. The DON said she contacted Resident #1's surgeon and notified the surgeon that there were no orders to send Resident #1 out for wound care. She said Resident #1's surgeon said he wanted Resident #1 sent to the wound care center for wound treatment. The DON said she received the wound orders and Resident #1 saw the wound physician weekly at the wound care center until he discharged . The DON said he and the NP corresponded with Resident #1's surgeon about wound care orders but did not contact the wound care physician that ordered the wound care treatments. The facility's pressure ulcer/skin breakdown policy last revised (MONTH) 2014 indicated .the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing, and application of topical agents if indicated for type of skin alteration . According to the National Pressure Ulcer Advisory Panel (NPUAP) website, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 7/8/19, noted the following pressure ulcer definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.

Based on interview and record review, the facility failed to ensure 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 reviewed for wound care. (Resident #1) The facility did not provide daily wound care as ordered for 6 weeks for Resident #1. Resident #1 developed a stage 2 pressure injury to his right trochanter (hip) wound that worsened into an unstageable pressure injury. This failure could place residents with wounds at risk for infection and worsening of existing wounds or pressure injuries. Findings included: A face sheet dated 06/28/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged home on[DATE]. His [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had intact cognition, made himself understood, and understood others. He required extensive assistance with most ADLs. Resident #1 had a [MEDICAL CONDITION], urinary catheter and admitted with 2 stage 4 pressure injuries. The hospital discharge orders dated 02/27/19 for Resident #1 included traditional wound vac (negative-pressure wound therapy) at 125 mm/hg pressure to left trochanter and sacral wounds. Wound vac to be changed on Monday, Wednesday, and Friday. Physician orders [REDACTED].#1 included a low air loss mattress and to clean left hip and coccyx with normal saline/wound cleanser, pat dry, skin prep, and apply negative pressure dressing at 125 mm/hg pressure every Monday, Wednesday, and Friday. A skin assessment dated [DATE] indicated Resident #1 admitted with pressure injuries to his coccyx (sacrum) and left trochanter (hip). Resident #1 had a [MEDICAL CONDITION] to his abdomen and a suprapubic catheter to his groin area with no abnormalities. Resident #1 had scattered bruising/discoloration to both his upper arms. A care plan last revised on 03/19/19 indicated Resident #1 required extensive assistance with ADLs. He had pressure injuries and was at risk for further skin breakdown. Interventions included weekly treatment documentation of each skin breakdown's width, length, depth, type of tissue, and exudate, apply negative pressure dressing to coccyx and left hip, obtain/monitor laboratory services as ordered, weekly skin documentation, a low air loss mattress while in bed, and a wheelchair cushion while in wheelchair. The care plan did not address Resident #1's wound to his right trochanter. A Braden scale evaluation for predicting pressure injuries dated 03/16/19 indicated Resident #1 was at low risk for developing pressure injuries. Wound care clinic notes dated 03/26/19 indicated Resident #1 had a new pressure injury to his right trochanter that was dressed with Allevyn and left in place for a week. The right trochanter wound measured 4.0x5.0x0.1cm, there was no tunneling or undermining. The wound had a medium amount of serosanguineous (both blood and the liquid part of blood serum) drainage, a small amount of red/pink granulation tissue within the wound bed, a small amount of necrotic (non-viable tissue due to reduced blood supply) tissue within the wound bed including adherent slough (dead tissue, usually cream or yellow in color). The wound was debrided (removal of unhealthy tissue from a wound to promote healing), post debridement measurements were 4.0x5.0x0.2cm and noted as a stage 2 wound. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. A skin assessment dated [DATE] indicated Resident #1had a shear/trauma wound (slide board injury) to his right trochanter that measured 5.0x3.5x0.1 cm with a small amount of serosanguineous drainage and healing well. A nursing note dated 03/29/19 indicated Resident #1 and his wife complained about dressing changes to right hip not being performed daily per wound care center recommendations. Educated resident that per RN assessment, it was not beneficial to change daily and could cause more injury to area when repeatedly removing and reapplying the dressing. There was no indication to change dressing daily unless there was excessive drainage. Collagen can be left on wound up to 5 days per protocol. Treatment nurse spoke to facility NP and she agreed with every other day dressing changes. A skin assessment dated [DATE] indicated Resident #1 admitted with pressure injuries to his coccyx (sacrum) and left trochanter (hip). Resident #1 had a [MEDICAL CONDITION] to his lower left abdomen and a suprapubic catheter to his groin area that was slightly pink at insertion site. Resident #1 had faded scattered bruising/discoloration to his bilateral upper extremities. He had a shear/trauma wound to his right trochanter that measured 4.8x3.0x0.1 cm with a small amount of serosanguineous drainage and healing well A treatment administration record (TAR) for (MONTH) 2019 indicated Resident #1 received wound care and wound vac changes every Monday, Wednesday, and Friday to his left trochanter and sacral wounds from 03/01/19 to 03/31/19. The TAR did not include wound care for Resident #1's right trochanter wound. Wound care clinic notes dated 04/02/19 indicated Resident #1 and his family reported the facility's treatment nurse wanted to stop wound vac and refused to perform daily wound care as ordered. The facility was called, and a message was left for the treatment nurse to please follow physician orders. Resident #1's wound to his right trochanter measured 3.6x3.0x0.1 cm, there was no tunneling or undermining. The wound had a medium amount of serosanguineous drainage and a small amount of necrotic tissue within the wound bed including adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. A wound care evaluation form did not address the right trochanter wound for the following dates: -3/22/19, 3/29/19, 4/5/19, 4/12/19, 4/19/19, 4/26/19, 5/3/19, or 5/10/19. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 4.8x3.0x0.1 cm with a small amount of serosanguineous drainage and was healing well. Wound care clinic notes dated 04/09/19 indicated Resident #1 and his family reported that the facility's treatment nurse was still not following wound care orders. Resident #1's wound to his right trochanter measured 4.0x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] for Resident #1 was not available. Wound care clinic notes dated 04/16/19 indicated Resident #1 and his family reported they were still concerned about the care being received at the facility. Resident #1's wound to his right trochanter measured 4.0x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.3x2.6x0.1 cm with a small amount of serosanguineous drainage and healing well. Wound care clinic notes dated 04/23/19 indicated Resident #1's wound to his right trochanter measured 3.3x2.6x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A wound care evaluation dated 04/26/19 did not address Resident #1's right trochanter wound. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.5x2.2x0.1 cm with a small amount of serosanguineous drainage and was healing well. Wound care clinic notes dated 04/30/19 indicated Resident #1's wound to his right trochanter measured 3.3x2.4x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A TAR dated (MONTH) 2019 for Resident #1 indicated he received wound care to his right hip every Monday, Wednesday, and Friday from 04/17/19 to 04/30/19. The record did not indicate the resident received care daily. A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.5x2.2x0.1 cm with a small amount of serosanguineous drainage. A wound care evaluation dated 05/03/19 did not address Resident #1's right trochanter wound. Wound care clinic notes dated 05/07/19 indicated Resident #1's wound to his right trochanter measured 3.5x2.5x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Physician orders [REDACTED].#1's right trochanter wound included to clean the wound with mild soap and water, [MEDICATION NAME] to wound, and change dressing every day. Resident #1's orders indicated to .please do daily wound care to right trochanter . A skin assessment dated [DATE] indicated Resident #1 had a shear/trauma wound to his right trochanter that measured 3.3x2.2x0.1 cm with a small amount of serosanguineous drainage and wound bed was slightly yellow with pink surrounding tissue. A wound care evaluation dated 05/10/19 did not address Resident #1's right trochanter wound. A treatment administration record dated (MONTH) 2019 for Resident #1 indicated he received wound care to his right hip, left hip, and coccyx every Monday, Wednesday, and Friday from 05/01/19 to 05/10/19. Wound care clinic notes dated 05/14/19 indicated Resident #1's wound to his right trochanter measured 3.2x2.4x0.1 cm. There was no tunneling or undermining, there was a medium amount of serosanguineous drainage and a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Resident #1's wounds were debrided. Resident #1 was at home from the nursing facility for at least 2 days where he was confused and running fever. Resident #1 was transported from the wound care clinic to the emergency department. A hospital operative note dated 05/16/19 indicated Resident #1 had surgical debridement performed to his left trochanteric wound, right trochanteric wound, and sacral wound. During an interview on 07/01/19 at 11:20 a.m., Resident #1 said he discharged from the facility on 05/10/19 and was admitted to the hospital on [DATE]. He said he had surgery on his left and right hip wounds on 05/16/19. He said he admitted to the facility with wounds to his left hip and sacrum. He said he had a wound vac during his stay at the facility and received wound care treatments on Monday, Wednesday, and Friday. He said he thought he tried to transfer himself and bumped into the sliding board, causing the wound to his right hip. He said the wound care physician ordered daily wound care to his right hip and they hand delivered the orders to the treatment nurse when they returned to the facility. He said the treatment nurse refused to perform daily wound care but acknowledged he received the wound care orders. Resident #1 said the treatment nurse performed wound care to his right hip on the same days when he changed the dressing for the wound vac. During an interview on 06/28/19 at 12:41 p.m., the treatment nurse said Resident #1 admitted to the facility with stage 4 pressure injuries to his left hip and coccyx area and a wound vac was in place on admission. The treatment nurse said Resident #1 admitted with orders to change the wound vac 3 times a week. He said Resident #1's surgeon debrided his wounds before admission and wanted Resident #1 to go to the wound care center once a week instead of seeing the wound care physician that came to the facility. The treatment nurse said Resident #1 attempted to transfer himself with a slide board and bumped his right hip. He said the area first looked bruised but eventually opened. He said the wound to Resident #1's right hip was not caused by pressure. He said he notified the NP and received an order for [REDACTED].#1's left hip, right hip, and coccyx wounds. The treatment nurse said Resident #1's wife would hand him the wound care physician orders [REDACTED]. He said the orders were vague. He said Resident #1's wife asked him why he was not performing daily wound care to Resident #1's wounds. He said he attempted to educate the wife that performing daily wound care could cause more harm than good. He said he called the wound care center once and spoke to the front office. He said they acted like they were offended when he questioned the daily wound care orders. He said he did not contact the wound care physician that ordered the daily wound care. He said all the wounds improved while the resident was at the facility. He said Resident #1 was non-compliant with meals and ate cereal for breakfast, wound not eat lunch, and his wife would bring him fast food for dinner. He said the resident's [MEDICATION NAME] kept dropping but the resident refused to eat the meals at the facility. He said Resident #1 was ordered Prostat 3 times a day, protein shakes, and vitamins. The treatment nurse said he documented Resident #1's left hip and coccyx wounds on the wound care log. He said he documented Resident #1's right hip wound on the weekly skin assessment. During an interview on 06/28/19 at 11:13 a.m., the NP said she saw Resident #1 at least once a week while he was at the facility. She said she saw Resident #1's wound a few times and they were improving. She said Resident #1 went out weekly for wound care, but the treatment nurse was good about contacting her about order clarifications. She said she occasionally clarified orders regarding Resident #1's wound care. During an interview on 06/28/19 at 2:04 p.m., the wound care center RN said Resident #1 saw the wound physician once a week at the clinic. She said Resident #1 had pressure injuries to his left trochanter and sacrum. She said the wound care physician ordered negative pressure therapy (wound vac) at 125 mm/hg pressure. She said the wound vac was ordered to be changed on Monday, Wednesday, and Friday. The wound care center RN said Resident #1 came in on 03/26/19 and a new wound was on his right hip. She said the wound care physician classified the wound as a stage 2 pressure injury. She said the wound care physician ordered daily wound care to the right hip. She said Resident #1 and his wife voiced concerns about the facility treatment nurse was not performing daily wound care to the right hip wound. She said they left messages for the treatment nurse at the facility to please carry out the physician orders. She said she assisted the wound care physician with Resident #1's wounds and his right hip wound eventually was unstageable. She said Resident #1 came to the wound care center on 05/14/19, after he was discharged from the facility, and was transported to the emergency department for confusion and fever. During an interview on 06/28/19 at 10:05 a.m., the DON said Resident #1 admitted to the facility with orders to change his wound vac every Monday, Wednesday, and Friday. She said there were no orders to send the resident out for wound care when he admitted . She said Resident #1's family complained that the surgeon that performed surgery on Resident #1's wounds wanted the resident to be sent out for wound care. The DON said she contacted Resident #1's surgeon and notified the surgeon that there were no orders to send Resident #1 out for wound care. She said Resident #1's surgeon said he wanted Resident #1 sent to the wound care center for wound treatment. The DON said she received the wound orders and Resident #1 saw the wound physician weekly at the wound care center until he discharged . The DON said he and the NP corresponded with Resident #1's surgeon about wound care orders but did not contact the wound care physician that ordered the wound care treatments. The facility's pressure ulcer/skin breakdown policy last revised (MONTH) 2014 indicated .the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing, and application of topical agents if indicated for type of skin alteration . According to the National Pressure Ulcer Advisory Panel (NPUAP) website, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 7/8/19, noted the following pressure ulcer definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.