Every finding on record at The Reserve at Richardson

Based on observation, interview and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council.The facility failed to provide a private space for resident council meetings. This failure could place residents who attended the resident council meetings at risk of not being able to voice concerns due to lack of privacy. Observation and interview on 05/20/2026 at 11:30 a.m. during a confidential resident group meeting held in a private therapy gym, revealed the meeting was normally held in the upstairs dining room. There were no doors or solid walls that separated the dining room from the open nurses' station or the two hallways leading into the dining room. The residents stated they did not feel they could express their opinions because staff would be able to hear them and that anyone could walk in and out of the dining room area. An interview on 05/20/2026 at 12:20 p.m. with the Activity Director revealed she had been hired in September of 2025 and that she knew the meeting should be held in a private area, but staff told her it had always been held in the upstairs dining room so she continued to have it there. She was not aware the residents had voiced any concerns about the meeting. An interview on 05/21/2026 at 4:35 p.m. with the Administrator revealed he expected the meeting to be held in a private area so the residents could voice concerns and the risk to not having the meeting in a private area could keep the residents from speaking freely or the wrong person could hear something. The facility did not have a specific policy regarding privacy of the Resident Council meetings.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of twenty residents (Residents #11, #46, #51,and #87) reviewed for infection control. 1.The facility failed to ensure LVN C performed hand hygiene when she suctioned, changed the tracheostomy's inner cannula, changed the g-tube's dressing, and changed Resident #11's feeding formula on 05/20/2026. 2.The facility failed to ensure CNA D wore a gown while changing Resident #46's linen, who had a midline IV (a thin tube inserted into the vein for delivery of medications) and pressure ulcer, on 05/19/2026. 3.The facility failed to ensure CNA D and the DOR wore gowns and performed hand hygiene when they performed Resident #51's incontinent care, who had an open wound, on 05/19/2026. 4.The facility failed to ensure CNA E wore a gown when she transferred Resident #87 and changed her clothes, who had a fistula and catheter, on 05/20/2026. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1.Record review of Resident #11's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck into the windpipe to allow air to fill the lungs) and gastrostomy status. Record review of Resident #11's Comprehensive MDS Assessment, dated 05/14/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care, was being suctioned (mechanical aspiration of pulmonary secretions to clear the airway), and had a feeding tube. Record review of Resident #11's Care Plan, dated 04/12/2026, reflected:- the resident had a tracheostomy, and the interventions were to ensure that the trach ties were always secured and to suction, as necessary.- the resident required tube feeding and one of the interventions was to provide tube feeding and flushes. Record review of Resident #11's Physician Order, dated 01/06/2026, reflected May suction for removal of secretions as needed. Record review of Resident #11's Physician Order, dated 12/25/2026, reflected Change Disposable Inner Cannula . using clean technique Daily and PRN. one time a day. Record review of Resident #11's Physician Order, dated 11/04/2026, reflected Cleans GT site with NS daily and apply barrier cream under bumper Keep Bumper tight against skin to prevent movement ay insertion site one time a day for GT care. Record review of Resident #11's Physician Order, dated 03/11/2026, reflected Enteral Feed Order every shift Jevity 1.2 cal 64 cc/hr X 22 hrs, with 150 ml water flush q 6 hrs. Monitor for Increased residual. Notify ADON. During an observation on 05/20/2026 at 9:28 a.m., LVN C prepared to suction Resident #11 and change his trach ties and feeding formula. She washed her hands and put on a pair of gloves. She sanitized the resident's overbed table, put a sheet of wax paper on top of the suction tip, the disposable inner cannula, two bottles of normal saline, some large cups, trach tie, a bottle of feeding formula, a syringe, and some gauzes. She removed her gloves, washed her hands, and put on a pair of gloves and a gown. She turned off the g-tube pump and took off the breathing mask on top of the resident's tracheostomy. She removed her gloves and put on another pair of gloves; no hand hygiene was done. She took the new trach ties and put a date on them. She changed her gloves again with no hand hygiene, turned on the suction machine, and started a sterile technique (a controlled practice to eliminate all microorganisms). She then opened a tracheostomy suction kit, opened a bottle of normal saline, and took off her gloves. She then took the package of sterile gloves from the kit and opened the outer wrapper by peeling back the edges of the wrapper. With her left hand, she grasped the folded inner surface of one glove and inserted her right hand and pulled the glove over the wrist. She then put on the second glove to her left hand by slipping her fingers under the cuff of the second glove, inserted the left hand, pulled it over to the wrist, and adjusted the sterile gloves on both hands. She removed the suction catheter with one hand, attached it to the catheter tip, and tested if it was working by dipping it in normal saline. She then inserted the catheter, applied suction while withdrawing the catheter in a rotating motion. After suctioning the resident, she took off her sterile gloves, put on a clean pair of gloves, and changed the resident's trach ties. After changing the trach ties, she took off her gloves and proceeded to change the inner cannula using again the sterile technique. After changing the inner cannula, she took off her gloves and put on a new pair of gloves. She then hung the new container of feeding formula and primed it. After priming the formula, she changed her gloves and checked for g-tube placement. She then took the syringe to check for the gastric residual. After checking for the residual and placement, she flushed the g-tube and connected the formula. After connecting the formula, she took off her gloves, put on a pair of gloves, and changed the g-tube dressing. She did not sanitize her hands between changing of gloves when she disconnected the g-tube, took off the breathing mask, changed the trach tie, changed the formula, and changed the g-tube dressing. She also did not sanitize her hands before putting on the sterile gloves. During an interview on 05/20/2026 at 10:20 a.m., LVN C said she knew she was supposed to sanitize her hands when she was changing her gloves to prevent cross contamination and infection control. She said Resident #11's family member only wanted her to change her gloves and not sanitize between changing gloves. She said, but she knew, hands should be sanitized when they were changing their gloves. She said sterile technique should be used during suctioning and when changing the inner cannula of the resident's tracheostomy. During an interview on 05/20/2026 at 10:22 a.m., Resident #11's family member said she did not tell her not to sanitize her hands when she was changing her gloves. She said if it was the right thing to do to help the resident, then it should be done. She said it was not the first time that LVN C did not sanitize her hands when changing her gloves. 2.Record review of Resident #46's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a pressure ulcer (wound on the skin caused by prolonged pressure to specific areas of the body) to the sacral region (bone at the buttocks). Record review of Resident #46's Comprehensive MDS Assessment, dated 05/02/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident was receiving an antibiotic and had a pressure ulcer. Record review of Resident #46's Comprehensive Care Plan, dated 04/28/2026, reflected that the resident was on antibiotic therapy and had a wound. The intervention for both was to administer antibiotics as ordered. Record review of Resident #46's Comprehensive Care Plan, dated 04/28/2026, reflected that the resident had a condition that required enhanced barrier precautions and one of the interventions was to don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/showering, transfers, providing hygiene, changing linens, toileting/brief changes, device care, med administration via enteral tube or central line, trach care and wound care. Record review of Resident #46's Physician Order, dated 05/14/2026, reflected Daptomycin (antibiotic for bacterial infections) Intravenous Solution Reconstituted (Daptomycin) Use 550 gram intravenously every 48 hours for Wound infection until 5/22/2026 until 05/22/2026 23:59. Record review of Resident #46's Physician Order, dated 05/12/2026, reflected Flush each port of the MIDLINE (a device inserted in the veins used for treatment) with 10 MLs of NS Q Shift both before and after medication administration. every shift. Record review of Resident #46's Physician Order, dated 04/28/2026, reflected Resident is on EBP and Standard Precautions R/T . MIDLINE and PRESSURE ULCER every shift for Enhanced barrier precautions medical condition Staff must don (put on) gown & gloves when performing high contact care such as bathing/showering, pericare (hygiene practices involved in cleaning the area between the thighs)/brief changes, dressing changes, meds via enteral tube or central line, toileting, transfers, providing hygiene, changing linens, device care. Record review of Resident #46's Physician Order, dated 05/08/2026, reflected Cleanse stage 4 to left fold buttocks with ns, pat dry, pack wound with Dakin moist kerlix and dry dressing qd and prn everyday shift for Skin/Wound support. During an observation on 05/19/2026 at 9:31 a.m., CNA D was inside Resident #46's room and was changing the resident's linen without a gown. It was observed that the resident had a midline IV catheter to his right upper arm. It was observed that there was a sign outside that the resident was on enhanced barrier precautions. During an interview on 05/19/2026 at 9:36 a.m., Resident #46 said he had an infected wound on his buttocks; that was why he was on antibiotics. 3.Record review of Resident #51's Face Sheet, dated 05/21/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pressure-induced deep tissue damage (pressure ulcer) of the sacral region. Record review of Resident #51's Comprehensive MDS Assessment, dated 04/27/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident had an unstageable (unable to determine the depth of the wound) pressure ulcer. Record review of Resident #51's Comprehensive Care Plan, dated 04/27/2026, reflected that the resident had a documented pressure ulcer and one of the interventions was to provide wound care. Record review of Resident #51's Physician Order, dated 04/24/2026, reflected Cleanse unstageable to left heel with ns, pat dry, apply medihoney and cal alg and dry dressing q M-W-F and prn every day shift every Mon, Wed, Fri for Skin/Wound support related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION. Record review of Resident #51's Physician Order, dated 05/07/2026, reflected cleanse unstageable to sacral region with ns, pat dry, apply medihoney and cal alg and dry dressing qd and prn every day shift for Skin/Wound support related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION. There was no order for EBP. During an observation on 05/19/2026 at 1:53 p.m., CNA D and the DOR provided Resident #51 with incontinent care. CNA D washed her hands and put on a pair of gloves she did not put on a gown. The DOR put on a pair of gloves but did not do hand hygiene and did not wear a gown. CNA D took off the resident's pants, removed her gloves, washed her hands, and put on a pair of gloves. CNA D unfastened the resident's brief, and the DOR pushed the brief between the resident's legs. CNA D cleaned the resident's perineal area (area between the legs), took off her gloves, washed her hands, and put on a pair of gloves. They then rolled the resident, CNA D cleaned the resident's bottom. After CNA D cleaned the resident's bottom, she took off her gloves, washed her hands, and put on a pair of gloves. The DOR took the brief, opened it, and handed it over to CNA D. The DOR did not change her glove after touching the soiled brief and before opening the brief. It was observed that the resident had a dressing to his bottom. It was also observed that there was no sign outside the door indicating that the resident was on EBP and there was no PPE cart. During an interview on 05/19/2026 at 2:19 p.m., CNA D said she was supposed to wear a gown when she changed Resident #46's linen because he had an IV and wound, but she forgot. She said she needed to wear a gown to protect the resident from infection. She said she did not know if she needed to wear a gown for Resident #51. During an interview on 05/19/2026 at 2:25 p.m., the DOR said she was supposed to change her gloves after touching Resident #51's soiled brief to prevent cross contamination. During an interview on 05/19/2026 at 2:43 p.m., the ADON said Resident #51 was on EBP before for diarrhea, but the loose bowel movement was already resolved. She said the resident had an open wound, so she believed the resident should still be on EBP, but she would check with the wound care nurse. During an interview on 05/19/2026 at 2:56 p.m., the Administrator-in-Training said as per their policy, if the wound did not have a drainage, EBP was not required. During an interview on 05/21/2026 at 1:38 p.m., the WCN said she was told by the Administrator a month ago that residents with wounds that did not have drainage did not require EBP. She said on the afternoon of 05/19/2026, she was told that Resident #51 required EBP, that was why she put back the EBP sign and the PPE cart. She said the Administrator-in-Training told her to put the EBP sign and PPE cart.During an interview on 05/21/2026 at 11:21 a.m., the DOR said she was told that gown should have been worn when they cared for Resident #51 because he had a wound, She said the purpose of the gown was to prevent spread of microorganisms. 4.Record review of Resident #87's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female re-admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder and acute kidney failure (kidneys stopped working). Record review of Resident #87's Comprehensive MDS Assessment, dated 04/29/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter and was undergoing dialysis (a medical treatment that removes waste products from the blood). Record review of Resident #87's Comprehensive Care Plan, dated 05/20/2026, reflected that the resident had an indwelling catheter and was undergoing dialysis. The interventions were to provide catheter care and check the dialysis site. Record review of Resident #87's Physician Order, dated 05/19/2026, reflected Keep urinary drainage bag below the level of the bladder at all times every shift related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED. Record review of Resident #87's Physician Order, dated 05/19/206, reflected Monitor Dialysis Access Site: PERMACATH (a thin tube inserted in the vein to allow cleaning of the blood) every shift related to END STAGE RENAL DISEASE (a condition where the kidneys can no longer function adequately). During an observation on 05/20/2026 at 8:39 a.m. revealed CNA F was about to transfer Resident #87 to her recliner. Before she transferred the resident, she changed the resident's clothing. She did not have a gown when she changed the resident and when she transferred to her wheelchair. During an interview on 05/20/2026 at 11:37 a.m., CNA F said she knew she was supposed to wear a gown when she changed and transferred Resident #87 because she had a catheter and was going to dialysis. She said she needed to wear a gown to prevent infection. During an interview on 05/21/2026 at 7:20 a.m., ADON A said the staff should do hand hygiene when they were changing their gloves to prevent cross contamination. She said the staff should change their gloves after touching the soiled brief and before touching the new brief for the same reason. She said gowns were required when caring for residents with wounds, mid-line IV, fistula, and catheter to prevent infection. She said they would do an in-service about infection control. During an interview on 05/21/2026 at 8:16 a.m., the DON said if a resident was on EBP, then the staff doing care should wear a gown every time they had contact with the resident to prevent cross contamination and spread of infection. She said EBP was required in addition to the gloves when caring for a resident that had a wound, a midline, a fistula, and a catheter. She said gowns should have been worn when the staff changed Resident #46's linen who had a pressure ulcer and a midline, when they did resident #51's incontinent care, who had an open wound, and when they changed and transferred Resident #87 who had a fistula and catheter. She said for Resident #51, they came to the conclusion that he required EBP because he had a wound that required dressing change. She said gloves should have been changed after touching the soiled brief because the gloves were already deemed dirty and could contaminate the new brief. She said the concerns discussed were all infection control issues. She said the expectation was for the staff to wear a gown when needed and to change their gloves after touching anything dirt. She said she would start an in-service to re-educate the staff about infection control. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was for the staff to be mindful not to spread any infection and that the staff would adhere to the policy of infection control. He said residents with wounds that needed dressing change, midline IV, pressure ulcers, and catheters should require EBP. He said he would coordinate with the DON about the infection control issues. Record review of the facility's policy Enhanced Barrier Precautions reviewed December 2025 reflected Policy Statement: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown and glove use during high contact resident care activities . Policy Interpretation and Implementation . apply to the care of all residents in the facility . wounds and/or indwelling medical devices . Enhanced Barrier Precautions include the following practices . 4. Gowns . a. Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, colostomy care, medication administration via g-tube, and device care or use: central line, urinary catheter, feeding tube, tracheostomy ., wound care: any skin opening requiring a dressing. Record review of the facility policy, Infection Control Guidelines for All Nursing Procedure reviewed December 2024 revealed Purpose: To provide guidelines for general infection control while caring for residents . 2. Gloves . a. Wear gloves (clean, non-sterile) when you anticipate direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material . c. Wear gloves when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. e. Change gloves, as necessary, during the care of a resident making sure to sanitize/wash hands in between to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).

Based on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date and were properly sealed. These failures could place residents at risk of food contamination and food-borne illness.Finding included: An observation on 05/19/26 between 9:15 AM and 9:45 AM in the facility's kitchen revealed:One gallon bag containing pasta noodles with an expiration date of 05/17, not properly sealed and exposed to air contaminants. One gallon bag containing two graham pie crusts was undated and revealed no expiration date. One gallon bag containing three graham pie crusts was undated and revealed no expiration date. One bag containing brown sugar dated 05/15/26 with no visible expiration date. One head of lettuce dated 05/18/26 with no visible expiration date was observed. One gallon bag containing two frozen beef patties dated 05/19/26 with no visible expiration date. During an interview on 05/21/26 at 11:35 AM, the DM verbally acknowledged he state surveyor observations and stated the listed items would be corrected. The DM stated once items were opened, they should be properly sealed and dated. The DM stated he was responsible for ensuring policy was followed. The DM stated he and one other kitchen aide was responsible for proper labeling and making sure that the items were labeled properly. The DM stated the risk to residents if policy was not followed was a health risk to the residents. The DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. The DM stated if food items were not dated when opened, then they would not know how long the item would last. The DM stated a full in-service completed in reference to food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. The DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness. During an interview on 05/21/2026 at 1:45 PM, the AIT stated he oversaw all departments, and ensured residents were taken care of. The AIT said the policy or procedure for storing food was, everything needed to be dated, and if opened, it needed to have an open date and an expiration date. He said the risk to residents if policy were not followed, was they could get sick from food borne illnesses. The AIT stated he would expect the DM to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. The AIT stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. Record review of the facility's undated Policy and Procedure Manual Food Storage, 7. All stock must rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold, or discarded. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for six of twenty residents (Residents #29, #44, #70, #74, #78, and #86) and one of three carts (Nurse Cart) reviewed for medication storage. 1.The facility failed to ensure that Resident #78's eye drops were not accessible to other residents on 05/19/2026. 2.The facility failed to ensure that Resident #70 analgesic topical gel was not inside his room on 05/19/2026. 3.The facility failed to ensure that Resident #86 did not have a tube of zinc oxide inside her room on 05/19/2026. 4.The facility failed to ensure that Resident #29 did not have a tube of zinc oxide inside his room on 05/19/2026. 5.The facility failed to ensure that Resident #44 did not have an antifungal powder tube inside her room on 05/19/2026. 6.The facility failed to ensure that Resident #74 did not have a tube of zinc oxide inside her room [ROOM NUMBER]/19/2026. 7.The facility failed to ensure that a bottle of probiotics with an instruction of Refrigerate after opening was stored inside the cart since it was opened on 02/10/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1.Record review of Resident #78's Face Sheet, dated 05/20/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dry eye syndrome (insufficient tear production). Record review of Resident #78's Comprehensive MDS Assessment, dated 04/03/2026, reflected that the resident had an intact cognition with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had dry eye syndrome. Record review of Resident #78's Comprehensive Care Plan, dated 04/01/2026, reflected that the resident rights will be respected and one of the interventions was to receive care, as necessary. Record review of Resident #78's Physician Order, dated 03/18/2026, reflected Artificial Tears Ophthalmic Solution 0.5-0.6 % (Polyvinyl Alcohol-Povidone (Ophth)) Instill 1 drop in both eyes every 12 hours as needed for DRY EYES EYE DROPS TO SELF ADMININSTER AT BEDSIDE PER MD. Record review of Resident #78's Self-Administration of Medication, dated 02/26/2026, reflected that the resident could safely administer her medications. During an observation and interview on 05/19/2026 at 9:05 a.m., revealed Resident #78 was in her bed, awake. It was observed that a container of eye drops was in her overbed table. The eye drops were in plain view, was accessible, and visible from the hallway. The resident said she would apply it to her eyes and would always put it on her overbed table. 2.Record review of Resident #70's Face Sheet, dated 05/20/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with unspecified pain. Record review of Resident #70's Comprehensive MDS Assessment, dated 03/02/2026, reflected that the resident had an intact cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident would experience pain occasionally. Record review of Resident #70's Comprehensive Care Plan, dated 03/22/2026, reflected that the resident was on pain medication and one of the interventions was to administer medications as ordered. Record review on 05/19/2026 of Resident #70's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 05/19/2026 at 9:09 a.m., revealed Resident #70 was in his wheelchair, awake. It was observed that a tube of topical analgesic gel was on top of the resident's side table. The analgesic gel was visible from the hallway and was on a plain view. The resident said the gel was for his hip and also for other parts of his body that was hurting. He said LVN B would get from the tube and apply it to him and then would leave it on his table. 3.Record review of Resident #44's Face Sheet, dated 05/21/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with rash and other nonspecific skin eruptions. Record review of Resident #44's Comprehensive MDS Assessment, dated 02/23/2026, reflected that the resident had an intact cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had rash and other nonspecific skin eruptions. Record review of Resident #44's Comprehensive Care Plan, dated 05/14/2026, reflected that the resident was having rashes and one of the interventions was to administer medications as ordered. Record review of Resident #44's Physician Order, dated 05/13/2026, reflected Cleanse rash to abd and chest with ns, pat dry, apply anti [NAME] cream and leave open to air qd and prn every day shift for Skin/Wound support related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION. Record review on 05/19/2026 of Resident #44's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 05/19/2026 at 9:30 a.m., revealed Resident #44 was in her bed, awake. It was observed that an antifungal powder was on top of her overbed table. She said the staff used the powder on her abdomen, and the powder was always left on her table. During an observation and interview on 05/21/2026 at 11:57 a.m., LVN B said she did not know about Resident #78's eye drops and she did not notice it during her round. She said she knew about Resident #70 having analgesic gel inside the room but did not question it. Said Resident #70 had an order for the analgesic gel, and he had one inside the cart. She said she would sometimes get from the tube inside the room. She said she was not sure if Resident #70 would apply some more gel on top of what she was administering. She said medications inside the room might cause overdosing, and the staff would not know how many times it was applied by the residents. She said even the pain-relieving gel could cause skin irritation depending on how often it was used. She said she would check the medications mentioned. 4.Record review of Resident #86's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #86's Comprehensive MDS Assessment, dated 05/16/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident was incontinent (unable to control) for bowel. Record review of Resident #86's Comprehensive Care Plan, dated 05/17/2026, reflected that the resident had an ADL Self Care Performance deficit and one of the interventions was to assist during toilet use. Record review on 05/19/2026 of Resident #86's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation on 05/19/2026 at 9:24 a.m., revealed Resident #86 was in her bed with eyes closed. It was observed that a tube of zinc oxide was on top of the resident's side table. 5.Record review of Resident #29's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #29's Comprehensive MDS Assessment, dated 05/03/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #29's Comprehensive Care Plan, dated 05/10/2026, reflected that the resident had an ADL Self Care Performance deficit and one of the interventions was to assist during toilet use. Record review on 05/19/2026 of Resident #29's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 05/19/2026 at 9:26 a.m., Resident # was in his bed, awake. It was observed that a tube of zinc oxide was on top of his side table. When asked if what the zinc oxide was for, the resident shrugged his shoulder. During an interview on 05/19/2026 at 9:34 a.m., CNA D said she was not the one who left the tube of zinc oxides on Resident #29 and Resident #86's side table. She said the staff used the zinc oxide when they cleaned them and changed their briefs. She said it should not be within reach of residents because some residents were confused and might eat the cream. 6.Record review of Resident #74's Face Sheet, dated 05/21/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #74's Comprehensive MDS Assessment, dated 05/01/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #74's Comprehensive Care Plan, dated 04/06/2026, reflected that the resident had mixed incontinence and one of the interventions was to check the resident every two to four hours and as required for incontinence. Record review on 05/19/2026 of Resident #74's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 05/19/2026 at 11:41 a.m., revealed Resident #74 was in her bed, awake. It was observed that a tube of zinc oxide was on top of the resident's side drawer and was in plain view. She said the staff would use it when they changed her. She said the staff always leave the tube for zinc oxide on top of her side table and very seldom put it in her drawer. During an observation and interview on 05/19/2025 at 11:44 a.m., LVN C said the tube of barrier cream should not be left inside the room or should be accessible to the residents because they might think that it was something edible and consume it or apply it to the face and eyes. She called CNA F and talked to her about Resident #74's barrier cream. During an interview on 05/19/2026 at 11:47 a.m., CNA F said she left the barrier cream on top of Resident #74 drawer because she was in a hurry to get the other residents up. She said it should not be accessible to the residents because residents that were confused might put it in their eyes and mouth. 7.During an observation on 05/20/2026 at 12:05 p.m., revealed a bottle of probiotics with an instruction at the back that said, Refrigerate after opening was inside the drawer of LVN B's cart. The probiotics had an opening date of 02/10/2026. During an observation and interview on 05/20/2026 at 12:06 p.m., revealed LVN B read the instruction at the back of the bottle of probiotics and said the instruction was said to refrigerate after opening. She said the probiotics were opened last February and had always been inside the cart since then. She said she did not notice the direction on the bottle. She said if the instructions said it should be refrigerated, then it should not be inside the cart. She said there was a reason why the manufacturer placed the direction, and it must have something to do with the effectiveness of the probiotics. She said she was responsible in checking which medication should be inside the refrigerator. During an interview on 05/21/2026 at 7:20 a.m., ADON A said barrier creams with zinc oxide should not be within reach of the residents. She said confused residents might mistakenly consume them or use them inappropriately. She said the barrier creams should be somewhere not accessible to the residents. She said medications, such as topical analgesic, should not be inside the residents' rooms for the same reason. She said Resident #78 had an order that stated she could administer her eye drops, but the eye drops should not be accessible to the other residents. She said she would check on Resident #44's antifungal powder was on plain view. She said they would start an in-service about medication storage. During an interview on 05/21/2026 at 8:16 a.m., the DON said medications, whether oral or topical, should not be inside the residents' rooms because the residents might use them inappropriately and that could result in adverse reactions. She said skin barriers were applied topically and could be harmful when ingested. She said the expectation was for the staff to be vigilant when they entered the residents' room to check for any medications and for staff using the skin barriers to not leave the tubes within reach of the residents. She said she would start an in-service to re-educate the staff about medication storage. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was for the staff to make sure there were no medications and barrier creams inside the residents' rooms because the residents might consume them or use them inappropriately. He said he would coordinate with the DON about the issue. Record review of facility policy Medication Storage in the Facility Policies and Procedures revised January 2018 revealed Temperature . C. medications requiring refrigeration are kept in a refrigerator. Record review of facility policy, Storage of Medications 2001 Med-Pass, Inc. revised April 2021 revealed Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for two of five residents (Resident #3 and Resident #87) reviewed for incontinent care. 1. The facility failed to ensure Resident #3's catheter bag was off the floor on 05/19/2026. 2. The facility failed to ensure that CNA E did not place Resident #87's catheter bag on top of the resident's bed, rendering the catheter to not be below the bladder while changing the resident's clothing on 05/20/2026. 3. The facility failed to ensure Resident #87's catheter bag was off the floor on 05/20/2026. These failures could place the residents at risk for urinary tract infection. Findings included: 1.Record review of Resident #3's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder. Record review of Resident #3's Comprehensive MDS Assessment, dated 04/29/2026, reflected that the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter. Record review of Resident #3's Comprehensive Care Plan, dated 04/07/2026, reflected that the resident had a suprapubic catheter (device inserted into the stomach to the bladder to drain urine) and one of the interventions was to change catheter bag when closed system was compromised. Record review of Resident #3's Physician Order, dated 01/15/2026, reflected SPC 16F (French: unit of measurement for catheter sizes) with 10_ml balloon DX for Suprapubic catheter use: Neurogenic Bladder (the normal bladder function is disrupted due to nerve damage). During an observation on 05/19/2026 at 11:41 a.m., revealed Resident #3 was in her bed with eyes closed, her catheter bag was hanging on the bed railing and was touching the floor. During an observation and interview on 05/19/2026 at 11:44 a.m., LVN C said the catheter bag should be off the floor because it could result in urinary tract infection. She went inside Resident #3's room and saw that the resident's catheter bag was touching the floor. She said, maybe, somebody changed and put the bed in the lowest position but did not notice that the bag was touching the floor. She raised the resident's bed until the catheter bag was off the floor. She said she would talk to CNA F, who was assigned to the resident, to remind her that catheter bags should not be touching the floor. She said she would also change the resident's catheter bag. During an interview on 05/19/2026 at 11:47 a.m., CNA F said she was not the one who changed Resident #3 and left the room with the catheter bag on the floor. She said the catheter bag should not be touching the floor because it could result in urinary tract infection. 2.Record review of Resident #87's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female re-admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder. Record review of Resident #87's Comprehensive MDS Assessment, dated 04/29/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter. Record review of Resident #87's Comprehensive Care Plan, dated 05/20/2026, reflected that the resident had an indwelling catheter and one of the interventions was to provide catheter care. Record review of Resident #87's Physician Order, dated 05/19/2026, reflected Keep urinary drainage bag below the level of the bladder at all times every shift related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED. During an observation on 05/20/2026 at 8:39 a.m., CNA F changed Resident #87's clothing, she placed the resident's catheter bag on top of the bed, where it remained. It was observed that there was urine was in the catheter tubing. During an interview on 05/20/2026 at 11:21 a.m., LVN B said the catheter bag should not be placed on top of the bed and should always be below the bladder to prevent urine from flowing back to the bladder that could result in infection. During an interview on 05/20/2026 at 11:37 a.m., CNA F said she put on Resident #87's pants, that was why she placed the catheter on top of the bed. She said she should have placed the catheter bag back to the railing as soon as she slipped the catheter bag in one of the legs of the resident's pants. She said it did not occur to her that urine could go back inside the resident's body and could cause infection. She said the facility provided check-offs with regards to catheter care but did not pay attention. 3.During an observation on 05/20/2026 at 9:43 a.m., Resident #87 was sitting in her recliner, her catheter bag was on the floor. During an observation and interview on 05/20/2026 at 9:44 a.m., LVN B said the catheter should have been secured to prevent it from falling to the floor. She said microorganisms could creep inside the catheter to the bladder causing urinary tract infection. She said she would also change the catheter bag. During an interview on 05/20/2026 at 11:37 a.m., CNA F said the catheter bag kept falling, that was why she just left it on the floor and forget to tell the nurse about it. She said the floor was dirty, making the catheter bag dirtier. During an interview on 05/21/2026 at 7:20 a.m., ADON A said the catheter bag should always be below the bladder to prevent urine from going back to the bladder that could eventually cause a urinary tract infection. She said the staff could hang the catheter bag on the other side if they needed to turn the resident. She said catheter bags should be off the floor because it could also cause UTI. She said the expectations were for catheter bags would always be below the bladder and off the floor. She said they started an in-service about catheter care. During an interview on 05/21/2026 at 8:16 a.m., the DON said the catheter bags should always be below the bladder to prevent backflow of urine from the catheter bag to the bladder. She said if there was a backflow, it could result in urinary tract infection. She said the staff should have hung the catheter again after putting the resident's pants on. She said the bags should not be touching the floor to keep it clean and prevent UTI. She said she would start an in-service to re-educate the staff about catheter care. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was that the catheter bag always be below the bladder and off the floor to prevent infection. He said he would coordinate with the DON about the catheter. Record review of the facility's policy Catheter Care, Urinary Catheter Care P & P revised June 18, 2018, reflected Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Input/Output . Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . Infection Control . Maintain clean technique . b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #54 and Resident #6) reviewed for abuse and neglect.The facility failed to ensure Resident #6 was free from abuse when Resident #54 hit him on 05/05/2026. This failure could place residents at risk of abuse and emotional stress.Findings include:Record review Resident #54's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: Hemiplegia and Hemiparesis following nontraumatic subarachnoid, Hemorrhage affecting right dominant side (a type of hemorrhagic stroke indicate damage to the brain. Because the brain's hemispheres control the opposite side of the body, right-sided motor symptoms stem from left-brain injury), Vascular dementia, severe, without behavioral disturbance (indicates advanced cognitive impairment that severely impacts independence but occurs without concurrent psychiatric or mood complications), Psychotic disturbance, mood disturbance, and anxiety (can indicate complex conditions like bipolar disorder with psychotic features, major depressive disorder with psychotic features, or severe trauma-related disorders). Record review of Resident #54's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/16/26, reflected the resident had a moderate cognitive impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 12. Resident #54 did indicate any Behavioral symptoms at the time assessment was completed. Record review of Resident #54's Care Plan with an initiation date of 12/18/2025 revealed Resident #54 have potential to demonstrate physical behaviors (hitting or trying to punch) r/t anger, and poor impulse control.Record review of Resident #54's Care Plan with an initiation date of 05/18/2025 revealed Resident #54 had the potential to demonstrate verbally and abusive behaviors r/t Mental / Emotional. Resident #54's Comprehensive care plan did not indicate behaviors toward staff or other residents.Record review or Resident #54's Progress notes on 05/05/2026 revealed no entries pertaining to the incident involving Resident #54 and Resident #6. Record review of Resident #6's Face Sheet revealed. revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis included: Secondary parkinsonism unspecified indicates symptoms are present, but the exact underlying cause is not yet determined, Bradykinesia: Slowness of movement, including difficulty initiating steps or smaller handwriting (micrographia), Rigidity: Stiffness and inflexibility in the limbs, neck, or trunk, Tremor: Shaking or trembling, often most prominent when the limbs are at rest, Neuromuscular dysfunction of bladder unspecified (the brain, spinal cord, or nerve damage interrupts signals to the bladder, resulting in symptoms like involuntary leakage, urgency, frequency, or the inability to fully empty the bladder), (The condition is a symptom or complication of an underlying neurological issue, Spinal cord injuries or diseases: Spina bifida, herniated discs, or trauma, Neurological disorders: Multiple sclerosis (MS), Parkinson's disease, or stroke). Record review of Resident #6's Quarterly MDS (tool used to assess health status) Assessment, dated 02/13/2026, reflected which indicated intact cognition with a BIMS (screening tool to assess cognitive status) score of 15. Record review of Resident #6's care plan with an initiation date of 11/11/2025 revealed Resident #6's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #6's Progress notes on 05/05/2026 revealed no entries pertaining to the incident involving Resident #6 and Resident #54. Record review of the facility's grievance dated 05/05/26 revealed Care for Resident # 6, was initiated via the Ombudsman in regard to resident #54 striking Resident #6 to the DON. During an interview on 05/21/2026 at 12:45 PM the OMB stated that about two weeks ago, on 05/05/2026 she was approached by Resident #54. Where Resident #54 admitted to striking Resident #6 on the leg. The OMB stated Resident #54 I was attempting to leave the room when Resident #6 was in my way, at which time I struck him in the leg Resident #6 stated during conversation that Resident #54 called Me a homosexual. I didn't bite or take his bait. The OMB stated Resident #6 stated he was okay, not hurt or had issues or concerns. The OMB stated on 05/05/2026, she informed the DON of the incident, at which point the staff took action and separated them initially and a room change was done later on same date. Record review of Texas Unified Licensure Information Portal (TULIP) on 5/21/26 at 8:25 A.M. revealed that no self-reported incidents regarding allegations of abuse were reported involving Resident #6 and Resident #54. During an interview on 05/21/2026 at 1:10 PM the DON stated during her investigation of care, [Resident #54 relayed to Ombudsman that he hit his roommate. The DON stated if there were a resident - to - resident altercation (verbally or physically), first thing would be to separate them, safety first, assess, notify the doctor and RP. The DON said if orders were given, she would follow through with the orders. The DON said, Both residents were in the W/C, and they were speaking to each and trying to maneuver around to exit the room. State Surveyor provided the DON the grievance form outlining the incident. The DON stated they would not report this incident such as the one described between Residents #54 & 6 to the state because they did a grievance. The DON felt it was not abuse. The DON stated during the time they were rooming together they never had issues with each other. The DON stated there were no other incidents of resident-to-resident altercation with Resident #54 as the perpetrator had occurred since Resident #54's incident on 05/05/26. During an interview on 05/21/2026 at 1:25 PM, State Surveyor provided the AIT the grievance form outlining the incident that occurred on 05/05/2026. The AIT confirmed he did not do an investigation into the incident involving Resident #54 striking Resident #6 on the leg. The AIT stated they would not ordinarily report an incident of abuse such as the one described with Residents #54 & #6 to the state because they did a grievance. The AIT stated they did not think it was abuse so he did not report it. During an interview on 05/21/2026 at 1:28 PM Resident #6 stated that another resident called him a homosexual and then called him the N word (racial slur) and an SOB. He stated that he wanted to hit him, but he did not. He was bipolar and things like that would make him want to react. Resident #6 stated Resident #54 kicked him in the shin; he did contact his skin, but it did not hurt nor did it leave any kind of mark. Resident #6 stated Resident #54 wanted his own room, and he thought he was doing that on purpose so they would move him. were both there and witnessed the altercation. Resident #6 stated they did move Resident #54 to another hall. Resident #6 was asked twice if he felt safe in the facility and he stated yes, both times. During an interview on 05/21/2206 at 2:02 PM SW stated she was not aware of the incident involving the two residents. Further advised in terms of a room change notification is usually a written notice and is a 5-day notice.During an interview on 05/21/2026 at 2:05 PM CNA G stated he heard yelling going on in the room and came in and immediately separated both Resident #54 & Resident #6. CNA G stated that he said he did not witness either of them hitting each other, he just heard the yelling and responded. During an interview on 05/21/2026 at 4:17 PM Resident #54 stated he did recall the incident, and he did kick him and that staff moved him to another hall. Resident #54 stated that he felt safe in the facility and that he had told the OMB what he had done.Record review of the facility Policy Abuse, Neglect and Exploitation dated revised on 12/2025 reflected:Policy: It is a policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent neglect, exploitation, and misappropriation of property. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of four residents (Resident #85) reviewed for feeding tube management. The facility failed to ensure LVN B checked Resident #85's gastric residual and g-tube placement before flushing and administering medications on 05/20/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included: Record review of Resident #85's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #85's Comprehensive MDS Assessment, dated 05/15/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach). Record review of Resident #85's Quarterly Care Plan, dated 04/15/2026, reflected that the resident required tube feeding and one of the interventions was to check for gastric residual (food, liquid, and secretions remaining in the stomach) and tube placement. Record review of Resident #85's Physician Order, dated 05/18/2026, reflected every shift for Tube Feeding Orders (JEVITY 1.5 @ 35ML/HR H20 FLUSH 35 ML/HR (USE WATER PROVIDED BY FAMILY) run 22 hours and 2 hours down time for ADL's. Record review of Resident #85's Physician Order, dated 05/14/2026, reflected every shift Auscultate (listening to the sounds inside the body using a stethoscope) for Tube Placement before feeding and medication administration Q Shift and PRN related to GASTROSTOMY STATUS. Record review of Resident #85's Physician Order, dated 05/14/2026, reflected every shift Check Residual prior to feeding if greater than 150 cc return contents and HOLD feeding and notify MD related to GASTROSTOMY STATUS. During an observation on 05/20/2026 at 9:06 a.m., LVN B turned off Resident #8's feeding machine and disconnected the g-tube from the formula. After disconnecting the g-tube, she took the syringe from the overbed table and flushed the g-tube with 30 cc of water, gave the medications one by one flushing between each medication. LVN B did not check for gastric residual or placement of the g-tube prior to administering the medications. During an interview on 05/20/2026 at 11:21 a.m., LVN B said she should check for residual before medication administration to assess if the resident's stomach was emptying well. She said if the stomach was not emptying well, adding liquid could result in aspiration or vomiting. She said the resident was on continuous feeding; that was why she did not check for the residual. She said she should also check the placement of the g-tube before medication administration to ensure the tube was not dislodged. During an interview on 05/21/2026 at 7:20 a.m., ADON A said g-tube placement and gastric residual should be checked before introducing water and administering medications. She said g-tube placement should be checked to ensure the g-tube was in the right place and would not cause aspiration. She said even though the residents were on continuous feeding, the placement should still be checked to see if the stomach could accommodate additional water and the medications. She said checking for the residual was also one way to assess if the stomach was emptying. She said not checking the residual might cause vomiting and aspiration pneumonia (food going inside the lungs). She said the expectation was for the staff to check for g-tube placement and the gastric residuals before flushing and administering medications. She said they would start an in-service about checking g-tube placement and residual checks. During an interview on 05/21/2026 at 8:16 a.m., the DON said the placement of the g-tube should be checked before flushing the g-tube and before medication administration to ensure the medications and the fluid would enter the stomach. He said checking the placement was a safety step to ensure the tube was not in other parts of the body, like the lungs, esophagus, and cavities inside the body, that could result in aspiration and ineffective feeding because the formula was not delivered to the intended site. She said gastric contents should also be checked, regardless of whether the mode of feeding was bolus or continuous, to ensure there was no delayed emptying of the stomach. She said the expectation was for the staff to follow the policies and procedures for enteral feeding. She said she would start an in-service to re-educate the staff about checking g-tube placement and the gastric residuals. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was for the staff to check g-tube placement and the residual content as per orders. He said he would coordinate with the DON about g-tube. Record review of the facility's policy Enteral Nutrition (delivery of food through feeding tube) reviewed December 2025 reflected Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered . Policy Interpretation and Implementation . 12. Staff caring for the residents with feeding tube will be trained on potential adverse effects . d. feeding tube associated complications . 13. Staff . will be trained . e. Clogging of the tube . 15. Risk of aspiration will be assessed . may be affected by . d. Failure to confirm placement of the feeding tube.

Based on observation, interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for for 2 (Resident #20 and Resident #66) of 5 residents reviewed for Advanced Directives. The facility failed to ensure that Resident #20 and Resident #66's OOH-DNR (Out of Hospital-Do Not Resuscitate) were completed correctly with both signatures not meeting the criteria for a qualified witness, making the forms invalid. This failure could affect all residents who have implemented an Advanced Directive and established their choice not to be resuscitated at the risk of receiving CPR (Cardiopulmonary Resuscitation) against their wishes.Findings included: Record review of Resident #20's face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included unspecified dementia, (a clear cognitive decline consistent with dementia but cannot identify the specific type), senile degeneration of the brain, (the progressive loss of brain cells and cognitive function associated with advanced aging), anxiety disorder and chronic kidney disease. Record review of Resident #20's quarterly MDS dated [DATE] reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #20 needed maximum assistance with toileting, showering self, upper and lower body dressing and personal hygiene. Record review of Resident #20's undated care plan reflected, Focus: I am a DNR, Date initiated: [DATE]. Goal: My wishes will be honored through next review, date initiated: [DATE], Revised on [DATE]. Interventions: If found absent of vital signs, do not initiate CPR, keep my family and physician updated on my condition, date initialed, [DATE]. Record review of Resident #20's DNR dated [DATE] reflected it had been signed by a qualified relative, an adult child. The two witnesses who signed were also family members. In an interview on [DATE] at 3:12 p.m., the qualified relative stated that both witnesses were family members related to Resident #20. Record review of the Out- Of -Hospital Do-Not-Resuscitate order from the Texas Department of State Health Services reflected the following: Definitions: Qualified Witnesses: Both witnesses must be competent adults,2) one of the witnesses may not be related to the person by blood or marriage. Record review of Resident # 66's face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included rhabdomyolysis (a breakdown of muscle tissue that leads to the release of muscle fiber into the blood), hypertension (high blood pressure), and acute kidney failure. Record review of Resident #66's admission MDS dated [DATE] reflected a BIMS of 15 indicating cognitively intact. Resident # 66 needed moderate assistance with toileting hygiene, upper body dressing and personal hygiene and maximum assistance with showering or bathing self and lower body dressing. Record review of the undated care plan reflected, Focus: I am a DNR, Date initiated: [DATE]. Goal: My wishes will be honored through next review, date initiated: [DATE], Interventions: If found absent of vital signs, do not initiate CPR, keep my family and physician updated on my condition, date initialed, [DATE]. Record review of Resident #66's OOH-DNR dated [DATE] reflected it had been signed by the facility's AIT and the facility Social Worker. Record review of the Out- Of -Hospital Do-Not-Resuscitate order from the Texas Department of State Health Services reflected the following: Definitions: Qualified Witnesses: Both witnesses must be competent adults, 7) may not be an employee of a health care facility, an officer, director or business office employee of the health care facility. In an interview on [DATE] at 4:44 p.m., the DON stated residents are a full code until the DNR is completed, the social worker checks them for accuracy before they are uploaded to the medical record. She stated the risk to the resident was that staff could follow the wrong directive. In an interview on [DATE] at 5:10 p.m., the Administrator stated that staff are not allowed to sign the DNR's and the risk could be an adverse outcome. The facility did not have a policy regarding the OOH-DNR's.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten residents (Resident #67) reviewed for pharmaceutical services. The facility failed to dispose of Resident #67's expired insulin on 05/21/2026. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and not receiving medications as ordered resulting to adverse effects.Findings included: Record review of Resident #67's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #67's Comprehensive MDS Assessment, dated 04/01/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #67's Comprehensive Care Plan, dated 04/21/2026, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #67's Physician Order, dated 02/03/2026, reflected NovoLog Injection Solution 100 UNIT/ML (Insulin Aspart) Inject subcutaneously (administer under the skin) two times a day for DM2. During an observation on 05/21/2026 at 12:01 p.m., revealed Resident #67's insulin KwikPen was inside a nurse's cart with an open date of 04/10/2026. During an observation and interview on 05/21/2026 at 12:02 p.m., LVN C said Resident #67's insulin was already expired because it was past twenty-eight days from its opening date. She said after 28 days, the insulin was already considered expired. She said the insulin should have been disposed of on 05/08/2026. She took the insulin and discarded it. She said it was an oversight on her part because she did not check the expiration date of the resident's insulin. She said expired medications could be less effective or more toxic. During an interview on 05/21/2026 at 7:20 a.m., ADON A said there should not be expired medication inside the carts because expired medications could be less potent and would not be able to provide the full benefit of the medications. She said the nurses administering the insulin were responsible for ensuring the insulin was not expired. She said most of the insulin had a shelf life of twenty-eight days and beyond that the insulin was already considered expired. She said the expectation was that the staff would check the carts for expired medications. She said they would start an in-service about expired medications. During an interview on 05/21/2026 at 8:16 a.m., the DON said the expired insulin should have been disposed after twenty-eight because it had already expired and could be less potent. She said the nurses were responsible for checking their carts for expired medications. She said she would start an in-service to remind the staff to always check the carts for expired medications. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was for the staff to check for the expiration date of any medications before administering them to prevent any adverse reactions. He said he would coordinate with the DON regarding the expired medication. Record review of the facility's policy Administering Oral Medications reviewed December 2025 reflected Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications . Steps in the Procedure . Check the expiration date on the medication.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of ten residents (Residents #46 and Resident #87) reviewed for respiratory care. 1.The facility failed to ensure Resident #46's nasal cannula was stored properly when not in use on 05/21/2026.2.The facility failed to ensure Resident #87's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 05/20/2026. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: 1.Record review of Resident #46's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #46's Comprehensive MDS Assessment, dated 05/02/2026, reflected the resident was cognitively intact (resident may need additional support and monitoring) with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had shortness of breath and was on oxygen therapy. Record review of Resident #46's Care Plan, dated 05/06/2026, reflected the resident had shortness of breath and one of the interventions was to administer oxygen as needed. Record review of Resident #46's Physician Order, dated 04/28/2026, reflected OXYGEN @ __2__ lpm via N/C OR FACE MASK TO MAINTAIN O2 SATS GREATER THAN 90% FOR SOB PRN every 8 hours as needed for SOB, O2 Sats. During an observation and interview on 05/20/2026 at 9:28 a.m., Resident #46 was in his chair, his nasal cannula was on top of his bed. Resident #46 said he would use oxygen occasionally, he said he went to therapy without oxygen. He said nobody told him to put his nasal cannula inside a bag and he did not have a bag for his nasal cannula. 2.Record review of Resident #87's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female re-admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #87's Comprehensive MDS Assessment, dated 04/29/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 12 (resident may need additional support and monitoring). The Comprehensive MDS Assessment indicated the resident had shortness of breath and was on oxygen therapy. Record review of Resident #87's Care Plan, dated 05/20/2026, reflected the resident had shortness of breath and one of the interventions was to administer oxygen as needed. Record review of Resident #87's Physician Order, dated 05/19/2026, reflected OXYGEN @ __2-4_____ lpm via N/C OR FACE MASK TO MAINTAIN O2 SATS GREATER THAN 90% FOR SOB PRN every 8 hours as needed for SOB, O2Sats. During an observation and interview on 05/20/2026 at 8:35 a.m., revealed Resident #87 was in her bed, awake, her nasal cannula was unbagged on top of the oxygen concentrator. She said she did not use her oxygen always. During an observation and interview on 05/20/2026 at 11:21 a.m., LVN B said the nasal cannula should be bagged to prevent any respiratory infection. She went inside Resident #46 and Resident #87's rooms, disconnected the nasal cannula, and threw them in the trash can. She said she did not notice the nasal cannulas was not bagged. She said for Resident #46, sometimes he would take it off or staff would take it off. She said she should educate Resident #46 to bag his nasal cannula if he takes it off. During an interview on 05/21/2026 at 7:20 a.m., ADON A said the nasal canula should be bagged when not in use to prevent any respiratory infection. She said sometimes, Resident #46 was the one who would take it off, so the staff should closely monitor the resident. She said they would do an in-service about respiratory care. During an interview on 05/21/2026 at 8:16 a.m., the DON said the staff was responsible in making sure the nasal cannula was bagged when not in use to prevent respiratory infection. She said the expectation was for the staff to bag the nasal cannula when not in use. She said she would start an in-service about respiratory care and would include the rehabilitation department because sometimes they would get the residents to go for therapy, and they were the ones taking the nasal canula off. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was for the staff to bag the nasal cannula when not in use to prevent respiratory issues. He said he would coordinate with the DON about the issue. Record review of facility's policy, Respiratory Therapy revised November 2011 reflected The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. 8. Keep the oxygen cannulas and tubing used PRN in a plastic bag when not in use.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 5 residents (Resident #6) reviewed for abuse and neglect.The facility was made aware of the incident on 05/05/2026 and did not investigate an allegation of abuse which Resident #6 was struck on the leg by Resident #54. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.Record review Resident #54's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: Hemiplegia and Hemiparesis following nontraumatic subarachnoid. Hemorrhage affecting right dominant side. (a type of hemorrhagic stroke indicate damage to the brain. Because the brain's hemispheres control the opposite side of the body, right-sided motor symptoms stem from left-brain injury). Vascular dementia, severe, without behavioral disturbance. (indicates advanced cognitive impairment that severely impacts independence but occurs without concurrent psychiatric or mood complications). Psychotic disturbance, mood disturbance, and anxiety. (can indicate complex conditions like bipolar disorder with psychotic features, major depressive disorder with psychotic features, or severe trauma-related disorders). Record review of Resident #54's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/16/26, reflected the resident had a moderate cognitive impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 12.Record review of Resident #54's Care Plan with an initiation date of 05/18/2025 revealed [Resident #54] Have potential to demonstrate verbally and abusive behaviors r/t Mental / Emotional. Resident #54's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #54's Care Plan with an initiation date of 12/18/2025 revealed [Resident #54] Have potential to demonstrate physical behaviors (Hitting or trying to punch) r/t Anger, Poor impulse control. Record review or Resident #54's Progress notes on 05/05/2026 revealed Resident #54 was monitored for changes or symptoms. Resident #54 had no emotional distress or changes noted.Record review of Resident #6's Face Sheet revealed. revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis included: Secondary parkinsonism unspecified indicates symptoms are present, but the exact underlying cause is not yet determined. Bradykinesia: Slowness of movement, including difficulty initiating steps or smaller handwriting (micrographia). Rigidity: Stiffness and inflexibility in the limbs, neck, or trunk. Tremor: Shaking or trembling, often most prominent when the limbs are at rest. Neuromuscular dysfunction of bladder unspecified (The brain, spinal cord, or nerve damage interrupts signals to the bladder, resulting in symptoms like involuntary leakage, urgency, frequency, or the inability to fully empty the bladder). (The condition is a symptom or complication of an underlying neurological issue. Spinal cord injuries or diseases: Spina bifida, herniated discs, or trauma. Neurological disorders: Multiple sclerosis (MS), Parkinson's disease, or stroke). Record review of Resident #6's Quarterly MDS (tool used to assess health status) Assessment, dated 02/13/2026, reflected which indicated intact cognition with a BIMS (screening tool to assess cognitive status) score of 15. Record review of Resident #6's care plan with an initiation date of 11/11/2025 revealed [Resident #6] Resident #6's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #6's Progress notes on 05/05/2026 revealed Resident #6 was monitored for changes or symptoms. Resident #6 had no emotional distress or changes noted.Record review of the facility grievance dated 05/05/26 revealed an allegation of Resident Care for Resident # 6, was initiated via the Ombudsman in regard to both residents to the DON. Record review of Texas Unified Licensure Information Portal (TULIP) on 5/21/26 at 8:25 A.M. revealed that no self-reported incidents regarding allegations of neglect were reported for resident #06. During an interview on 05/21/2026 at 12:45 PM OMB stated that she was approached by Resident # 54, where he admitted to striking Resident #6 in the leg. OMB stated spoke with both resident's, Resident #6 stated during conversation, Resident #54 called Me a Homosexual, I didn't bite or take his bait. Resident #6 stated was okay not hurt or had issues or concerns. OMB stated advised the DON, of the incident at which point they took action and separated them initially and a Room change was done later on same date. During an interview on 05/21/2026 at DON stated during her investigation of Care, Resident relayed to Ombudsman that he hit his roommate. Interviewed were no witnesses resident is well. The DON stated if there were a Resident - to - Resident altercation (verbally or physically), first thing would be to separate them, safety first, assess, notify doctor and RP. DON said if orders were given, she would follow through with the orders. Both residents were in the W/C and they were speaking to each and trying to maneuver around to exit the room. The DON stated they would not report a grievance such as the one described between Resident #54 & 6 to the state because they did a grievance. DON felt this was not abuse. During an interview on 05/21/2026 at 1:25 PM, the (AIT) confirmed he did not do an investigation. AIT stated they would not ordinarily report a grievance such as the one described with Resident #54 & 6 to the state because they did a grievance. did not think it was abuse so he did not report it. During an interview with SW at 2:02 PM stated she was not aware of the incident involving the two residents. Further advised in terms of room change notification is usually a written notice and is a 5 day notice.During an interview on 05/21/2026 at 2:45 PM ADMIN confirmed the AIT, did not complete an investigation. Further added after looking into this perhaps this should have been reported. Record review of the facility Policy Abuse, Neglect and Exploitation dated revised on 12/2025 reflected:It is a policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent neglect, exploitation, and misappropriation of property. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident ' s body. 3. Physical injury of a resident, of unknown source. V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:I. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.VII. Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #54, and #6) reviewed for freedom from abuse, neglect, and exploitation.The facility failed to report an allegation of resident abuse for Resident #6 to the State Survey Agency within the allotted time frame of 2 hours, after being advised of the incident occurrence on 05/05/26 when Resident #54 admitted to striking Resident #6.These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. Findings included:Record review Resident #54's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: Hemiplegia and Hemiparesis following nontraumatic subarachnoid. Hemorrhage affecting right dominant side. (a type of hemorrhagic stroke indicate damage to the brain. Because the brain's hemispheres control the opposite side of the body, right-sided motor symptoms stem from left-brain injury). Vascular dementia, severe, without behavioral disturbance. (indicates advanced cognitive impairment that severely impacts independence but occurs without concurrent psychiatric or mood complications). Psychotic disturbance, mood disturbance, and anxiety. (can indicate complex conditions like bipolar disorder with psychotic features, major depressive disorder with psychotic features, or severe trauma-related disorders). Record review of Resident #54's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/16/26, reflected the resident had a moderate cognitive impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 12.Record review of Resident #54's Care Plan with an initiation date of 05/18/2025 revealed [Resident #54] Have potential to demonstrate verbally and abusive behaviors r/t Mental / Emotional. Resident #54's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #54's Care Plan with an initiation date of 12/18/2025 revealed [Resident #54] Have potential to demonstrate physical behaviors (Hitting or trying to punch) r/t Anger, Poor impulse control.Record review or Resident #54's Progress notes on 05/05/2026 revealed Resident #54 was monitored for changes or symptoms. Resident #54 had no emotional distress or changes noted. Record review of Resident #6's Face Sheet revealed. revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis included: Secondary parkinsonism unspecified indicates symptoms are present, but the exact underlying cause is not yet determined. Bradykinesia: Slowness of movement, including difficulty initiating steps or smaller handwriting (micrographia). Rigidity: Stiffness and inflexibility in the limbs, neck, or trunk. Tremor: Shaking or trembling, often most prominent when the limbs are at rest. Neuromuscular dysfunction of bladder unspecified (The brain, spinal cord, or nerve damage interrupts signals to the bladder, resulting in symptoms like involuntary leakage, urgency, frequency, or the inability to fully empty the bladder). (The condition is a symptom or complication of an underlying neurological issue. Spinal cord injuries or diseases: Spina bifida, herniated discs, or trauma. Neurological disorders: Multiple sclerosis (MS), Parkinson's disease, or stroke). Record review of Resident #6's Quarterly MDS (tool used to assess health status) Assessment, dated 02/13/2026, reflected which indicated intact cognition with a BIMS (screening tool to assess cognitive status) score of 15. Record review of Resident #6's care plan with an initiation date of 11/11/2025 revealed [Resident #6] Resident #6's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #6's Progress notes on 05/05/2026 revealed Resident #6 was monitored for changes or symptoms. Resident #6 had no emotional distress or changes noted.Record review of the facility grievance dated 05/05/26 revealed an allegation of Resident Care for Resident # 6, was initiated via the Ombudsman in regard to both residents to the DON. Record review of Texas Unified Licensure Information Portal (TULIP) on 5/21/26 at 8:25 A.M. revealed that no self-reported incidents regarding allegations of neglect were reported for resident #6.During an interview on 05/21/2026 at 12:45 PM OMB stated that she was approached by Resident # 54, where he admitted to striking Resident #6 in the leg. OMB stated spoke with both resident's, Resident #6 stated during conversation, Resident #54 called Me a Homosexual, I didn't bite or take his bait. Resident #6 stated was okay not hurt or had issues or concerns. OMB stated advised the DON, of the incident at which point they took action and separated them initially and a Room change was done later on same date. During an interview on 05/21/2026 at DON stated during her investigation of Care, Resident relayed to Ombudsman that he hit his roommate. Interviewed were no witnesses resident is well. The DON stated if there were a Resident - to - Resident altercation (verbally or physically), first thing would be to separate them, safety first, assess, notify doctor and RP. DON said if orders were given, she would follow through with the orders. Both residents were in the W/C and they were speaking to each and trying to maneuver around to exit the room. The DON stated they would not report a grievance such as the one described between Resident #54 & 6 to the state because they did a grievance. DON felt this was not abuse. [NAME] stated during the time they were rooming together they never had issues with each other. there were no other incidents of resident-to-resident altercation with Resident #54 as the perpetrator had occurred since Resident #54's incident on 05/05/26. During an interview on 05/21/2026 at 1:25 PM, the AIT confirmed he did not do an investigation. AIT stated they would not ordinarily report a grievance such as the one described with Resident #54 & 6 to the state because they did a grievance. did not think it was abuse so I did not report it. During an interview with SW at 2:02 PM stated she was not aware of the incident involving the two residents. Further advised in terms of room change notification is usually a written notice and is a 5 day notice.During an interview on 05/21/2026 at 2:45 PM ADMIN confirmed the AIT, did not complete an investigation. Further added after looking into this perhaps this should have been reported.Record review of the facility Policy Abuse, Neglect and Exploitation dated revised on 12/2025 reflected:Policy: It is a policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent neglect, exploitation, and misappropriation of property. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident ' s body. 3. Physical injury of a resident, of unknown source. VII. Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for one of eighteen residents (Resident #87) and one direct care staff (LVN B) of three direct care staff reviewed for accident hazard. 1. The facility failed to ensure CNA E did not transfer Resident #87 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself, and leave the resident suspended in the air via the Hoyer lift without supervision on 05/20/2026. 2. The facility failed to ensure LVN B did not leave a container of germicidal wipes (substance that destroys germs and microorganism) on top of her cart unattended on 05/20/2026. These failures could place residents at risk of injuries and exposure to toxic chemicals. Findings included: 1.Record review of Resident #87's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female re-admitted to the facility on [DATE]. The resident was diagnosed with reduced mobility. Record review of Resident #87's Comprehensive MDS Assessment, dated 04/29/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident was dependent on the staff for transfer. Record review of Resident #87's Care Plan, dated 05/20/2026, reflected that the resident had an ADL self-care performance deficit and one of the interventions was to transfer via Hoyer lift. During an observation on 05/20/2026 at 8:57 a.m. revealed CNA E was about to transfer Resident #87 from the bed to the recliner via Hoyer lift. She went inside the resident's room with a Hoyer lift and asked the resident if she wanted to be transferred to her wheelchair. The resident said she wanted to be transferred to her recliner instead. CNA E rolled the resident and fixed the Hoyer sling onto the resident's back. After fixing the Hoyer sling, she hooked the loops of the Hoyer sling to the sling attachment hooks of the Hoyer lift and started to raise the resident by holding the remote control in her right hand. When the Hoyer sling with the resident was up, she started to move the Hoyer lift away from the bed towards the resident's recliner. Once the Hoyer lift was near the recliner, she spread the legs of the Hoyer lift and continued to push the Hoyer lift towards the recliner. Nobody was guiding the Hoyer sling while it was being raised and while it was pushed towards the recliner. CNA E then went out of the room, leaving the resident dangling in the air. She returned to the resident's room with LVN B, and both lowered the resident to her recliner. Once the resident was in her recliner, they unhooked the loops of the Hoyer sling from the Hoyer lift, and pulled the Hoyer lift away from the wheelchair. During an interview on 05/20/2026 at 11:21 a.m., LVN B said she told CNA E that Resident #87 wanted to be transferred to her recliner. She said she was not aware that CNA E had already prepared the resident for transfer and started the transfer. She said CNA E only called her when she was about to lower the resident. She said CNA E should have called her, or another staff member, before raising and maneuvering the lift to make sure that the transfer was safe, and no injuries would happen to the resident. She said, if she were busy, she could always ask for somebody else's assistance. During an interview on 05/20/2026 at 11:37 a.m., CNA E said she knew that transfer via Hoyer lift required two-person assistance, but she was in a rush that was why she did the transfer by herself. She said she should have called another staff member before she transferred Resident #87 to make sure the transfer was safe. She said she went out of the room to call another staff because she cannot lower the resident to the recliner without somebody assisting Resident #87. 2.During an observation on 05/20/2026 starting at 7:27 a.m. to 9:21 a.m. revealed a container of germicidal wipes was on top of LVN B's cart. It was observed that LVN B was going in and out of some residents' rooms to do treatments and was closing the doors while she was doing the treatments. LVN B would leave the container of germicidal wipes on top of her cart, unattended. At 9:21 a.m., she went inside a resident's room, turned her back from her cart, and left the lid of the container open with some wipes visibly out. It was observed that at the back of the container was a note that said Keep out of reach of children. It was observed that several residents were passing by the cart. During an observation on 05/20/2026 at 10:48 a.m. revealed LVN B's cart was parked outside the nurses' station. The container of germicidal wipes was still on top of her cart, and the lid was still open. It was observed that nobody was inside the nurses' station. During an interview and observation on 05/20/2026 at 11:21 a.m., LVN B said she used the germicidal wipes to sanitize the bp cuff and the glucometer that she was using. She said she forgot to put the container of germicidal wipes inside the drawer of her cart when she went inside a residents' room. She said she should have placed the germicidal wipes inside the cart before he closed the door to give medications because residents might be able to get hold of the wipes and use them to clean their faces and eyes that could result in irritations. She said some residents were confused and might go inside the rooms of other residents. She took the container of germicidal wipes and put it inside the last drawer of the cart she was using. She said there they had a population that would wander around the facility. During an interview on 05/21/2026 at 7:20 a.m., ADON A said transfer via Hoyer lift should be done by two staff to ensure resident safety and better control of the lift's movement. She said improper technique could lead to falls and injuries. She said she should have called another staff member before raising the Hoyer lift. She said the container of disinfectant, closed or opened, should have been placed inside the cart when staff were leaving their cart. She said residents could get some and use them on their face and body. She said the wipes could cause irritation, that was why the staff were using gloves everytime they used the wipes. She said the expectation was that transfer via Hoyer lift would always be done by two staff members to ensure safety. She said another expectation was for the staff not to leave the germicidal wipes within reach of the residents. She said they would start an in-service about Hoyer transfer and storage of germicidal wipes. During an interview on 05/21/2026 at 8:16 a.m., the DON said staff could not transfer a resident via Hoyer lift by themselves because it was dangerous. She said a one-person transfer via Hoyer lift could present safety issues to the resident and to the staff as well. She said the resident might fall that could result in injuries, or the machine could tilt to one side and fall on the staff. She said the germicidal wipes should not be left unattended because the residents might get hold of the wipes and use them to clean their eyes. She said the expectation was for all the staff to follow their policy about transferring via Hoyer lift and not to leave the germicidal wipes unattended. She said she would start an in-service to re-educate the staff about proper transfer, and the harm germicidal wipes could cause. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was that two staff would transfer residents using Hoyer lift because it was dangerous and the residents could be seriously injured. He said another expectation was to store the germicidal wipes accordingly before walking away from their carts to ensure that residents would not be able to get any. He said he would coordinate with the DON about the transfer and the germicidal wipes. Record review of the facility's policy Lifting Machine, Using a Mechanical reviewed December 2025 reflected Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . General Guidelines . 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Record review of facility policy, Storage of Medications 2001 Med-Pass, Inc. revised April 2021 revealed Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care . shall be stored separately from regular medications.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #87) of nineteen residents reviewed for dignity. The facility failed to treat Resident #87 with dignity and promote enhancement of their quality of life when the resident was not provided a privacy bag for her catheter bag on 05/20/2026. This failure could place the residents at risk of not having their right to a dignified existence maintained.Findings included: Record review of Resident #87's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old female re-admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #87's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 04/29/2026, reflected that the resident had a moderate cognitive impairment (resident may need additional support and monitoring) in cognition with a BIMS (screening tool used to assess cognitive status) score of 12. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #87's Care Plan, dated 05/20/2026, reflected that the resident had an indwelling catheter and one of the interventions was to provide catheter care. Record review of Resident #87's Physician's Order, dated 05/19/2026, reflected Monitor Foley (device used to help drain urine from bladder) Catheter Q Shift for leakage, blockage, sediment buildup, or low output. Every shift. During an observation on 05/20/2026 at 8:35 a.m. revealed Resident #87 was in her bed, awake. It was observed that the resident had a catheter bag hanging on the side frame of the bed. The catheter bag did not have a privacy bag, and the bag and the urine inside the bag could be seen from the hallway. During an interview on 05/20/2026 at 8:55 a.m., Resident #87 said she had a catheter because her kidneys were not working right. She said she only had the catheter on her last hospitalization. During an interview on 05/20/2026 at 11:21 a.m., LVN B said Resident #87 just came back from the hospital and was re-admitted to the facility with the catheter. She said she did not notice that the resident's catheter bag did not have a privacy bag. She said the facility used a catheter bag with a flap so that they did not need to put a privacy bag. She said whoever admitted the resident should have changed the catheter bag to the one with a flap, or put a privacy bag on, or placed it on the other side of the bed where it would not be visible from the hallway. She said it would be a dignity issue because the resident could be embarrassed. During an interview on 05/20/2026 at 11:37 a.m., CNA E said she did not notice that the catheter bag did not have a privacy bag. She said if she noticed it when she did her rounds, she would tell the nurse about it because it should be visible from the hallway. During an interview on 05/20/2026 at 2:34 p.m., Resident #87 said the catheter was new for her and would not appreciate it if other individuals would see that she had a catheter. She said, at that point, she was still not accustomed to having a catheter, and it would embarrass her if others could see it. During an interview on 05/21/2026 at 7:20 a.m., ADON A said whoever admitted Resident #87 the night before should have made sure that the resident's catheter bag was inside a privacy bag or changed it to a catheter with a leaf. She said the other staff that were caring for her should have noticed it when they went inside the resident's room. She said the resident might be embarrassed because others could see her bag with urine. She said they would do an in-service about dignity. During an interview on 05/21/2026 at 8:16 a.m., the DON said if Resident #87 was embarrassed then it was a dignity issue that her catheter bag could be seen from the hallway. She said it should have been changed to the catheter bag that the facility was using, which was a catheter with a leaf or put the bag on the other side of the bed not visible from the hallway. She said the expectation was for the staff to provide dignity. She said she would start an in-service to re-educate the staff that the resident had a right to a dignified existence. During an interview on 05/21/2026 at 9:01 a.m., the Administrator-in-Training said the expectation was that the catheter bag was covered to prevent embarrassment. He said the staff could use the fig leaf urinary drain bag to keep the bag covered. He said he would coordinate with the DON about the catheter bag without a privacy bag. Record review of facility policy Quality of Life - Dignity reviewed December 2024 revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . Policy Interpretation and Implementation . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by . a. Helping the resident to keep urinary catheter bags covered.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in a locked cart or under direct observation of authorized staff in an area where residents could access it for one (Nurse Cart) of one cart reviewed for medication storage. The facility failed to ensure that LVN B locked the nurse cart before leaving it unattended on 12/02/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose, adverse reactions, or misuse of medications.Findings included: Observation on 12/02/2025 at 10:04 AM, revealed a nurse medication cart was parked outside the nurse's station unlocked. The cart and the drawers were facing the hallway, the drawers contained medications. It was observed that a resident in a wheelchair was sitting approximately ten steps from the open cart. During an observation and interview on 12/02/2025 at 10:06 AM, MA C saw the cart and locked it. She said the cart was used by the nurses, but she was not sure who was currently using it. She said the cart should always be locked when not in use because residents, staff, and visitors might open it and get some medications from the cart. MA C said residents, confused or not, might consume the medications causing allergies or overdose. In an interview on 12/02/2025 at 10:10 AM, ADON A stated the carts should be locked every time they were left unattended. She said the staff should lock the carts before leaving them to prevent unauthorized individuals from opening them. She said confused residents might open the cart and ingest something to which they were allergic. She said the expectations was the staff using the carts would lock the cart after using them or leaving them unattended. She said she would find out who was using the cart so she could talk to the staff and remind him or her to always lock the cart. She said she would coordinate with the DON to do an in-service about the importance of the locking the carts. In an interview on 12/02/2025 at 11:50 AM, the DON stated she was made aware about a cart left unlocked. She said the staff should be mindful to lock their carts everytime they would step away from their carts. She said resident, staff, or even visitors might open the drawers and got hold of the medications inside. She said adverse reactions could result such as allergic reactions or even overdose. She said she would do an in-service about locking the carts every time the staff would leave their carts. She said she did not even know how long the cart was left unlocked. She said the expectation was for the staff to lock the carts when left unattended. In an interview on 12/02/2025 at 1:28 PM, the Administrator stated the expectation was for all the carts, nurses' carts, medication aide carts, and the wound care carts, would always be locked to protect the residents from getting any medications that they might be allergic to. She said she would collaborate with the DON to do an in-service pertaining to locking the carts. In an interview on 12/03/2025 at 3:01 PM, LVN B stated he left his cart to go to the restroom. He said he should have made sure his cart was locked before leaving it so that nobody could open it. He said a resident might consume the medications that could lead to hypotension, hypoglycemia, allergic reactions, or even overdose. LVN B said he would be mindful to keep his cart locked when he was not using it. Record review of the facility's policy titled Storage of Medications dated December 2024 reflected Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for one (Resident #1's) of ten residents reviewed for privacy and confidentiality. The facility failed to ensure ADON A did not leave Residents #1's medical information exposed and unattended on top of the nurse's station countertop on 12/02/2025. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.Findings included: Record review of Resident #1's Face Sheet, dated 12/02/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 11/30/2025, reflected the resident was unable to complete the interview to determine the BIMS (screening tool used to assess cognitive status) score. The MDS indicated the resident had depression. Record review of Resident #1's Comprehensive Care Plan, dated 04/28/2025, reflected the resident had depression and one of the interventions was to administer medications as ordered. Record review of Resident #1's Physician's Order, dated 11/26/2025, reflected Quetiapine Fumarate Oral Tablet 150 MG Verbal Active (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for DEPRESSION. An observation on 12/02/2025 at 10:07 AM, revealed an untitled piece of paper was left on top of a nurse's station countertop. On the piece of paper was Resident #1's name, medical record number, her Physician's name, the proposed course of therapy, the name of the medication, and condition being treated. As per the paper, the condition being was a psychotic behavior. The paper was left unattended, facing the hallway, and nobody was in the nurse's station. During an observation and interview on 12/02/2025 at 10:10 AM, ADON A stated she was the one who left the piece of paper on top of the nurse's station countertop. She took the paper and dropped it inside the nurse's station. She said she should have flipped it or put it inside the nurse's station because Resident #1's medical information was exposed and could be seen by anybody that would go to the nurse's station. She said the resident's medical information was restricted to unauthorized individuals and it was a HIPAA violation if the information was visible to others that was not providing care to the residents. During an observation and interview on 12/02/2025 at 10:59 AM revealed Resident #1 was in her bed, awake. The resident did not reply when asked if she felt down lately. In an interview on 12/02/2025 at 11:50 AM, the DON stated personal and medical information about a resident should not be exposed for everybody to see because they were confidential. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said the staff was expected to provide full privacy and confidentiality of information for all residents. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on 12/02/2025 at 1:28 PM, the Administrator stated the expectation was the staff to make sure the residents' personal and medical information was not exposed and protected because it was a violation of the residents' privacy and confidentiality. He said he would collaborate with the DON to do an in-service about privacy and confidentiality. Record review of the facility's policy titled Resident Rights dated December 2024 reflected Policy Interpretation and Implementation . These rights include the resident right's right to . t. privacy and confidentiality. Record review of the facility's policy titled Protected Health Information (PHI), Management and Protection of dated December 2023 reflected Policy Statement . Protected Health Information (PHI) shall not be used or disclosed . Policy Interpretation and Implementation . 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Residents #1, #2, and #3) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light systems in Residents #1, #2, and #3's rooms were in a position that was accessible to the resident on 06/18/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #1's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 05/27/2025, reflected the resident had a severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 07. The Quarterly MDS Assessment indicated the resident was dependent on staff for personal hygiene, transfer, and bed mobility. Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 06/18/2025 at 8:56 AM revealed Resident #1 was in her bed, awake. It was observed that the resident's call light was hanging on the railing of the top portion of the bed. She said she seldom used the call light and she usually saw it at the side of her bed. The resident searched for her call light and said she could not find it. Resident #2 Record review of Resident #2's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #2's Quarterly MDS Assessment, dated 05/27/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident required substantial assistance for toileting, shower, and dressing. Record review of Resident #2's Comprehensive Care Plan, dated 05/26/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 06/18/2025 at 9:06 AM revealed Resident #2 was in her bed, awake. It was noted that her call light was on the floor. When asked where her call light was, the resident shrugged her shoulders. Observation and interview on 06/18/2025 at 9:10 AM, revealed CNA C stated call lights should be with the residents at all times so they could call the staff if they needed to. She said she did not notice that Resident #1 and #2's call lights were not with them when she last checked the said residents. She went inside Resident #1's room and saw the call light was hanging on the railing of the bed and was not within the reach of the resident. She took the call light from the railing and placed it somewhere Resident #1 could reach it. She then went to Resident #2's room and saw the resident's call light was on the floor and even the cord of the call light could not be reached by the resident. She took the call light from the floor and placed it somewhere the resident could reach it. She said staff should make sure the call lights were within reach of the residents before they leave the room so that the needs of the residents could be addressed and also to prevent falls. In an interview on 06/18/2025 at 9:17 AM, LVN F stated the call lights should be with the residents at all times in cases like the residents needing assistance or needing something from the nurse. He said he did not notice the call lights were not with Residents #1 and #2 when he did his round. He said the risk of the residents not having their call lights could be falls and frustrations. Resident #3 Record review of Resident #3's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #3's Quarterly MDS Assessment, dated 06/06/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident required assistance for transfer and walking. Record review of Resident #3's Comprehensive Care Plan, dated 05/09/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. The Comprehensive Care Plan did not indicate that the resident was refusing to have his call light on his side. Observation and interview on 06/18/2025 at 9:47 AM revealed Resident #3 was in his bed, awake. It was observed that his call light was on the floor behind the side table. When asked where was his call light, the resident did not answer. Observation and interview on 06/18/2025 at 9:50 AM, revealed ADON B stated the call lights were important and should always be with the residents in case they needed assistance or help. She said whenever a staff was done with their treatment or care, they needed to make sure the call lights were with the residents before leaving the room. She said the call lights were for all residents, dependent or independent, and all the staff were responsible in making sure the call lights were with the residents. She said she would do an in-service about call light placement. In an interview on 06/18/2025 at 1:28 PM, ADON A stated call lights were used by the residents to call the staff. Some residents were bed bound and could not get up to call the staff. She said, even for the residents that could get up, the call lights should still be with them because they might be having medical issues and nobody would know. ADON A said all the staff and managers were responsible for the call lights. She said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. She said she would initiate an in-service regarding call light placement. In an interview on 06/18/2025 at 1:32 PM, the Administrator stated the call lights were used by the residents to communicate their needs to the staff. He said the expectation was for the staff to make sure the call lights were with the residents before leaving their rooms. He said they would re-educate the staff about call light placements. Record review of the facility's policy Answering the Call Light revised December 2024 revealed Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #6) of one residents reviewed for Respiratory Care. The facility failed to ensure Resident #6's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 06/18/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #6's Face Sheet, dated 06/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with asthma (lung disorder caused by narrowing of the airways) and shortness of breath. Record review of Resident #6's Comprehensive MDS Assessment, dated 06/05/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated that the resident had asthma. Record review of Resident #6's Comprehensive Care Plan, dated 06/18/2025, reflected the resident had an ineffective gas exchange (disruption of the oxygen and carbon dioxide exchange in the lungs) and one of the interventions was to administer medications and respiratory treatments as ordered. Record review of Resident #6's Physician Order, dated 01/07/2025, reflected Ipratropium-Albuterol Solution 0.5 - 2.5 (3) mg/3 mL 3 ml inhale orally every 4 hours as needed for SOB or wheezing via nebulizer. Observation and interview on 06/18/2025 at 9:29 AM revealed Resident #6 was in her bed, awake. A nebulizer machine was noted on the resident's side table with a breathing mask connected to it. The breathing mask was not bagged. She said the nurse would put it on and took it off after the breathing treatment was done. She said it was also the nurse who would put it in the drawer. She said she was not aware where the nurse put it after taking it off. In an interview on 06/18/2025 at 9:32 AM, LVN G stated the order for Resident #6's breathing treatment was as needed. She said as needed or daily, the breathing mask should be bagged and kept clean to prevent respiratory infection and other respiratory issues. She said she did not notice the unbagged breathing mask when she did her rounds. it was observed that LVN G disconnected the breathing mask and said she would change it. In an interview on 06/18/2025 at 1:34 PM, ADON B stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of any respiratory issues. She said the expectation was for the staff to be mindful and make sure the breathing mask was bagged after administering the breathing treatment. She said it did not matter if the order was daily or as needed, the breathing mask must be in a plastic bag to keep it clean. She said she would conduct an in-service about respiratory care specifically about bagging the breathing mask. In an interview on 06/18/2025 at 1:32 PM, the Administrator stated the breathing mask should be stored properly to prevent development of respiratory issues. He said they would re-educate the staff regarding proper storage of the breathing masks. Record review of the facility's policy, Departmental (Respiratory Therapy) -Prevention of Infection reviewed December 2024 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol . 7. Store the circuit in plastic bag.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for two (Resident #4 and Resident #5) of two residents reviewed for Storage of Drugs and Biologicals. The facility failed to ensure that no medications were inside Resident #4 and Resident #5's room. This failure could place the residents at risk of overdose or misuse of medications. Findings included: Resident #4 Record review of Resident #4's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with nasal congestion, rashes, and bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows). Record review of Resident #4's Comprehensive MDS Assessment, dated 05/06/2025, reflected the resident was cognitively intact (capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had asthma and bipolar disorder. Record review of Resident #4's Comprehensive Care Plan, dated 06/18/2025, reflected the resident had an ineffective gas exchange (disruption of the oxygen and carbon dioxide exchange in the lungs) and one of the interventions was to administer medications and respiratory treatments as ordered. The Comprehensive Care Plan did not indicate that the resident could self-administer her medications. Record review of Resident #4's Physician Order on 06/18/2025 reflected the resident did not have an order for nasal spray. Record review of Resident #4's Physician Order, dated 05/13/2025, reflected Nystatin Powder . Apply 1 application transdermal two times a day for redness. Record review of Resident #4's Assessment on 06/18/2025, reflected no assessment for self-administration of medications. Observation and interview on 06/18/2025 at 9:13 AM revealed Resident #4 was in her bed, awake. It was noted that there was a container of nasal spray and a small cup with powder on her side table. She said she would do her nasal sprays and would apply the powder on herself. When asked what the powder on the cup was for, the resident said the powder was for her redness on her lower abdomen . Observation and interview on 06/18/2025 at 9:17 AM, revealed LVN F stated he did not notice that there was a nasal spray on Resident #4's side table. He said the powder was for her rashes. He said, since the powder was a treatment, the nurses were supposed to administer the powder. He said there should be no medication in the resident's room because of the danger of adverse reactions such as allergy and overdose. He said he would go the resident's room and would talk to the resident. Observation and interview on 06/18/2025 at 9:21 AM revealed ADON A was holding Resident #4's nasal spray and said she talked with the resident regarding the medication left inside the room. She said there should be an assessment in place that the resident could self-administer her medications as well as a care plan about it. She said she also needed a physician order for the nasal spray. She said no medications should be inside the room because the resident might accidentally consume more than needed and overdose. She said she would check the other rooms if there were medications inside the rooms. She said she would do an in-service about checking if there were medications inside the room and not leaving medications inside the room. Resident #5 Record review of Resident #5's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with allergic rhinitis (an allergic reaction to tiny particles in the air called allergens), rashes, and depression (persistent feeling of sadness or loss of interest). Record review of Resident #5's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had depression. Record review of Resident #5's Comprehensive Care Plan, dated 03/14/2025, reflected the resident used antidepressant medication and one of the interventions was to educate the resident about risks, benefits and the side effects and/or toxic symptoms of medication. The Comprehensive Care Plan did not indicate that the resident could self-medicate. Record review of Resident #5's Physician Order on 06/18/2025 reflected the resident did not have an order for eye drops. Record review of Resident #5' Physician Order, dated 09/26/2024, reflected Cleanse peri area and apply barrier cream and antifungal powder q shift and prn. Record review of Resident #5's Assessment on 06/18/2025, reflected no assessment for self-administration of medications. Observation on 06/18/2025 at 9:22 AM revealed Resident #5 was in her bed, awake. It was noted that there were Systane eyedrops and antifungal powder at her bedside table. In an interview on 06/18/2025 at 9:35 AM, Resident #5 said she had been using the Systane for her dry eyes. She said she did not know if the facility knew about it but it had always been in her bedside table. She said the staff would apply the power on her bottom after the staff clean and change her. In an interview on 06/18/2025 at 12:33 PM, LVN G said she did not notice that Resident #5 had Systane and antifungal powder at her bedside table. She said she would check it as soon as the interview was over. She said it should not be on the resident's bedside table because the resident might accidentally drink it or a confused resident might take it use it differently. In an interview on 06/18/2025 at 1:34 PM, ADON B stated there should be no medications inside the residents' rooms because accidental consumption might cause adverse reactions such as allergic reactions and overdose. She said she would check the rooms if there were any medications that the residents were using to self-medicate. She said she would talk to Resident #5 to see if she needed the eyedrops and get an order for it. She said there should also be an assessment that the resident was capable of doing the eyedrops by herself. In an interview on 06/18/2025 at 1:32 PM, the Administrator stated the expectation was no medications would be inside the residents' rooms to prevent any untoward incidents like overdose and allergic reactions. He said they would re-educate the staff to check the residents' rooms if there were medications inside and if there were, make sure the residents were capable of self-administration. Record review of facility policy, Storage of Medications 2001 Med-Pass, Inc. revised April 2021 revealed : Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care . shall be stored separately from regular medications.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #5) of 1 resident reviewed for Infection Control. The facility failed to ensure CNA D performed hand hygiene and changed her gloves while providing incontinent care to Resident #5 on 06/18/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #5's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diarrhea (loose bowel movement). Record review of Resident #5's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was incontinent for bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 03/14/2025, reflected the resident had an ADL self-care performance deficit and one of the interventions was the resident required assistance for toilet use. Observation on 06/18/2025 at 9:22 AM revealed CNA D and CNA E were about to do incontinent care for Resident #5. Both CNAs washed their hands and put on pairs of gloves. CNA D positioned herself to the left side of the resident while CNA E was on the right side. CNA D unfastened the resident's brief and pushed it between the resident's legs. CNA E cleaned the resident's perineal area (area between the legs). In the process of incontinent care, CNA E ran out of gloves and CNA D said she would get her some from the box of gloves placed on the overhead table of the resident. CNA D removed her gloves and pulled some gloves from the box. CNA D did not sanitize her hand before touching the new gloves. After cleaning the perineal area, both CNAs assisted the resident to her left side and CNA E continued to clean the resident's bottom. After cleaning the resident's bottom, she took off her gloves, sanitized her hands, and put on a new pair of gloves. Both CNAs assisted the resident to roll to her right side and CNA D proceeded to clean the other side of the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief, and she asked CNA E to hand her over the brief that was placed on the resident's overbed table. CNA E took the new brief from the overhead table and handed it to CNA D. CNA D did not change her gloves after cleaning the resident's bottom and before touching the new brief. CNA D put the brief under the resident and fixed it. After fixing the brief, both CNAs took off their gloves and washed their hands. In an interview on 06/18/2025 at 9:35 AM, CNA D stated she should have changed her gloves after cleaning the resident's bottom and before touching the new brief because her gloves were already soiled. She said not changing her gloves could cause transfer of germs from her soiled gloves to the new brief. She said she should sanitize her hands as well before putting on a new pair of gloves. She said she would be mindful to change her gloves after touching something dirty and do hand hygiene. In an interview on 06/18/2025 at 9:40 AM, CNA E stated they were doing good until the gloves were not changed after CNA D did not change her gloves after cleaning the resident's bottom. She said she should have reminded CNA D to change her gloves and sanitize her hands before handing her the new brief. She said touching the new brief with soiled gloves could also cause urinary tract infections. In an interview on 06/18/2025 at 1:34 PM, ADON B stated CNA D and CNA E made her aware of the failure during incontinent care. She said she reminded both CNAs to change their gloves after touching something dirty or presumed dirty to prevent cross contamination and urinary tract infection. She said she also reminded CNA D to do hand hygiene after taking off the gloves. She said the expectation was for the staff to change their gloves when going from dirty to clean and to do hand hygiene in between changing of gloves. She said she would do a one-on-one in-service with both CNAs and then would also do an in-service for all the staff providing direct care. In an interview on 06/18/2025 at 1:32 PM, the Administrator stated not changing the gloves when going from soiled to clean and not sanitizing in between changing of gloves could contribute to cross contamination and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control and hand hygiene. He said they would re-educate the staff about infection control and the importance of hand hygiene. Record review of the facility's policy, Hand-Washing/Hand Hygiene reviewed December 2024 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . j. After contact with blood or bodily fluids . m. After removing gloves . Applying and Removing Gloves . l. Perform hand hygiene before applying non-sterile gloves. Record review of the facility's policy Infection Control Guidelines for All Nursing Procedures reviewed December 2024 revealed Purpose: To provide guidelines for general infection control while caring for residents . 4. Employees must wash their hands . d. After removing gloves . 5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub . b. Before donning sterile gloves . j. After removing gloves.

Based on observations, interview, and record review, the facility failed to ensure resident received adequate supervision to prevent Resident #1's accidents from an elopement for (Resident #1) 1 of 6 residents reviewed for wandering, elopement, accidents, hazards, and supervision. On 01/26/2025, the facility failed to identify potential hazards and follow internal systems in place for Resident #1 to prevent her from exiting thru unlocked doors located in the dining area leading to a corridor land fire exit door which connected to a stairwell where she experienced an unwitnessed fall down the stairs and sustained multiple serious injuries that included right wrist and extensive facial fractures. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/10/2025 at 3:30 PM. The noncompliance began on 01/26/2025 and ended on 02/02/2025. The facility corrected the noncompliance before the investigation began. This failure could place residents at the facility at risk of injury and a decreased quality of life, significant harm, or death. Findings Included: Review of Resident #1's Face Sheet dated 03/10/2025 revealed she was an [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included dementia, major depressive disorder, osteoporosis (loss of bone density causing brittle bones,) repeated falls, and cognitive communication deficit. Review of Resident #1's Admission MDS dated [DATE] revealed she required corrective lenses and was severely cognitively impaired with BIMS score of 04. She required a walker and/or wheelchair for mobility and required supervision for toilet, tub, and/or shower transfers. Resident #1's MDS revealed no documentation of acute change in mental status and she had no behavioral symptoms of hallucinations, delusions, or physical or verbally aggressive behavior directed towards others. Review of Resident #1's Comprehensive Care Plan dated 01/31/2025 revealed she was at risk for falls related to a history of falling and at risk for wandering and elopement. Interventions for falls included: -Anticipate needs -Ensure call light was within reach and to encourage Resident #1 to use for assistance -Educate resident, family, caregivers about safety reminders -Encourage Resident #1 to participate in activities that promote exercise, physical activity -Ensure Resident #1 has appropriate footwear -Follow safety protocol -Therapy evaluate and treat as ordered and as needed Interventions for wandering and elopement included: -Clearly identify Resident #1's room and bathroom -Engage resident in purposeful activity -Schedule time for regular walks and appropriate activity Review of facility Provider Investigation Report date 02/07/2025, submitted by facility DON revealed: [Resdient #1] is a [AGE] year old female who admitted to the [Facility] on 1/6/25 . Resident diagnosis history include dementia, dysphagia, other abnormalities of [NAME] and mobility, repeated falls, [multiple organ dysfunction,] osteoporosis and recent fall in December 2024 with [right] clavicle fracture and 2 [right] rib fractures. Resident is alert and oriented [to person and herslef,] able to voice needs and follow direction. [BIMS] score 3. At baseline; resident uses rolling walker to ambulate and walk around the hallways of the facility several times throughout the day . [Resident #1] was resting in bed most of the day watching tv. She ate her meals and the staff assisted her with toileting. At approximately 2:30pm, resident was seen ambulating around the hallways like she is usually and was smiling and talking with the other residents. She would be sitting in her room on the bed and then ambulate to the dining room and sit at a table looking out the window. Staff noted resident had a runny nose after dinner time and completed covid test with the res [result] of negative. No other signs or symptoms noted. Vital signs stable. Resident stated she felt fine and no issues. Resident walked to room from dining room several times after dinner and was checked on frequently by staff and all needs met. At approximately 6:50, [CNA a] went through the foyer area to the breakroom to use the restroom. At 6:55, [CNA A] heard emergency alarm ringing. She quickly completed her task and rushed to the alarm that was still sounding and resident observed laying on the floor of hallway. Alerted nurse [LVN Z] and other staff immediately who administered first aid. Review of Resident #1's Hospital Clinical Records after the incident on 01/26/2025, dated 01/30/2025, revealed she had a fall down 3 steps and her injuries included: -Right non-displaced distal radius fracture (wrist area) -Extensive bilateral facial fractures (fracture of the bones of the face on both sides) -Nasal bone and septum fractures (partition between the left and right nostril area) -[NAME] II fractures bilaterally (area to the top of the nose, extending down to above the lip area) -Bilaterial orbital floor and rim fractures (eye area) -Bilaterial maxillary sinus fractures (area between the nose, cheek, and upper jaw area) -Right pterygoid plate fracture (connects the lower jaw to cheekbone) -Lower lip laceration -Columella laceration (bottom, underside of the tip of nose) Attempts were made to interview Resident #1 on 03/06/2025 at 11:20 AM, 03/07/2025 at 8:45 AM, and 03/10/2025 at 8:55 AM were not successful due to her cognitive status. In observation of Resident #1 on 03/06/2025 at 11:20 AM, 03/06/2025 at 12:45 PM, 03/06/2025 at 1:35 PM, 03/07/2025 at 8:45 AM, and 03/10/2025 at 8:55 AM she was observed at the nurses station, the dining room, or the hallway under direct supervision with staff. In interview with CNA A on 03/06/2025 at 1:43 PM, she stated she worked the day of the incident [01/26/2025] and stated shortly after dinner time that evening, she went to the bathroom in the employee break room. She stated the employee breakroom and bathroom was located through a door near the dining room. This corridor had surplus supplies and led to the emergency fire exit door. She stated the day of the incident, while she was in the employee break room bathroom located near the emergency fire door, she heard the emergency exit fire door alarm followed by a scream. She stated she then rushed to the back [emergency fire exit] door [to the] stairs and found Resident #1 at the bottom of the stairwell on the floor. She stated she quickly alerted the nurses at the facility to the incident, and Resident #1 was quickly assessed, provided first aid, and sent out to the hospital for further treatment. She stated she was aware of Resident #1's care needs that included frequent monitoring, re-direction, and fall precautions. In review of facility's Provider Investigation Report, dated 02/07/2025, LVN Z provided a statement that stated he was the charge nurse at the time of the incident and was responsible for Resident #1's care. He stated the day of the incident, Resident #1 was at her baseline and had no unusual or new behaviors. He stated he saw Resident #1 sitting at a table around 6:30 PM in the dining room speaking to another resident. LVN Z stated that approximately 4 minutes later CNA A ran up to me stating [Resident #1] was on the floor. He stated Resident #1 was quickly assessed, provided first aid, and sent out to the hospital for further treatment. He further stated Resident #1 was sent out within 5 minutes of the incident. Attempts were made to interview LVN Z on 03/06/2025 at 1:00 PM and 03/10/2025 at 4:30 PM were not successful due to staff taking personal leave. In review with the facility's ADON C on 03/06/2025 at 1:22 PM, she stated she was familiar with Resident #1 and her care needs that included frequent monitoring, re-direction, and fall precautions. She stated she took care of Resident #1 a couple days before her incident and she was at her baseline, which was pleasantly confused. She stated staff kept her close to the nurse's station for close monitoring because of her fall history and wandering risk. She stated the incident on 01/26/2025 was right after dinner service and CNA A found her within minutes of when the incident occurred. She stated Resident #1 was sent promptly out to the hospital and returned a few days later. She stated when Resident #1 came back from her hospital stay, her room was moved closer to the nurse's station, her care plan updated to engage Resident #1 in activities and have even more monitoring to ensure her safety. She stated Resident #1's condition was bruised up upon her return to the facility and that she had and order for a brace for a wrist fracture. She stated leadership conducted multiple in-services, an elopement drill, and a keypad lock was installed on the initial door Resident #1 exited out from. She stated Resident #1 has not had any further incidents or accidents since her return and her safety has been intact. In interview with facility's DON on 03/07/2025 at 2:32 PM, she stated that Resident #1's care needs that included frequent monitoring, re-direction, and fall precautions. She stated these care needs were appropriately assessed and accounted for on Resident #1's assessments and comprehensive care plan. She stated facility staff were aware of Resident #1's care requirements and made their best attempts to accommodate the resident's needs without violating her resident rights. She stated the facility did everything she could to protect the resident and adhered to the [Centers for Medicare and Medicaid] critical pathway while planning Resident #1's care at the facility. She stated prior to the incident, residents had never attempted to go through the door located near the dining area and did not need to be secured. She stated an incident of this nature had never occurred at the facility to her knowledge. She stated after the incident, a multi-digit keypad lock was installed on the initial door Resident #1 exited out from to ensure no other residents were able to access this area in the future. DON further stated in response to the incident, that multiple in-services were provided to staff related to abuse, neglect, exploitation, physical environment and door alarms, wandering/elopement, and location of and the purpose of the facility's elopement binder. To conclude the in-service and training, a facility-wide elopement drill was conducted on 02/02/2025 to ensure all of the interventions the facility were practices and able to be implemented post incident to ensure Resident #1 and the other residents at the facility would be safe in their care. She stated again this incident was unforeseeable, but the facility took swift and comprehensive action afterwards to ensure resident safety moving forward. In interview with facility's Administrator on 03/10/2025 at 11:45 AM, he stated he was familiar and accommodating of Resident #1's care needs that included frequent monitoring, re-direction, and fall precautions. He stated the facility did their best to assess and accommodate Resident #1's needs but this incident was unforeseeable. He stated he worked very diligently to find appropriate interventions to manage Resident #1's behaviors. The day of the incident the DON called him to notify him of the incident. He stated the physical environment and doors were checked that night to ensure proper functionality. He stated the next day, a keypad lock was installed on the initial door Resident #1 exited though. He stated multiple in-services related to abuse, neglect, exploitation, physical environment and door alarms, wandering/elopement, and location of and the purpose of the facility's elopement binder were provided to staff; and a facility-wide elopement drill was conducted on 02/02/2025 to conclude all of the interventions the facility implemented post incident. Interviews conducted with Administrator, DON, ADON A, ADON B, CNA C, CNA F, PTA D, LVN E, LVN G, LVN H on 03/06/2025, 03/07/2025, and 03/10/2025 between 9:00 AM - 5:00 PM, revealed no evidence that Resident #1 displayed behaviors outside of her baseline. Review of facility in-service and elopement drill, Preparation for Mock Elopement Drill, dated 02/02/2024 included objectives that included preparation for a mock elopement drill, elopement drill, expected response, and a detailed multi-step elopement procedure check list evaluated by the facility's DON. Approximately 25 staff signatures were observed on the attendance record. Review of facility's Elopement Binder on 03/10/2025 at 2:25 PM revealed Resident #1 was included with a clear picture, face sheet, and other pertinent demographic information. In observation of the facility's doors on 03/06/2025 at 1:22 PM, a keypad lock was present on the first door located within the facility dining room area. The next door beyond, where the emergency fire door exit was located, was observed and tested to ensure functionality. In interview with Administrator, DON, ADON A, ADON B, CNA C, CNA F, PTA D, LVN E, LVN G, LVN H on 03/06/2025, 03/07/2025, and 03/10/2025 between 9:00 AM - 5:00 PM, they stated Resident #1's required frequent monitoring, re-direction, and fall precautions. Her interventions included relocating Resident #1's room closer to the nurses station, proper footwear for Resident #1, promoting physically focused activities and other enrichment activities, along with enhanced monitoring to ensure Resident #1's safety . They stated an elopement drill was conducted on 02/02/2025 with education provided on abuse, neglect, and exploitation. Additionally, Resident #1 had no incidents, accidents, or falls since the incident on 01/26/2025. In review of facility's Provider Investigation Report, dated 02/07/2025, provider actions taken post-incident included: abuse/neglect, in-service completed safe surveys completed with no adverse findings; elopement risk assessment updated; all doors checked by maintenance supervisor on 1/27/25 with no adverse findings elopement drill completed on 2/3/25 and to be completed quarterly or as needed. All findings to be reviewed in monthly QAPI meeting and review of any adverse findings Review of facility policy, Falls - Clinical Protocol, rev. 12/2024 revealed: Cause identification . for an individual who has fallen, staff will attempt to define possible causes . Treatment/Management . Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . Monitoring and Follow-up . the staff and physician will monitor and document the individual's response to interventions intended to reduce falling and the consequences of falling . If interventions have been successful in preventing falling, the staff will continue with current approaches . A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/10/2025 at 3:30 PM. The noncompliance began on 01/26/2025 and ended on 02/02/2025. The facility corrected the noncompliance before the investigation began.

Based on interviews and record reviews the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of twenty-two residents reviewed for falls. The facility failed to ensure the OT was trained to provide adequate assistance to prevent accidents for Resident #1 who was a two person assist with ADL care. As a result, the resident fell during an attempted transfer and was later taken to the hospital and found to have a tibial fracture. This failure could place the residents at risk for injury. Findings included: Review of Resident #1's face sheet dated 04/03/23 reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Hemiplegia (paralysis on one side of the body), Muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Osteopenia of the bones (a condition that begins as you lose bone mass and your bones get weaker), Pain, Hyperlipidemia (an excess of lipids or fats in your blood), and Lack of Coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Review of Resident #1's MDS Assessment, dated 03/24/23, reflected a BIMS (Brief Interview for Mental Status) score of 13. Review of Resident #1's functional status of extensive one-person assist for bed mobility, locomotion on/off unit, toilet use, and personal hygiene. The resident also required total dependence with two-person assist for transfers and dressing. Also, total dependence with one-person assist for walk in corridor and bathing. Walk in room occurred once or twice with one-person assist. Review of Resident #1's Care Plan, last updated 11/27/22, reflected the resident's ADL needs, including transfers, were not addressed. Review of Resident #1's Care Plan, dated 09/23/23, last updated 04/03/23, reflected the following: Focus Goal Interventions Position Freq/Resolved o I have had an actual fall with major injury Poor Balance, Unsteady gait fall with fracture 3/27 Date Initiated: 03/27/2023 Revision on: 04/03/2023 o My right tibia (the shinbone, the larger of the two bones in the lower leg) will resolve without complication by review date. I have a follow up appointment with orthopedic MD on 4/3/2023. Date Initiated: 04/03/2023 Revision on: 04/03/2023 Target Date: 02/23/2023 o All transfers will be completed with mechanical lift and 2 staff members. Date Initiated: 03/27/2023 o I am NWB to right leg secondary to fracture tibia for 6-8 weeks per Texas Joint Institute. Date Initiated: 04/04/2023 Revision on: 04/05/2023 o Knee brace discontinued per TJI while at rest. Brace to be worn during transfers and when out of facility for the next month. Date Initiated: 04/04/2023 Revision on: 04/05/2023 o Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 04/03/2023 o Resident preference to have brace placed on by nurse when incontinent care provided. Date Initiated: 04/04/2023 Review of Resident #1's Physician's Order, dated 03/20/23, reflected Description: OT initial eval completed and POC established. OT clarification for 5x/wk for treatment to include treatments for therex, theract (systematic and planned performance of body movements or exercises which aim to improve and restore function), neuro re-ed (neuromuscular [relating to nerves and muscles] re-education), self care. Order Type: Therapy Orders Review of the Physical Therapy PT Evaluation & Plan of Treatment, Certification Period: 03/20/23-01/14/23 reflected, Initial Assessment, Current Referral: Reason for referral: Patient exhibits new onset of decrease in strength, decreased need for assistance from others, reduced functional activity tolerance, decrease in transfers and decrease in functional mobility indicating the need for PT to increase functional activity tolerance, increase LE ROM and strength and facilitate (I) with all functional mobility. Prior Level of Function: Transfers = CGA Short-Term Goal - Patient will safely perform functional transfers with Mod (A) for safety awareness with reduced risk for falls in order to decrease level of assistance from caregivers. (Target: 04/09/23) Prior Level of Function Baseline (prior to onset) (03/20/23) Transfers - CGA Total Dependence w/o attempts to initiate Long-Term Goal - Patient will safely perform functional transfers with Min (A) for safety awareness with reduced risk for falls in order to decrease level of assistance from caregivers. (Target: 04/14/23) Prior Level of Function Baseline (prior to onset) (03/20/23) Transfers - CGA Total Dependence w/o attempts to initiate Assessment Summary: Clinical Impressions: Pt is a 67 yo female with CVA and Rt hemiplegia referred to PT with muscle weakness, lack of coordination, balance deficits in standing resulting in increased burden of care and decreased functional mobility. Reason for Skilled Services: Patient requires skilled PT services to increase LE ROM and strength, increase functional activity tolerance and assess functional abilities in order to enhance patient's quality of life by improving ability to decrease level of assistance from caregivers and safely maneuver in/out of bed. Risk Factor: Due to the documented physical impairments and associated functional deficits, the patient is at risk for increased dependency upon caregivers, further decline in function and decreased skin integrity. Skilled Intervention Focus: Restoration Review of the Concern Log for March 2023, reflected Resident #1 filed a concern on 03/27/23, stating she was dropped during therapy. The DON was assigned to the concern on 03/27/23. The Resolution reflected the DON made self report to HHSC, in-serviced staff, and therapy. Review of an incident/accident report for Resident #1, dated 04/11/23, reflected under Fall Incidents Resident #1 had a fall on 03/27/23 at 11:40 AM. This report was completed by the DON. Review of Resident #1's Risk Management, Incident #1009 notes, reflected the following: Date of Incident: 3/27/23 11:40 therapist came to this nurse and states that the resident was on the floor. therapist states that the resident was assisted to the floor due to her knees buckling. this nurse immediately went to assess the resident. Resident observed laying on the floor in the supine position (the patient is face up with their head resting on a pad positioner or pillow and their neck in a neutral position) with pillow underneath head. resident exhibits no signs of distress. upon assessment no injuries noted and the resident is at her baseline for movement in upper and lower extremities. Resident states that her knees buckled while being transferred. assessment complete Review of Resident #1's hospital MRI results, dated 03/28/23, reflected Exam: MRI of the right knee without IV contrast Clinical history: Right knee pain status post fall Comparison: None available IMPRESSION: 1. Evidence of an acute nondisplaced lateral tibial plateau fracture. Review of the facility's in-service documentation, following Resident #1's fall, reflected the following in-services were conducted: All Staff in-service - Use Gait Belt for All Transfers-No Lifting, dated 03/27/23; Post Fall Huddle Form, 03/27/23; Residents Requiring Mechanical lift Require Two People for All Transfers, dated 03/29/23; Abuse and Neglect, 03/29/23 Review of Resident #1's Nursing Order from the Orthopedic Specialist, dated 04/03/23, reflected She (Resident #1) is clear for ROM as tolerated of her right knee, but NWB on the RLE for the next 6-8 weeks. Patient should continue PT for ROM of her knee, out of the knee brace, to prevent stiffness. I recommend she discontinue knee brace/immobilizer while at rest to prevent skin breakdown. She can wear it during transfers and when out of her facility for the next month. However, if she is more comfortable in the brace when at rest she can wear it at rest as well for the next month, as long as her skin does not breakdown. In an interview on 04/11/23 at 10:15 AM with the DON revealed the resident reported the aide dropped her on 03/27/23. She stated x-rays were ordered and completed. The x-rays did not show a fracture, however, the resident was sent to the hospital on 03/28/23,and an MRI was conducted. She stated the MRI showed a fracture. She stated because of the injury and how the resident described the incident, she wrote up an action plan on the aide. She stated she initiated an in-service on Abuse and Neglect. She stated she also talked to them to ensure everyone was on the same page with the proper way to transfer residents. She stated she stressed that everyone is expected to utilize gait belts, lifts, and proper techniques with every resident and at all times. She also noted, the resident is very particular of how she wants things done and she will let her wishes be known. She stated she will also let them know when she is not pleased with something. She stated the resident has her cell number, as well as the Charge Nurse's numbers and the Administrator's number. She stated she calls them at any given time, no matter the time of day or night, when she is not pleased. In an interview on 04/11/23 at 12:19 PM with the OT revealed she stated at the time of the incident on 03/27/23, she was moderate assistance. She stated prior to the incident, the resident was a one-person transfer with the therapy team. She stated with nursing, the staff used a mechanical lift. She stated the resident stated she was tired, so the therapy session was not a strenuous one. She stated, after the session, they took the resident back to her room and let her sit in her wheelchair for about two hours sat her in the chair in her room. She stated the resident was to sit in the chair for a while, because it was a new chair and she needed to get used to the chair and they were trying to help her build up her tolerance for sitting up in the chair. She stated at around 11:30 AM, she returned to the resident's room to check on her. She stated at that time, she realized the sling was not under her for the nursing staff to get her back in the bed. She stated by the time the resident was pretty fatigued from sitting up and wanted to get back into bed. She stated the resident was insistent on getting back in bed. She stated at that point, she was trying to appease the resident and give her what she wanted, which was to get back in bed. She stated its easier to already have the sling in the chair, prior to her sitting in it. She stated because the resident was a one-person transfer with therapy staff and she had just transferred her by herself, the week prior, with no issues, she didn't feel it would be a problem to transfer her this time. She stated she angled the resident towards her left side so she could transfer her from the left side. She stated before she stood the resident up, she made sure the residents feet were a shoulder width apart, which is the proper position for standing. She stated she believes when she was turning the resident, that's when the right foot slide behind her. She stated typically, the resident's right foot would stay in place and the resident would be able to slide the right foot around with her as she turned. But this time, he slide behind her. She stated that's when she couldn't help the resident and the resident couldn't help her to ensure she could move her safely to the bed. She stated at that point, she told the resident she was going to help her to the ground, because there was no way out of the situation. She stated she was holding the resident from behind and the resident sat down gently, bottom first and then she laid the resident down and put a pillow under her head. She stated the resident's feet were toward the head of the bed. She stated the resident's' legs were bent a little bit because a nightstand was in the way. She stated once she got the resident to lay down, she then pushed the nightstand out of the way, so her legs could stretch out. She stated she had worked with the resident for months and never had an issue. She stated she was aware that for nursing, she had to have two people to transfer and that they used a sling and a mechanical lift, however, she was not aware that they, as therapist had to use two people to do it because they always did it with one person. She stated the reason she and the PT assistant transferred the resident that morning is because they happened to meet up at the resident's room at the same time. So they just did it together. She stated the resident has been comfortable with therapy transferring her without the mechanical lift and doing it with one person, however, she has never been comfortable with nursing staff transferring her and has always insisted they do it with the mechanical lift. She stated it has been this way for months. She stated this incident has taught her that it is important for things to be the same across the board, so the residents receive the same level and manner of care from all departments. She stated if that is not followed, it could result in injury to the resident. In an interview on 04/11/23 at 12:32 PM with Resident #1 revealed she stated last month (March 2023), the OT came to her room to check on her and she told her she was tired and wanted to get back in bed. She stated the OT helped her up and as she was trying to turn toward the bed, the OT dropped her. She stated she was facing the head of the bed and she stated when she landed on the floor, her feet legs were bent to where her knees were up. She stated her legs could not straighten out because the nightstand was in the way. She stated her knees had not been bent that much in a very long time and she stated she feels that something must have popped because she was in pain. She stated the OT moved the nightstand out of the way so her legs could stretch out, however, the damage had been done by that point. She stated the OT went and got Nurse A and an aide. She stated they checked her out and helped her into bed. She stated she knew something was wrong because her knee was hurting. She stated she did not understand why they didn't send her to the hospital when it happened. She stated she kept telling them she was in pain and they gave her pain meds and later that evening, they had X-rays done. She stated they didn't send her to the hospital until after she talked to the Nurse Practitioner. She stated she felt like the fall could have been prevented if the OT had used the belt, like the aides do. In an interview on 04/11/23 at 1:31 PM with the DOR, revealed she stated how they handle residents is usually a case-by-case situation. She stated the Resident #1 had been minimum to moderate assist since she returned from the hospital. She stated when the resident was receiving therapy prior to her hospital stay, they had gotten her strong enough to be contact guard (ready-to-respond supervision) for transfers. She stated normally, they train nursing staff to transfer in the same manner as how therapy does it, so they could maintain continuity with the residents' progress. She stated Resident #1 would not allow it because she was very adamant about nursing staff using the Mechanical lift. Resident #1 stated she was more comfortable for nursing staff to use the lift and she was more comfortable with the therapist transferring her the way they had been. She stated nursing department consults with therapy to determine best method for transfers and mobility for MDS and Care Plans. She stated the rehab department goes off of the assessment of the evaluating therapist, to determine how they work with the resident, and they adjust based on the progress of the resident. She stated they have done things case-by-case for each resident, and it sometimes differs from nursing determinations and there has never been an issue or injury until this resident. She stated based on what happened with this resident on 03/27/23, she acknowledges that going different routes could result in harm to the resident. She stated going forward, they will reevaluate and work with nursing to be more cohesive. In an interview on 04/11/23 at 2:40 PM with Nurse A, revealed she stated she was still learning the nursing processes of the facility. She stated usually nursing staff referred to the therapy's determination when determining the functionality of the residents. She stated if residents come from the hospital, nursing staff go with the notes from the hospital. She stated she was not sure who determined how Resident #1 was to be transferred. She stated the resident had not transferred with her. She stated ever since she had worked at the facility, the resident had always been in bed when she checked on her. She stated if the resident had needed to be transferred, she would refer to the resident's Care Plan and MDS to see what method she required. She stated if therapy and nursing are not on the same page with how a resident is to be transferred, falls and/or injuries could happen, some injuries may even be major. She stated the most recent in-service on transfers on 03/29/23, included topics of gait belt use, mechanical lifts, one or two-person assist, the proper way to transfer and the importance of following what's in the system for each resident. In an interview on 04/12/23 at 2:56 PM with the DON she stated the therapy department works with the residents according to their abilities and the goal is to improve their ability to function. She stated the nursing staff refer to the system to see what level of care each resident needs, and they act accordingly. She stated with Resident Resident #1, its not always that simple because she insists on them doing what she feels comfortable with. She stated, on 03/27/23, the OT told them she assisted the resident to the floor and went to get assistance, which is what she should have done. She stated the resident was comfortable with therapy transferring her the way they had been doing and if the resident's wishes were being followed, which is what they are supposed to do .as in honoring the resident's right to choose. She stated she did not understand how they could be at fault for following the resident's choice. She stated once she was notified of the incident, she took all of the appropriate steps to ensure it doesn't happen again. She stated the system said the resident required two-person assist, however, the resident did not require the therapist to follow that and she was comfortable with it, and there had never been any problems with it prior to this incident. She stated the risk of not following what is in the system, would be that the resident could fall, could be injured. However, they have been written up for not honoring resident's rights, so they were keeping that in mind and trying to honor her rights and wishes. In an interview on 04/11/23 at 3:14 PM with the Administrator, revealed he stated he interviewed Resident #1 on 03/27/23, and she told him that as the therapist was helping her to transfer, her knee buckled and that's how she lost balance, and the therapist told her she was going to help her to the ground. He stated the resident did not say she was in pain after being asked by several people. He stated she was talking to her family member, later that day and she told her family member what had happened. He stated after her conversation with her family member, she then started complaining of pain. He stated that's when they contacted the physician again and the physician ordered an X-ray. He stated the next day, Resident #1 was still complaining of pain and she expressed pain to the NP, who told them to send her to the hospital. He stated the staff were trying to do whatever they could to accommodate the resident. He stated therapy had been working to get the resident comfortable with ther new customized wheelchair, so she can get to the point of getting up and getting out of bed and out of her room and start socializing more and being more active. He stated therapy was transferring her in a way that enabled her to be used to getting in the wheelchair. He stated he believed both departments were doing it the right way, because it was the way the resident wanted, and it was working both ways. He stated they have in-serviced all staff, including the rehab department. He stated everyone had been working with the residents, with whatever method the residents were comfortable with. He stated they had to honor the residents' right to choose, while still working to help improve the quality of life and functionality of the resident. He would not say that there was a risk in everyone not using the same method of transferring the resident. He stated they had changed the way they operate, since the incident because, even in therapy, they had to begin to use the mechanical lift and two-person assist for all transfers. Review of the facility's gait belt policy, revision date 12/2022, and titled Use of Gait Belt Policy reflected: 3. It will be the responsibility of each employee to ensure they have it (gait belt) available for use at all times when at work. 5. Failure to use gait belt properly could result in harm to employee and resident and may result in termination.

Based on observation, interview, and record review the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four (Residents #1, 11, #31, and #34) of ten residents reviewed for pressure ulcers. The facility failed to ensure nursing staff provided pressure ulcer treatment as ordered by the physician; monitor nursing staff to ensure proper identification, assessment, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures led to deterioration in pressure ulcers on Residents #1, 34, #11, and #31 and placed them at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and hospitalization . An Immediate Jeopardy (IJ) was identified on 10/13/21 at 1PM. While the IJ was removed on 10/16/21, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectives of their Plan of Removal. Findings included: Record review of Resident #1's MDS assessment, dated 06/28/21, reflected she was an [AGE] year-old woman admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her functional abilities were listed as extensive one-person assistance with toilet use, bed mobility, and had total dependence requiring 1-person assistance with transfers. A BIMS score was not completed and Resident #1 cognitive skills were coded as Severely impaired- never/rarely made decisions. Rejection of care was code as 0 . Behavior not exhibited. Record review of Resident #1's comprehensive care plans reflected the following plans and interventions: . pressure ulcer development [related to] immobility [as evidence by] stage 4 sacral wound . Date initiated 08/06/2020 . Revision on: 06/03/2021 . Administer medications as ordered . Administer treatments as ordered . Apply [low air loss] mattress . Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Turn and position [every 2 hours] and prn .bladder incontinence [related to] loss of peritoneal tone . use disposable briefs. Change [every 2 hours and as needed] Review of Resident #1's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Place one wedge above and below wound to offload pressure off. Turn every 4 [hours] if possible . Start date: 03/24/2021 .Sacral wound care: Cleanse with [normal saline], pat dry, apply collagen matrix, cut [MEDICATION(S)] blue to size, moisten with [normal saline], wring out excess [normal saline], cover with foam and then cover with Tegraderm. Every 12 hours as needed for wound care . Start date: 09/09/2021 . Sacral wound care: Cleanse with [normal saline], pat dry, apply collagen matrix, cut [MEDICATION(S)] blue to size, moisten with [normal saline], wring out excess [normal saline], cover with foam and then cover with Tegraderm. Every day shift for wound . Start date: 09/10/2021 Review of Resident #1's Wound Physician M's assessments reflected the following: 1. 09/28/21: Wound #1 .Site . Sacrum . Type . Pressure ulcer . Length . 1.3cm . Width . 0.5cm .Depth . 0.4cm . Stage 4 . Wound Progress Improved . Stage 4 sacral ulcer: [improved] finally. No dressing in place still . Deconditioning: Frequent turning, [low airloss] mattress, high protein diet 2. 10/05/21: Wound #1 .Site . Sacrum . Type . Pressure ulcer . Length . 1.1cm . Width . 0.8cm .Depth . 0.4cm . Stage 4 . Undermining 0.7cm . Wound Progress Stable . Stage 4 sacral ulcer: plateaued again likely due to no dressing. No dressing in place still. **I think wound is worsening as it is constantly saturated with urine without a dressing on** Will encourage nursing to keep the wound dressed with waterproof dressing. Hopefully will improve with keeping it clean and dry. Deconditioning: Frequent turning, [low airloss] mattress, high protein 3. 10/12/21: Wound #1 .Site . Sacrum . Type . Pressure ulcer . Length . 1.3cm . Width . 0.8cm .Depth . 1cm . Stage 4 . Undermining 0.5cm . Wound Progress Declined . Stage 4 sacral ulcer: plateaued again likely due to no dressing. No dressing in place still. **I think wound is worsening as it is constantly saturated with urine without a dressing on** Deconditioning: Frequent turning, [low airloss] mattress, high protein diet Review of Resident #1's progress notes from 08/01/21 through 10/16/21 reflected the following: 1.9/17/2021 12:45 [PM] COMS - Skin Only Evaluation Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: sacrum Pressure Ulcer / Injury Stage: Stage IV - Full thickness tissue loss.Wound Bed: Granulation. Wound Exudate: None. Peri Wound Condition: WNL.Dressing Saturation: None. No wound odor. No tunneling. No undermining.Skin warm and dry to touch. No new skin issues noted . 2.9/17/2021 12:49 [PM] COMS (R) Braden Evaluation . Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Mobility: Very limited. Nutrition: Adequate. Friction & Shear: Potential problem. Result: At Risk Score: 16.0 . 3.9/24/2021 [8:26 AM] COMS (R) Braden Evaluation . Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Mobility: Very limited. Nutrition: Adequate. Friction & Shear: Potential problem. Result: At Risk Score: 16.0 4.9/24/2021 [8:27 AM] COMS - Skin Only Evaluation Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: sacrum Pressure Ulcer / Injury Stage: Stage IV - Full thickness tissue loss.Wound Bed: Granulation. Wound Exudate: None. Peri Wound Condition: NL.Dressing Saturation: None. No wound odor. No tunneling. No undermining . 5.10/8/2021 [8:26 AM] COMS (R) Braden Evaluation .Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Mobility: Very limited. Nutrition: Adequate. Friction & Shear: Potential problem. Result: At Risk Score: 16.0 Clinical Suggestions: Draw sheet utilized. Wheelchair cushion utilized. Turned and repositioned at least q.2 hours while in bed . 6.10/8/2021 [8:27 AM] COMS - Skin Only Evaluation . Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time. No Issues At This Time . 7.10/13/2021 [2:18 AM] . COMS - Skin Only Evaluation Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: sacrum No wound odor. No tunneling. No undermining. Tissue: Warm. No new wound noted. Clinical Suggestions: Resident advised to frequently shift weight and raise buttocks while sitting in chair. Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Resident is turned, ambulated, moved at least every 2 hours. PRN medication administered and effectiveness evaluated . 8.10/13/2021 [2:41 PM] Administrator Note . Communicated IJ to Dr . 9.10/13/2021 [5:34 PM] Nurse's Note . Resident has a PU to sacrum area. Wound has no drainage, no odor no maceration. Site cleaned with NS, treated with collagen [MEDICATION(S)] blue foam dressing covered with Tegederm. Resident verbalized no pain at this time. Head to toe skin assessment done. [No other] wound noted at this time. Resident stated she does not like to wear sock before she put on her shoes. This nurse educated resident risk of PU if shoes gets stock on skin. Resident said ok. Daughter notified of resident's wound condition inconsistent wound care and the wound dr's suspicion. Daughter appreciated the phone call. NP notified of the wound getting worse. No new order at this time . 10. 10/14/2021 10:03 [AM] physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She underwent debridement of sacral decubitus on 11/6 presumably by [Wound Care Physician M] Wound culture grew moderate E.coli . concerns wound worsening by Wound care team. We are consulted for ID management . 11.10/15/2021 [7:40 PM] COMS (R) Braden Evaluation . Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Mobility: Completely immobile. Nutrition: Adequate. Friction & Shear: Potential problem. Result: Moderate Risk Score: 14.0 . Review of Resident #1's Treatment Administration Records (TARs) for October 2021 reflected Resident #1's sacral wound care was not signed as completed on the following dates: 10/06/21, 10/07/21, 10/08/21, 10/11/21, and 10/13/21. An observation and interview on 10/12/21 at 10:15 AM revealed MDS Nurse B donned PPE including face shield, gloves, and gown and entered Resident #1's room. Resident #1 was lying in bed on her back with her head of bed elevated. There were no assistive devices (pillows or wedges) used to offload pressure to the resident's sacral wound. There was a wedge on the resident's nightstand and one on the floor. MDS Nurse B told Resident #1 she would be completing her wound care and laid the resident's bed flat. MDS Nurse B opened the resident's brief and had Resident #1 turn onto her right side. Resident #1's brief was visibly saturated with a yellow tinged liquid and there was red blood on the brief in the section where Resident #1's buttocks were. Resident #1 had a circular open wound to her sacral area that was approximately 2cm in diameter and 1cm deep. There was no dressing in place. MDS Nurse B completed wound care by cleaning the wound with saline and gauze. She then applied a powder into the wound bed and inserted a blue foam into the wound bed. MDS Nurse B then covered the wound with a transparent dressing. During wound care Resident #1 said Ouch. MDS Nurse B asked the resident if she was in pain, and Resident #1 responded yes. MDS Nurse B stated she would be gentler and continued with the wound care. MDS Nurse B stated there was not a dressing in place before she completed wound care because the wound care physician had done rounds earlier that morning and had removed the dressing. MDS Nurse B also stated she was unaware if the facility had a wound care nurse but was asked to go on rounds with the wound care physician that day by the DON. MDS Nurse B said when she arrived to go on rounds with the wound care doctor, the doctor had already seen some of the residents and the doctor refused to wait to complete her rounds until the MDS Nurse B was ready to provide the wound care to the residents. She stated she would be completing wound care for all residents, and that day was her first day providing direct nursing care to the residents. After completing wound care, MDS Nurse B completed incontinent care and repositioned the resident onto her back with the head of bed elevated approximately 45 degrees. MDS Nurse B did not use any devices to offload pressure from Resident #1's sacral wound area. In an observation and interview on 10/13/21 at 7:49 AM revealed CNA G was in Resident #1's room and was about to perform incontinent care. CNA G removed Resident #1's brief and turned her onto her right side. The brief was noted to be saturated with a yellow tinged liquid and there was no dressing on place to Resident #1's sacral wound. After completing incontinent care, CNA G closed the resident's brief, and dressed Resident #1. CNA G then transferred Resident #1 into her wheelchair and a therapy staff arrived to work with Resident #1. CNA G stated Resident #1 did not have a wound. CNA G stated she knew who had wounds because she observed the residents' skin during incontinent care and during showers. She stated she was not aware if there as any documentation on which residents had wounds. She stated that all residents, including those with wounds, should be turned and repositioned every two hours. CNA G stated she was aware Resident #1 had the wedges in her room. She stated the purpose for the wedges was to place them under Resident #1's feet because she laid in bed all night long. CNA G said if she noted any redness or skin issues, she would notify the nurse. She stated if a nurse was not notified of a wound or skin alteration, this could lead to a worsening wound. CNA G stated she did not receive any education on specific wound care interventions for any of the residents she worked with. In an interview on 10/13/21 at 8:05 AM RN E stated she was helping with treatments today, and she would be completing residents' wound care. She stated she was not notified Resident #1 did not have a dressing in place to her sacral wound. RN E stated wound care was performed at the intervals ordered by the physician. She stated it should also be completed as needed if a dressing became soiled or dislodged. She stated she expected CNAs to notify a nurse if a resident's dressing became soiled or dislodged. She stated she had not provided any training to the CNAs on which residents had wounds. RN E stated if a dressing became soiled or dislodged and was not replaced, this could lead to wounds worsening or infections. In a telephone interview on 10/13/21 at 8:17 AM, Wound Physician M stated she had seen Resident #1 on 10/12/21. She stated Resident's #1's sacral wound was bleeding because she had debrided the wound (removal of damaged tissue or foreign objects from a wound). Wound Physician M stated she did not remove a sacral wound dressing from Resident #1; she did not have a dressing in place. Wound Physician M also said Resident #1 did not have a sacral wound dressing in place for about the past 6 weeks. Wound Physician M said Resident #1's wound was probably getting deeper because there has been no dressing. Wedge is never in place when I look at her and that is also contributing to her wound getting worse. Wound Physician M stated the decline in Resident #1's wound was avoidable if the dressings were kept in place and wedges were used per her orders. In observation on 10/15/21 at 11:49 AM, CNA R and a therapy staff transferred Resident #1 from her wheelchair and into her bed. CNA R positioned Resident #1 on her back and raised the head of the bed at an approximately 90-degree angle. The wedges were not in use; one was on the floor and another was on the nightstand. Resident #1 was not offloaded from her sacral wound. An observation on 10/16/21 at 9:15 AM revealed Resident #1 was in bed. She had a dressing to her sacral wound dated 10/16/21. Wedges were not in use; one was on the floor and another was on the nightstand. In an interview on 10/16/21 at 10:00 AM the Administrator was notified Resident #1's wedges were not in place. Record review of Resident #34's MDS Assessment, dated 09/21/21, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS score was 14 indicating intact cognitive function. He did not exit any behavioral symptoms including rejection of care. His functional abilities were listed as extensive one-person assistance with toilet use, bed mobility, and had total dependence requiring 1-person assistance with transfers. Record review of Resident #34's comprehensive care plans reflected the following plans and interventions: . Potential for skin integrity impairment [related to] Stage 2- right shin, open areas to left shin, right ankle, right knee, 8/19/21- surgical left ischial Stage 4, surgical right sacral stage 4, surgical left heel unstageable . Date initiated: 01/21/2021 . Revision on 08/19/2021 . Administer treatment and medications as ordered . air mattress . encourage/assist with turn and position frequently and as needed . Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #34's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Air mattress in use due to impaired skin integrity . start date 08/19/2021 . Left ischial: cleanse with [normal saline], pat dry, apply [MEDICATION(S)] Blue to open area only, cover with dry dressing only. Every shift for surgical wound . start date 09/30/2021 .remain in bed at all times with head of bed not to exceed 30 degrees until cleared by wound physician for sitting protocol . start date 09/22/2021 . Right ischial [hip]: Cleanse with [normal saline], apply calcium alginate, and cover with dry dressing twice daily. Every shift for open wound . start date 10/06/2021 Review of Resident #34's Wound Physician N's assessments reflected the following: 1.Wound Type: Pressure Ulcer . Wound Location: Right Sacral . Initial Assessment (12/9/2020) . Length: 2.19cm .Width: 7.14cm .Depth: 0.2cm . Most Recent Assessment (9/29/2021) . Length: 6cm . Width: 5cm . Depth: 2cm . Tunneling 3.5cm 2. Wound Type: Pressure Ulcer . Wound Location: Left Heel . Initial Assessment (12/9/2020) . Length: 2.86cm .Width: 2.46cm .Depth: 0.2cm . Most Recent Assessment (9/29/2021) . Length: 3cm . Width: 5cm . Depth: 0.2cm Review of Resident #34's progress notes from 08/01/21 through 10/16/21 reflected the following: 1.10/6/2021 [2:32 PM] COMS (R) Braden Evaluation . Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Bedfast. Mobility: No limitation. Nutrition: Excellent. Friction & Shear: Problem. Result: At Risk Score: 16.0 . 2.10/6/2021 [2:39 PM] COMS - Skin Only Evaluation . Skin: Skin is ashen in color. Mucous membranes are moist. Excess saliva present. Skin warm/dry to touch. Normal skin turgor.Resident has current skin issues. Skin Issue: Deep Tissue Injury. Skin Issue Location: Right buttock No wound odor. No tunneling. Skin Issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: Right heel No wound odor. Skin Issue: Skin Graft. Skin Issue Location: left buttock Dressing Saturation: Moderate (26-75%). No wound odor.return from Carrollton Medical Center. Drsgs. dry and intact. New order for left buttock entered. IV antibiotics continues. Will continue to monitor . 3.10/13/2021 [8:29 PM] COMS (R) Braden Evaluation . Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Bedfast. Mobility: No limitation. Nutrition: Excellent. Friction & Shear: Problem. Result: At Risk Score: 16.0 . Review of Resident #34's Treatment Administration Records (TARs) for October 2021 reflected Resident #34's right hip wound care (which was scheduled twice a day) was not signed as completed on the following dates: 10/10/21 twice, 10/11/21 twice, and 10/12/21 once. In an interview on 10/11/21 at 11:47 AM, Resident #34 stated his wound dressing has not been cleaned and changed. Resident #34 said he had two wounds and the one on his right buttocks was supposed to be cleaned and changed by the nurses twice a day and the one on his left buttocks was done by Wound Physician N on Mondays, Wednesdays, and Fridays. Resident #34 said he was getting two more sores to his buttocks. Resident #34 said his incontinence pad was supposed to be changed every four hours but it was not being changed. In an interview and observation on 10/14/21 at 11:18 AM revealed Resident #34 stated he had requested his wound dressing be changed on the previous night shift and it was not completed. Observation of Resident #34's right hip revealed he had a thick dressing in place which was saturated with a yellow and pink tinged liquid. The dressing was not labeled with the date or initials. The re-usable incontinent pad under the resident's buttocks was discolored with a tan colored substance and the edges of the dirty area were a darker brown. There were also crumbs of a yellow and green substance on the pad. The DON entered the resident's room and observed Resident #34's right hip dressing and incontinence pad. The DON stated the nurse would complete wound care now for the resident and the aide would clean Resident #34 and change his linens. Review of Resident #11's MDS assessment, 08/10/21, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was incontinent of bowel and bladder. She was totally dependent for bathing and required extensive 1-person assistance for toilet use. She did not exit any behavioral symptoms including rejection of care. Her BIMS score was 3 indicating a severe cognitive impairment. Review of Resident #11's comprehensive care plans reflected the following plans and interventions: .Stage 2 pressure ulcer to left elbow . pressure ulcer will show improvement by the next review date . Date Initiated: 10/09/2021 . Target Date: 12/31/2021 .Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LEFT ELBOW WOUND . Off load left elbow to prevent injury to site Review of Resident #11's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Then place elbow on pillow. every 12 hours as needed for wound care AND every day shift every 2 day(s) for wound care Review of Resident #11's Wound Physician M's assessments reflected the following: 1. 09/28/21: Wound #1 .Site . Left elbow . Type . skin tear/friction . Length .2 cm . Width . 2cm .Depth . 0.5cm . Wound Progress Declined .Still no padding. Will again discuss with nursing. Likely with osteo[[CONDITION(S)]]. Will biopsy bone next visit if needed . Frequent turning 2. 10/07/21: Wound #1 .Site . Left elbow . Type . Pressure ulcer . Length .2.8 cm . Width . 2.2cm .Depth . 0.8cm . Stage unstageable . Undermining 1.8cm . Wound Progress Declined .No dressing and no padding this time. Will again discuss with nursing. Likely with osteo[[CONDITION(S)]]. Will biopsy bone next visit if needed. Likely will culture also .unable to self offload. Frequent turning 3. 10/12/21: Wound #1 .Site . Left elbow . Type . Pressure ulcer . Length . 3cm . Width . 2.8cm .Depth . 0.4cm . Stage unstageable . Undermining 0.7cm . Wound Progress Declined .No dressing and no padding this time. Will again discuss with nursing. Likely with osteo[[CONDITION(S)]]. Will biopsy bone next visit if needed. Likely will culture also .unable to self offload. Frequent turning Review of Resident #11's progress notes from 08/01/21 through 10/16/21 reflected the following: 1.9/23/2021 [8:49 PM] COMS - Skin Only Evaluation . Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time . 2.9/23/2021 [8:50 PM] COMS (R) Braden Evaluation . Sensory Perception: Very limited. Moisture: Rarely moist. Activity: Bedfast. Mobility: Completely immobile. Nutrition: Very poor. Friction & Shear: Problem. Result: High Risk Score: 10.0 . 3.9/30/2021 10:53 [AM] Dietary Progress Note . Wound Report from 9/23/21 Showing St 2 to Left Elbow . 4.10/1/2021 [3:34 AM] COMS - Skin Only Evaluation . Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time . 5.10/1/2021 [3:36 AM] COMS (R) Braden Evaluation .Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Bedfast. Mobility: Completely immobile. Nutrition: Adequate. Friction & Shear: Problem. Result: High Risk Score: 12.0 . 6.10/8/2021 [4:31 AM] COMS (R) Braden Evaluation . Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Bedfast. Mobility: Completely immobile. Nutrition: Very poor. Friction & Shear: Problem. Result: High Risk Score: 10.0 . 7.10/8/2021 [4:38 AM] COMS - Skin Only Evaluation . Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Skin Tear. Skin Issue Location: left elbow Length:2.8 Width (cm): 2.2 Depth:0.8 Wound Bed: Slough. Wound Exudate: None . 8.10/13/2021 [2:40 PM] Administrator Note . Notified Dr of IJ . 9.10/13/2021 [7:44 PM] COMS - Skin Only Evaluation . Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: Right Elbow Length:2.6 Width (cm): 2 Wound Exudate: serosanguineous. DressingSaturation: Moderate (26-75%). No wound odor. No tunneling. Undermining noted.Left foot, apply form dressing for prevention . 10.10/13/2021 [8:58 PM] COMS (R) Braden Evaluation . Sensory Perception: Very limited. Moisture: Very moist. Activity: Chairfast. Mobility: Completely immobile. Nutrition: Adequate. Friction & Shear: Problem. Result: High Risk Score: 11.0 Clinical Suggestions: Draw sheet utilized. Utilized foam wedge(s) for positioning. Incontinent products utilized after each incontinence episode. HOB elevated less than, equal to 30 degrees and [NAME] knees. Changed position at least q.1 hour while in wheelchair. Weight shifted q.15 minutes while in wheelchair. Turned and repositioned at least q.2 hours while in bed. Supplements offered per order. Tray set up and routine meal assistance offered as needed. Small, frequent position changes encouraged. Activities encouraged as tolerated. Meals encouraged . 11.10/15/2021 [2:05 PM] Order Note . LEFT ELBOW WOUND CARE: CLEANSE WITH NS, PAT DRY, cover with dakins moistened gauze, COVER WITH FOAM DRESSING AND WRAP WITH [MEDICATION(S)]. THEN OFFLOAD WITH WEDGE. two times a day every 2 day(s) for wound care AND every 12 hours as needed for wound care . 12.10/15/2021 [2:23 PM] Nurse's Note . Resident wound care provided per physician order, no concern noted at this time, no s/s of infection noted at this time, resident reposition, wound off load . 13.10/15/2021 [6:41 PM] Order Note . LEFT ELBOW WOUND CARE: CLEANSE WITH NS, PAT DRY, cover with dakins moistened gauze, COVER WITH FOAM DRESSING AND WRAP WITH [MEDICATION(S)]. THEN OFFLOAD WITH WEDGE. two times a day every 2 day(s) for wound care AND every 12 hours as needed for wound care .Wound round done. Resident in bed. Wound dressing CDI. Resident repositioned X 2 person assist. wound off loaded at this time . An observation on 10/11/21 at 9:45 AM revealed Resident #11 was lying in bed with the head of the bed elevated. She was noted to have a contracture to her right hand and had gauze placed inside the palm of her right hand. Resident #11's left elbow was bent, she had a dressing in place, and there was not a pillow or wedge to offload the area covered by the dressing. Resident #11 was non-interviewable. In an observation on 10/11/21 at 1:00 PM Resident #11 was lying in bed with the head of the bed elevated. Resident #11's left elbow was bent, she had a dressing in place, and there was not a pillow or wedge to offload the area covered by the dressing. An observation on 10/13/21 at 7:40 AM revealed Resident #11 had a dressing to her left elbow dated 10/12. Her left elbow was not padded, nor was it offloaded with a pillow or wedge. In a telephone interview on 10/13/21 at 8:17 AM, Wound Physician M said Resident #11's elbow wound was much much worse, because now it extends down to the bone and it's foul smelling. Wound Physician M stated she planned on obtaining a bone biopsy from Resident #11 to check for [CONDITION(S)] (infection in a bone). Wound Physician M stated Resident #11's wound was worsening was avoidable because Resident #11's elbow should be padded, that's what the order says. She stated she did not observe Resident #11's elbow being padded, including when she saw Resident #11 on 10/12/21. In an interview on 10/13/21 at 1:38 PM, RN U, who was assigned to work with Resident #11, revealed she was an agency nurse who had worked at the facility as needed but this was her first shift working at the facility in months. She stated, I think they have a shift to sift report, but was unable to locate the report. RN U stated she was normally notified of which residents had wounds during verbal report with the leaving nurse. RN U stated she could not remember who had wounds on the hall she was assigned. She stated CNAs were responsible for repositioning the resident, but it was not documented, because it was just an expected thing. In an interview on 10/13/21 at 1:51 PM, CNA V, who was assigned to work with Resident #11, said she had worked at the facility since the end of June 2021. CNA V stated she mainly worked the 300 hall and was not aware of any resident who requires any special devices or had special care instruction related to wounds. She stated she was not aware of any place she would look to find out who had wounds or special instruction and the nurse would have to tell [her] about special equipment to prevent wounds. CNA V said she did not receive any specific training or instructions about any residents who have wounds. Review of Resident #31's MDS assessment, dated 09/24/21, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was incontinent of bowel and bladder. She required extensive 1-person assistance for toilet use and bathing. She did not exit any behavioral symptoms including rejection of care. She did not have a BIMS score and her cognitive skills were listed as severely impaired. Review of Resident #31's comprehensive care plans reflected the following plans and interventions: bowel incontinence [related to] loss of sensation . Date Initiated: 08/20/2020 . Revision on: 06/05/2021 . will be continent . use(Size) disposable briefs. Change (FREQ) and prn . INCONTINENT: Check me (FREQ) and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes . Stage 4 to sacral area pressure ulcer [related to] Immobility Date Initiated: 09/01/2020. Revision on: 06/03/2021. Pressure ulcer will show signs of healing and remain free from infection by/through review date . Target Date: 10/20/2021 . Administer medications as ordered. Monitor/document for side effects and effectiveness . apply air mattress q shift . Encourage/assist with turn and position [every 2 hours] and prn . Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Serve diet as ordered, [NAME] [TRUNCATED]