Every finding on record at The Woodlands Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 15 residents (Resident #1) reviewed for pain management.The facility failed to administer Resident #1's scheduled pain medications on o5/29/2026 at 4:oopm Resident #1 did not receive Baclofen 5 mg, one tablet by mouth three times daily; Tramadol 50 mg, two tablets by mouth three times daily; and Zanaflex 6 mg, one capsule by mouth three times daily, as scheduled.This failure could place the resident at risk for increased pain, delayed treatment and pain management interventions.Findings included:Record review of Resident #1's Face Sheet, dated 10/02/2025, revealed a [AGE] year-old male, admitted on [DATE].Record review of Resident #1's Quarterly MDS assessment, dated 04/02/2026, revealed a BIMS score of 15, indicating that he was cognitively intact. Section GG functional ability documented the resident required setup or clean-up assistance for eating. The resident was coded as requiring supervision or touching assistance for oral hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, rolling left to right, sit-to-lying, lying-to-sitting on the side of the bed, sit-to-stand, chair/bed-to-chair transfers, wheeling 50 feet with two turns, and wheeling 150 feet. The resident was coded as requiring partial/moderate assistance for toilet transfers, tub/shower transfers, toileting hygiene, showering/bathing, and lower body dressing.Record review of Resident #1's care plan, revised on 04/20/2026, revealed:Problem:Category: Pain and non-participatory in plan of care for medication.Goal:No adverse outcomes.Approach:Educate resident on the risks and benefits of taking medications as prescribed.Record review of Resident #1's Medication Administration Audit Report, dated 06/04/2026, revealed that Resident #1 did not receive his Tramadol 50 mg, Baclofen 5 mg, and Zanaflex 6 mg at the scheduled administration time of 4:00 p.m. on 05/29/2026.During an interview with LVN-B on 06/04/2026 at 10:00 a.m., she stated that she did not administer Resident #1's medications because he was difficult to locate. She stated that she did not administer Resident #1's scheduled 4:00 p.m. medications on 05/29/2026, which included Tramadol 50 mg, Baclofen 5 mg, and Zanaflex 6 mg. She further stated that she did not notify the charge nurse or the Director of Nursing (DON).During an interview with the physician (MD) on 06/04/2026 at 11:00 a.m., she stated that LVN-B should have notified her that Resident #1 did not receive his scheduled medications at 4:00 p.m. on 05/29/2026. She stated that notification was necessary to inform her why the medications were not administered. The physician further stated that one missed dose of Resident #1's medications would not likely result in adverse effects and that the medications could be resumed at the next scheduled administration time.During an interview with the DON on 06/04/2026 at 11:30 a.m., she stated that she was not notified that Resident #1 did not receive his scheduled medications at 4:00 p.m. on 05/29/2026. She stated that the process for missed medications was for the LVN-B to notify the charge nurse, who then notified the ADON), who in turn notified the DON. She further stated that one missed dose would not likely result in an adverse reaction.During an interview with the ADON on 06/04/2026 at 11:50 a.m., she stated that she was not notified that Resident #1 did not receive his scheduled medications at 4:00 p.m. on 05/29/2026. She stated that the process for missed medications was for the nurse to notify the charge nurse, who then notified the ADON, who in turn notified the DON. She further stated that one missed dose would not likely result in an adverse reaction.During an interview with Resident #1 on 06/04/2026 at 2:33 p.m., he stated that he did not receive his 4:00 p.m. medications on 05/29/2026. He stated that he was not experiencing severe pain and that he later requested his medications at approximately 7:30 p.m.; however, the nurse informed him that he could not receive them because he was scheduled to receive medications again at 8:00 p.m.During an interview with the Administrator on 06/04/2026 at 3:15 p.m., he stated that he was not notified that Resident #1 did not receive his medications on 05/29/2026 at 4:00 p.m. He stated that when a resident's medication was not administered, the ADON, DON, physician, and Administrator should be notified. He further stated that Resident #1 was capable of informing staff if he was experiencing pain and needed his medications.Record review of the facility's Pain Management Policy, dated 10/19/2019, stated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 (Resident #1) of 10 residents and 1 facility reviewed for sanitary conditions. Debris, dirt, and black sticky spots of dried hand sanitizer were observed along hall A. Resident #1 had a brownish red ring inside of his toilet bowl, toothpaste splatters on the mirror, and had a strong smell of urine left behind in the toilet bowl. Room A had a dark brown ring inside the toilet bowl and brown fecal splashed inside of the toilet bowl. These failures could place residents at risk of diminished quality of life and infection. Findings included: Record review of Resident #1's face sheet dated 4/25/26 revealed a [AGE] year-old man whose most recent admission was 10/2/25. Admitting diagnoses were quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), neuromuscular dysfunction of the bladder (refers to what happens when an injury or disease interrupts the electrical signals between your nervous system and bladder function), congestive heart failure, full incontinence of feces (when there is trouble managing or controlling when one has a bowel movement), and colostomy status (an opening in the colon that lets stools pass from the body without going through the anus). Record review of Resident #1's care plan initiated on 01/14/19 revealed that he had an ADL self-care performance deficit related to multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), hypertension (high blood pressure), and hemiplegia (is paralysis or severe weak is paralysis or severe weakness affecting one side of the body, usually caused by brain or spinal cord damage). On 3/11/22, care plan was updated to include that Resident #1 refused to utilize the sink in his room for hygiene needs and utilized the public sink by the dining room instead. Due to the disease process of multiple sclerosis, Resident #1 had limited mobility. Record review of Resident #1's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 15 (normal cognitive functioning). In an observation and interview on 04/25/26 at 12:11 p.m., on Hall A on the long-term care unit, debris, dirt, and food particles were seen along the hallway floor. A black, sticky substance was observed on the floor beneath 3 hand sanitizer dispensers, which appeared stuck to the floor's surface but it could be partially lifted with slight pressure. In an interview on 04/25/26 at 12:16 p.m., Resident #1 stated that housekeeping cleaned his room daily but they were inconsistent with how they cleaned. He stated that one member of housekeeping would mop without sweeping first and that his bathroom had not been thoroughly cleaned and stated that there was a black ring in the toilet because of prolonged unclean conditions. Resident #1 stated that someone came to clean his bathroom earlier that day, but they left behind a pair of dirty gloves on the counter. In an observation of Resident #1's bathroom, there was a pair of balled up gloves on the counter, the mirror had toothpaste splatter marks that were spread out over the mirror, and there was a strong smell of urine coming from the toilet, that had dark yellow urine inside. Resident stated that he did not use the restroom due to his catheter and when the aids poured out the urine from his handheld urinal, they did not flush the toilet. In an observation on 04/25/26 at 12:45 p.m., Room A was checked for cleanliness. Inside the bathroom, the mirror contained visible water and toothpaste splashes. The toilet bowl was observed to have a black ring inside the bowl and dark brown fecal splashes were on the commode and the assisted toilet chair. In an interview and observation on 04/25/26 at 1:33 p.m., CNA A stated that CNAs were responsible for making the bed and patient care and housekeeping was responsible for cleaning the bathrooms. She stated that when she emptied the urinal, she would pour its contents into the toilet, flush, then rinse the urinal out. She stated that she did empty out Resident #1's urinal earlier that morning but she stated that she flushed the toilet. When she was informed that the toilet was not flushed and there was a strong smell of urine in the bathroom, she stated that if the toilet was not flushed it was because the toilet handle was not working right and she had informed someone in maintenance. CNA A accompanied the surveyor to Resident #1's bathroom and she was asked to flush the toilet. The toilet was flushed fully without concern. CNA A stated that she guessed it was working now. After flushing, the toilet, a brownish red ring remained in the toilet bowl. In an interview on 04/25/26 at 1:45 p.m., HK A, stated that her cleaning process included sweeping prior to mopping, and disinfecting surfaces. She explained that she took her time to clean the bathroom and would first spray the toilet down to let the disinfectant sit, then she would use three different rags to clean the back of toilet, front, and the sides. She would also scrub inside of the toilet bowl, cleaning mirrors, and thoroughly scrubbing toilets, including under the rim. She stated that cleaning conditions may vary depending on resident behaviors and room conditions and HK A stated that rooms could become soiled after cleaning due to resident activity. When she was shown a picture of the toilet bowl inside Resident 1's room, she stated that the brown ring in the toilet could have been from mildew or a buildup and she stated that if the toilet bowl had a ring in it, it could have been like that for a while. In an interview on 04/25/26 at 4:21 p.m., the DON stated that she had not received any complaints from Resident #1 regarding housekeeping and stated that Resident #1 refused to speak with her or communicate any of his concerns to her for reasons she was not aware of. She stated that she expected housekeeping to keep things clean for the residents and the harm in not doing so could be improper infection control and the risk of residents getting sick. In an interview with the 4/25/26 at 4:31 p.m., The EVS stated that he had worked at the facility for 3 years and he oversaw housekeeping and maintenance in the building. He stated that housekeeping was to clean the rooms daily and he was responsible for following up to make sure it was completed. When housekeeping cleaned, they were to focus on sanitation, which meant making sure the handles and high touch surfaces were wiped down, cleaning bathrooms and toilets, and spraying/wiping down beds. When informed that the halls were covered in debris and there were toilets that had rings inside the bowl, he stated that all housekeeping staff were assigned one hall that were to clean for that shift. He stated that he would try to clean up every time he had the opportunity if he saw something out of order but he could not catch everything. The EVS stated his expectation of housekeeping staff was for them to clean thoroughly everyday. Record review of the facility's policy titled: General Housekeeping Policies (not dated) stated that:All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain or increase their competency.Floors are maintained in good condition and cleaned regularly. Floor polished provide a non-slip finish and rugs are not used except for non-slip entrance mats.Clean and disinfect toilet including the tank, seat, bowl, and base. Bowl cleaner should only be used inside of the bowl.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of eight residents (Resident #5) reviewed for resident rights. The facility failed to provide care in a manner that promoted maintenance of a resident's quality of life on 1/27/26 when Resident #5 was left in the shower alone, cold, and unclothed for approximately 5 minutes and was unable to call for help. This deficient practice could place residents at risk of fearfulness, helplessness and loss of dignity.Findings included:Record review of Resident #5's admission Record generated on 4/13/26 revealed he was admitted to the facility on [DATE]. He had diagnoses of multiple sclerosis (a chronic, often disabling autoimmune disease of the central nervous system (brain and spinal cord) where the immune system destroys the myelin sheath protecting nerves), major depressive disorder (a serious mental health condition characterized by at least two weeks of persistent, severe sadness, loss of interest in activities, fatigue, and sleep/appetite changes that interfere with daily life) and quadriplegia (paralysis affecting all four limbs and the torso, caused by damage to the cervical spinal cord or brain). He was [AGE] years of age. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 15, indicating he had no cognitive impairment. He used a wheelchair for mobility. He required substantial/maximal assistance with personal hygiene and was dependent on others for bathing, including washing, rinsing and drying self. He had functional limitations in range of motion in his upper extremities with impairment on one side and had limitations in lower extremities with impairments on both sides. Record review of Resident #5's Care Plan dated 2/14/23 revealed Resident #5 had an ADL self-care performance deficit related to multiple sclerosis and hemiplegia. The resident's goal was to maintain his current level of function in ADLs through the review date of 6/29/26. Interventions included providing bathing/showering and personal hygiene assistance. The resident requires total assistance with 2 person (sic) with tub bath/shower 3x week as necessary. the resident requires extensive assistance of 1 person with personal hygiene and oral care.In a telephone interview on 4/13/26 at 12:39pm 12:39pm, CNA R said she cared for Resident #5 three times. She said the last time she cared for him, she gave him a shower. She said herself and CNA E helped him get into the shower chair. She said they went to the shower room and it was occupied. CNA R got him a blanket. She said when the other resident left, CNA R and Resident #5 went into the shower room. She said she got him situated in the shower, put the call light in reach, and asked if he needed help. Resident #5 responded that he needed help with his legs and feet. She said she told Resident #5 that she would give him privacy and return to help. She said she went to the restroom and returned about 5 minutes later. She said when he returned he was upset and thought she had been gone for too long. She said he had not started giving himself a shower. She said Resident #5 was safe in the shower without supervision and was not a fall risk. She said she thought he could wash himself. She said she left to give him privacy. In an interview, observation and record review on 4/13/26 at 2:15pm, Resident #5 let me read a note on his phone that described being left alone in the shower room. He said during the shower he could not reach the faucet, could not do anything himself and was sitting there with no cover and was cold. He reached for his phone that was on his lap. His left hand was contracted and he could not move his fingers. He used the back of his left hand to stabilize his phone. He operated his phone using his right arm and hand. Record review of the note in his phone indicated it was dated 1/27/26 and read, [CNA R] came to my room at 4:15 pm to shower me. It was the worst shower that I have ever had in my life. When (CNA R) put me in the shower, she took the sheet and hospital gown that I had on. This left me naked. Next, [CNA R] said, I'm going to the bathroom, I'll be right back. I didn't think anything about it. [CNA R] was gone for over an hour. This left me naked and cold, unable to do anything to help myself. [CNA R] didn't bother to hang my catheter bag up anywhere, she left it in my lap. This caused me to urinate on my leg. She didn't leave me a towel or anything to cover up with. There was no hot water and since it was January, it was cold. I used the shower head to bang on the wall and yelled as loud as I could but [CNA R] was gone. The note said he reported it to Former ADON C.In an interview on 4/13/26 at 2:58pm, the Administrator stated he was not aware of a complaint regarding Resident #5 related to being left alone in the shower room unattended.Surveyor attempted to contact Former ADON C and CNA E by phone on 4/13/26 without success. In an interview on 4/13/26 at 4:00pm, the DON said she had worked at the facility for a few weeks. When asked if residents could be in the shower room independently, she said it would depend on the resident's capabilities, and gave examples as to whether they were alert and oriented, how much care they needed, and if they wanted privacy. She said she was a little familiar with Resident #5 and talked to him for the first time today. She said he would need assistance in the shower, but said if Resident #5 was yelling at the caregiver, was noncompliant with care, then the CNA may decide to leave. She said they tried to meet his needs. State surveyor explained that did not seem to be the case during an incident a few months ago, and she said there was no way of knowing what was said between the resident and CNA. In an interview on 4/13/26 at 4:20pm, when asked if Resident #5 should be left alone in the shower room when being bathed, LVN I said Resident #5 was alert and oriented. He said they would do the shower how he wanted it, including closing the curtain if he requested privacy and checking on him every 3-5 minutes. Record review of the facility's policy for Activities of Daily Living dated 5/26/23 read, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, groom and oral care. a resident who is unable to carry out activities of daily living will received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to immediately inform the physician when resident arrived to the facility for 1 of 14 residents (CR#1) reviewed for resident rights.1. The facility failed to contact the physician when CR#1 had an unwitnessed fall on 1/17/2026 that resulted in a head injury.2. The facility failed to notify physician of CR#1 unwitnessed fall with head injury3. The facility failed to call 911 emergency services when initially requested by family4. CR #1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. These failures could place residents at risk of decline in health status, increase level of pain, and could lead to more serious injuries. Findings Included:Record review of CR #1 face sheet revealed a [AGE] year-old female who arrived at the facility on 1/16/26 with a diagnosis of grade 4 glioblastoma multiforme with chemo treatment and brain resection (brain cancer), cerebral edema s/p brain resection (fluid in the brain), left hemiparesis s/p cerebral infarct (weakness on left side), CAD x2 stents (coronary artery disease), diabetes mellitus (insufficient insulin), hypertension (high blood pressure), seizure disorder (unprovoked seizures), arthritis affecting left wrist (inflammation in the joints), and multiple falls at home. She was discharged [DATE].Hospital after visit summary record review of medication list dated 1/16/26 revealed the following needed:Albuterol 90 mcg/act inhaler (as needed)Alcohol Swabs for glucometerAmlodipine 5 MG (Wait until 1/17 take 1 tablet) (treat high blood pressure)Aspirin EC 81 MG EC tablet take 1 by mouth daily (last given 1/16/26 at 9:07am)Azelastine (treat runny nose) 0.1% nasal spray (commonly known as Astelin. Administer 1 spray into each nostril in the morning and 1 spray in evening as directed).Centrum silver vitamin (1 tablet by mouth 1 time daily)Cyclosporine (treat chronic eye disease) 0.05% administer in both [NAME] in the morning and 1 drop in the evening (last time given was 1/16/26 at 6:12am).Dexamethasone (treat severe inflammation, allergies, asthma, autoimmune conditions, and certain cancers) 4 mg_start taking 1/17/26 (last time given 1/16/26 at 6:12am) take 1 tablet in morning and 1 in the evening.Fluticasone (used to treat asthma and reduce inflammation) 50 MCG/ACT (flonase) nasal spray administer I spray in morning and 1 in the evening.Furosemide (treat fluid retention caused by heart failure, liver disease, or kidney disorders) 20 MG (commonly known as Lasix) tablet take by mouth 1time each day.Lacosamide (treat seizures) 200 Mg Tablet (Known as Vimpat) take 1 tablet in morning and 1 table in eveningLancet Device with Ejector (use to check sugars once day due to type 2 diabetes)Metformin (used to treat diabetes) XR 500 MG 24-hour tablet (take in the evening)Ondansetron 8 MG (known as Zofran_as needed for nausea_take at bedtime)Pantoprazole (treat excessive stomach acid) 40 MG (known as ProtoNix_start taking on 1/17/26_last time given 1/16/26 at 6:12amRosuvastatin (used to treat high chloresterol) 10MG (take 0.5 tablets by mouth 1 time each day_Last time given was 1/16/26 at 9:07am)Trelegy Ellipta (used to treat COPD, which limis airflow in the lungs) 100-62.5-25 MCG aerosol powder_Inhale 1 puff 1time daily)Valsartan (used to treat high blood pressure, and heart failure) 320 MG tablet (known as Diovan start taking 1/17/26_last time given 1/16/26 at 9:07am Record Review of EMS Run Report revealed the following:2:17 am blood pressure 198/114 2:24 am blood pressure 198/114 Pulse 652:24 am blood pressure 207/110 Pulse 612:34 am blood pressure 207/110 Pulse 642:34 am blood pressure 99/70 Pulse 622:37 am blood pressure 1961/98 Pulse 652:44 am blood pressure 196/98 Pulse 612:46 am blood pressure 173/95Record Review of CR#1's Vitals in nursing notes revealed:Blood Pressure taken 1/16/26 at 6:32pm 133/77Temp 1/16/26 at 6:32pm 97.7Pulse 1/16/26 at 6:32pm 88 bpmRespirations 1/16/26 at 18 Breaths/min O2 1/16/26 at 6:32pm 97.0%Record Review of nursing notes dated 1/16/26 at 7:57pm revealed CR#1 was admitted via stretcher with dx of left sided weakness & Cerebral edema. Vitals taken by LVN A were Temp 97.4, Pulse 70, Blood Pressure 164/100, O2 Sats 98% room air. Incontinent of b/b.Record Review of nursing notes dated 1/16/26 at 8:49pm CMA A wrote dexamethasone tablet 4 mg_Give 1 tablet by mouth two times a day for inflammation. Medication Unavailable.Record Review of nursing notes dated 1/16/26 at 8:50pm CMA A wrote CycloSporine Emulsion 0.05% Instill 1 drop in both eyes two times a day for dry eyes due to inflammation. Medication Unavailable.Record Review of nursing notes dated 1/17/26 at 1:20am, RN A wrote, Around 1:20 AM the resident was seen on the floor and brought back to bed and had V/S assessed. No swelling or bruising upon initial assessment. 30 minutes later the resident had a small swelling the left side of her forehead.Record Review of nursing notes dated 1/17/26 at 4:18am, RN Awrote, Change of Condition. Resident fell and had a bruise on her left forehead. Resident transferred to hospital.Record Review of email sent to facility and corporate office from the FM on 1/17/26 at 4:21am revealed the following:[ ATTN: Administrator, Director of Nursing, and Risk Management]Demand for Action:Your staff has created a dangerous environment. You have an inexperienced nurse admitting to sleep deprivation and an inability to manage his caseload, and support staff who prioritize their phones over patient safety.[CR#1] is currently at the emergency room being evaluated for head trauma-an injury sustained because your staff failed to ensure she had a call light or safe surroundings.I require an immediate response from the [Director of Nursing] regarding:1. Why I was not called immediately upon the fall.2. Why a patient with a seizure history was left without a call button.3. Why a nurse is on the floor admitting to being sleep-deprived and unable to care for his assigned patient load.I expect a call immediately to discuss how you intend to rectify this liability.[FM][Contact Number]Record review of Hospital Notes dated 4/1/26 revealed CR#1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. On 3.31.26 at 10:45am, during a telephone interview with the FM, she stated the incident report was somewhat accurate with a lot of inaccuracies, which was why she sent the email. She stated on 1/17/26, a little after 1:00am, her mother had fallen on the floor while trying to go to the restroom as she was unable to locate her call light, and her phone was not within reach. She stated CR#1's call light was behind her bed and not in reach. The FM stated no staff member called her from the facility. She stated she became aware of the fall and medication issue from CR#1, which was why she arrived that early morning to find CR#1 with a horrendous swollen knot on the left side of her head from falling. The FM stated when she arrived at the facility, a CNA, later Identified as CNA A, escorted the FM and her boyfriend down to CR#1's room. The FM stated she arrived at the facility at 1:40am, and RN A was nowhere to be found. The FM stated CNA A called RN A on the phone and the call went to voicemail. The FM stated CNA A located RN A outside in his car, which time she informed RN A that CR#1's FM needed to speak with him. The FM stated she asked RN A what happened to CR#1's head and RN A appeared shocked that CR#1's head was swollen. The FM stated she told RN A she left CR#1 in his care and she was neglected. The FM stated RN A was passive aggressive, elevated his voice and told her that he was responsible for more residents than CR#1 and that the number of residents he had was overwhelming. The FM stated, during the conversation exchange with RN A, he stated CR#1 was not the only resident who had fallen in the facility. The FM stated this statement is what really upset her and she demanded her mother be sent to hospital for further examination. She stated the RN A refused to call 911 stating he needed permission from the DON. The FM stated RN A called the DON to see if he could call the regular ambulance service and not 911 and was given permission. She stated the ambulance arrived between 3:25am - 3:40am. The FM stated no medication arrived at 3:00am for CR#1. On 3.31.26 at 6:35pm in a telephone interview with RN A he stated he vaguely remembered the incident with CR#1. He stated he remembered CR#1 falling. RN A stated he called the doctor and FM and did not get an answer from either one, so he called the Former DON to get authorization and was given permission to send CR#1 out 911. RN A stated the negative of not sending resident out 911 could have been CR#1 could have sustained a brain bleed or stroke. RN stated protocol was followed when caring for CR#1.On 4/13/26 at 2:53PM in an interview with the Admin he stated the expectations of a nurse when a resident experienced a fall, especially an unwitnessed fall, is to do an assessment, neuros, and vital signs before picking resident off the floor. The family and doctor should be contacted immediately afterwards. The negative effect of picking up the resident could cause more injury. The Admin stated the assessment should be completed as soon afterwards. The Admin stated if a family request resident to be sent out to hospital, then the resident should be sent out. The Admin stated all residents should be treated with dignity and respect at all times.On 4/13/26 at 3:00pm in a telephone interview with MD he stated he would have to check his charts to see if he received a message from the facility. The MD stated if he had received a message from the facility then his NP would have knowledge of it. MD stated he would call his NP and have her return the call with results. On 4/13/26 at 3:46pm in a telephone interview with NP she stated that when a new resident arrived to the facility she gets a text from the facility that says, new patient admitted room number so-and-so. she stated that she had not received a call from the facility regarding CR#1 nor had she received a call, message or text from LVN A regarding medication review or from RN A regarding CR#1's fall with head injury. NP stated on 1/20/26 she received a voicemail from DON A asking if she was notified about CR#1's allegations. NP stated that she was not. On 4/14/26 at 3:09pm in a telephone interview with LVN A, she stated she was working at the time the resident arrived at the facility. She stated the resident came into the facility on a stretcher with her family members accompanying her. She stated she called the doctor to verify the meds. She stated she did not call the pharmacy and that the call to the pharmacy was typically for residents who entered the facility with pain medication (narcotics). When asked if she got a voicemail when she called the doctor or left a message, LVN A stated she did not leave a message on voicemail, she is sure that she either spoke with the MD or the NP. LVN A stated her calling the MD or NP should have been documented in her nursing notes. She stated she followed protocol. LVN A stated she would have to look at the nursing notes and can't remember much about the admission process due to the elapsed time. However, she stated all of what she did is in the nursing notes. LVN A stated the adverse effect of not documenting what occurred is It didn't happen. LVN A stated the blood pressure was 164/100 (she could not say if this was a mistake or not) during the time resident was admitted , but no interventions were put in place. She stated she worked the 6:00am - 6:00pm shift and stayed later, which is when CR#1 arrived at the facility. Record review of facility's Promoting/Maintaining Resident Dignity policy dated 1/13/23 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignityand respect resident rights.2. During interactions with residents, staff must report, document and act upon information regardingresident preferences.5. When interacting with a resident, pay attention to the resident as an individual.10. Speak respectfully to residents; avoid discussions about residents that may be overheard.

Based on interview, and record review, the facility failed to ensure that residents received treatment and necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with professional standards of practice and resident choices, for 1 to 14 (CR#1) residents reviewed for Quality of care.The facility failed to ensure that appropriate preventative measures, monitoring, and interventions were consistently implemented to reduce the risk of falls and ensure CR#1's safety in accordance with accepted standards of nursing practice.The facility failed to respond timely to CR#1 who was in distress after a fall on 1/17/26. The facility failed to conduct appropriate post-fall assessments for CR #1 after a fall on 1/17/26 resulting in multiple breakdowns in care, including failure to respond timely to a resident in distress, which resulted in delayed treatment. CR #1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. These failures could place residents at risk for avoidable injuries and compromised quality of care resulting in hospitalization.Based on interview, and record review, the facility failed to ensure that residents received treatment and necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with professional standards of practice and resident choices, for 1 to 14 (CR#1) residents reviewed for Quality of care. The facility failed to ensure that appropriate preventative measures, monitoring, and interventions were consistently implemented to reduce the risk of falls and ensure CR#1's safety in accordance with accepted standards of nursing practice.The facility failed to respond timely to CR#1 who was in distress after a fall on 1/17/26. The facility failed to conduct appropriate post-fall assessments for CR #1 after a fall on 1/17/26. These failures could place residents at risk for avoidable injuries and compromised quality of care resulting in hospitalization. Findings Included Record review of CR #1 face sheet revealed a [AGE] year-old female who arrived at the facility on 1/16/26 with a diagnosis of grade 4 glioblastoma multiforme with chemo treatment and brain resection (brain cancer), cerebral edema s/p brain resection (fluid in the brain), left hemiparesis s/p cerebral infarct (weakness on left side), CAD x2 stents (coronary artery disease), diabetes mellitus (insufficient insulin), hypertension (high blood pressure), seizure disorder (unprovoked seizures), arthritis affecting left wrist (inflammation in the joints), and multiple falls at home. She was discharged [DATE]. Record review of CR#1's physician orders dated 1/16/26 revealed resident was to be administered:Cyclosporine (treat chronic eye disease) 0.05% administer in both [NAME] in the morning and 1 drop in the evening 1/16/26;Azelastine (treat runny nose) 0.1% nasal spray (commonly known as Astelin. Administer 1 spray into each nostril in the morning and 1 spray in evening as directed) Start dated 1/16/26 at 6:00pm;Monitor for pain every shift. Use 0-10 scale(A) for Alert resident Used Pain AD (B) for confused residents document which pain scale used to assess residents pain rating every shift (start dated 1/16/26 6:00pm-D/C date 1/20/26 8:59am;Vital signs every shift_Start date 1/16/26 at 6:00pm- 1/20/26 8:59am) Record Review of nursing notes dated 1/16/26 at 8:49pm CMA A wrote dexamethasone tablet 4 mg_Give 1 tablet by mouth two times a day for inflammation. Medication Unavailable. Record Review of nursing notes dated 1/16/26 at 8:50pm CMA A wrote CycloSporine Emulsion 0.05% Instill 1 drop in both eyes two times a day for dry eyes due to inflammation. Medication Unavailable. Record review of CR#1's Hospital after visit summary medication list dated 1/16/26 revealed the following:Albuterol 90 mcg/act inhaler (as needed)Alcohol Swabs for glucometerAmlodipine 5 MG (Wait until 1/17 take 1 tablet) (treat high blood pressure)Aspirin EC 81 MG EC tablet take 1 by mouth daily (last given 1/16/26 at 9:07am)Azelastine (treat runny nose) 0.1% nasal spray (commonly known as Astelin. Administer 1 spray into each nostril in the morning and 1 spray in evening as directed).Centrum silver vitamin (1 tablet by mouth 1 time daily)Cyclosporine (treat chronic eye disease) 0.05% administer in both [NAME] in the morning and 1 drop in the evening (last time given was 1/16/26 at 6:12am).Dexamethasone (treat severe inflammation, allergies, asthma, autoimmune conditions, and certain cancers) 4 mg_start taking 1/17/26 (last time given 1/16/26 at 6:12am) take 1 tablet in morning and 1 in the evening.Fluticasone (used to treat asthma and reduce inflammation) 50 MCG/ACT (flonase) nasal spray administer 1 spray in morning and 1 in the evening.Furosemide (treat fluid retention caused by heart failure, liver disease, or kidney disorders) 20 MG (commonly known as Lasix) tablet take by mouth 1time each day.Lacosamide (treat seizures) 200 Mg Tablet (Known as Vimpat) take 1 tablet in morning and 1 table in eveningLancet Device with Ejector (use to check sugars once day due to type 2 diabetes)Metformin (used to treat diabetes) XR 500 MG 24-hour tablet (take in the evening)Ondansetron 8 MG (known as Zofran_as needed for nausea_take at bedtime)Pantoprazole (treat excessive stomach acid) 40 MG (known as ProtoNix_start taking on 1/17/26_last time given 1/16/26 at 6:12amRosuvastatin (used to treat high cholesterol) 10MG (take 0.5 tablets by mouth 1 time each day_Last time given was 1/16/26 at 9:07am)Trelegy Ellipta (used to treat COPD, which limits airflow in the lungs) 100-62.5-25 MCG aerosol powder_Inhale 1 puff 1time daily)Valsartan (used to treat high blood pressure, and heart failure) 320 MG tablet (known as Diovan start taking 1/17/26_last time given 1/16/26 at 9:07am Record review of Hospital Notes dated 4/1/26 revealed CR#1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. Record review of the facility's Investigation Summary revealed the facility was made aware on 1/28/26 by CR#1's FM who alleged CR#1 was verbally abused by CNA A by telling CR#1 to go to sleep because she was bothering the other resident in the room. Additional allegation was made by CR#1's FM who indicated CR#1 had not received all her medications on the night of her admission 1/16/26. The summary report revealed the following:CR#1 was discharged at the report.The accused (CNA A) did not show up for the scheduled meeting regarding these abuse and neglect allegations. The facility conducted life satisfaction rounds on 3 rooms and no issues noted.Facility staff were all reeducated on abuse and neglect, customer service, appropriate redirection of residents with behaviors, notification to families & physician on new admission medication arrival & scheduling; accordingly, staff interviews, RP informed, MD informed, and Ombudsman aware.Facility Investigation Interview with RN A who stated CR#1 was admitted around 4:30pm on 1/16/26 and began exhibiting erratic behavior and speaking incoherently, requiring frequent assistance. RN A stated CR#1 was shown all of her medications ordered, and informed she would receive what was available in the facility that night, and other medications would be in after early morning delivery. RN A stated at no time during his shift and or he entered the room with CNA A did he hear her be verbally abusive to CR#1, and CR#1 did not report or verbalize any concerns regarding verbal abuse or missed medications.Facility (Previous) Investigation Interview with CNA A regarding CR#1 indicated she arrived for her shift at 10:00pm and answered CR#1's call light. CNA A stated CR#1 was leaning off the bed and told her she had to pee. CNA A stated she assisted CR#1 to the restroom then back to bed, with her call light, water, and phone next to her and within CR#1's reach. CNA A stated CR#1's roommate complained about traffic in and out of the room and noise from resident. CNA A stated she used a calm approach to communicate/redirect CR#1 that her roommate was trying to get some sleep and she should try and get some sleep too.11 days after the abuse and neglect allegations, the facility Investigation in-service training reports were (Abuse and Neglect, medication availability, reconciling medications and admission orders, change in condition and timely notification, and customer service), completed 2/3/26. Record Review of EMS Run Report revealed the following:2:17 am blood pressure 198/114 2:24 am blood pressure 198/114 Pulse 652:24 am blood pressure 207/110 Pulse 612:34 am blood pressure 207/110 Pulse 642:34 am blood pressure 99/70 Pulse 622:37 am blood pressure 1961/98 Pulse 652:44 am blood pressure 196/98 Pulse 612:46 am blood pressure 173/95 Record Review of CR#1's Vitals in nursing notes revealed:Blood Pressure taken 1/16/26 at 6:32pm 133/77Temp 1/16/26 at 6:32pm 97.7Pulse 1/16/26 at 6:32pm 88 bpmRespirations 1/16/26 at 18 Breaths/min O2 1/16/26 at 6:32pm 97.0% Record Review of nursing notes dated 1/16/26 at 7:57pm revealed CR#1 was admitted via stretcher with dx of left sided weakness & Cerebral edema. Vitals taken by LVN A were Temp 97.4, Pulse 70, Blood Pressure 164/100, O2 Sats 98% room air. Incontinent of b/b. Record Review of nursing notes dated 1/17/26 at 1:20am, RN A wrote, Around 1:20 AM the resident was seen on the floor and brought back to bed and had V/S assessed. No swelling or bruising upon initial assessment. 30 minutes later the resident had a small swelling the left side of her forehead. Record Review of nursing notes dated 1/17/26 at 4:18am, RN A wrote, Change of Condition. Resident fell and had a bruise on her left forehead. Resident transferred to hospital. Record Review of email sent to facility and corporate office from the FM on 1/17/26 at 4:21am revealed the following: ATTN: Administrator, Director of Nursing, and Risk Management, I am writing to formally document the appalling neglect, unsafe environment, and gross unprofessionalism experienced by [CR#1], within less than 24 hours of her admission to the facility.CR#1 was admitted on Friday, January 16, 2026, at approximately 5:15 PM. By early Saturday morning, your facility had already failed in its duty of care, resulting in a fall, head trauma, and an emergency transfer to the hospital.The Timeline of Negligence (Saturday, [DATE]): 1:16 AM: I received a distress call CR#1, not your staff, stating she had fallen, hit her head, and was bleeding. She begged me to come get her. The fact that the family was notified by the traumatized patient and not the nursing staff is an immediate failure of protocol. Arrival (~1:40 AM): Upon entering the facility, I found a staff member named [CNA A] at the nurses' station with her feet up, on her personal phone. She was completely disengaged. The Incident: [CNA A] escorted me to the room, admitting she had cleaned blood from my mother's head and applied a cold towel. However, she had not escalated the issue to the nurse. Cause of Fall: CR#1 was left with no access to a call button and her phone had been unplugged and moved out of reach. When she attempted to retrieve it to call for help, she fell. Verbal Abuse: CR#1 reported that after she fell, [CNA A] told her she needed to go to sleep because she was bothering the other patient. This lack of empathy is reprehensible. Medical Neglect: [CNA A] informed me she had not received her scheduled night medications.Conduct of RN A:After waiting 15 minutes for the Nurse on Duty to appear, I witnessed RN A entering from a side door carrying a bag of food, appearing annoyed.1. Lack of Awareness: He asked RN A what happened, despite being the nurse on duty. He then contradicted himself, claiming he had already evaluated her and she was fine, yet he was unaware of her critical medical history (seizures and brain tumor).2. admission of Incompetence: When I questioned his assessment, RN A became passive-aggressive. He explicitly stated that: Patients fall all the time here. He has only been a nurse for four months. He is sleep-deprived and responsible for 30 patients.3. Aggression: When I challenged his lack of empathy and aggressive tone, he raised his voice at me.Demand for Action:Your staff has created a dangerous environment. You have an inexperienced nurse admitting to sleep deprivation and an inability to manage his caseload, and support staff who prioritize their phones over patient safety.CR#1 is currently at the emergency room being evaluated for head trauma-an injury sustained because your staff failed to ensure she had a call light or safe surroundings.I require an immediate response from the Director of Nursing regarding:1. Why I was not called immediately upon the fall.2. Why a patient with a seizure history was left without a call button.3. Why a nurse is on the floor admitting to being sleep-deprived and unable to care for his assigned patient load.I expect a call immediately to discuss how you intend to rectify this liability.[FM][Contact Number]On 3.31.26 at 10:45am during a telephone interview with FM She stated the incident report was somewhat accurate with a lot of inaccuracies, which is why she sent the email. She stated on 1/17/26 a little after 1:00am her mother had fallen on the floor while trying to go to the restroom as she was unable to locate her call light, and her phone was not within reach. She stated CR#1's call light was behind her bed and not in reach. FM stated CR#1 told her it took staff a while to help her up. And while she was there, CR#1 informed her she didn't get all of her medication and the facility has brushed it under the rug. She stated she never heard anything about the RN A doing any follow-up assessments on CR#1 or checking on her medication. FM stated no staff member called her from the facility. She stated she became aware of the fall and medication issue from CR#1, which is why she arrived that early morning to find CR#1 with a horrendous swollen knot on the left side of her head from falling. FM stated when she arrived at the facility, a CNA, later Identified as CNA A, escorted FM and her boyfriend down to CR#1's room. FM stated she arrived at the facility at 1:40am. FM stated RN A was nowhere to be found. FM stated CNA A called RN A on the phone and the call went to voicemail. FM stated CNA A located RN A outside in his car, which time she informed RN A that CR#1's FM needed to speak with him. FM stated she asked RN A what happened to CR#1's head and RN A appeared shocked that CR#1's head was swollen. FM stated she told RN A she left CR#1 in his care and she was neglected. FM stated RN A was passive aggressive, elevated his voice and told her that he was responsible for more residents than CR#1 and that the number of residents he had was overwhelming. FM stated RN A stated he cleaned CR#1 up after picking her up from the floor and at this time CNA A interjected and stated CNA A cleaned her up, but the CNA said she said she did. FM stated during the conversation exchange with RN A he stated CR#1 was not the only resident who had fallen in the facility. FM stated this statement is what really upset her and she demanded her mother be sent to hospital for further examination. FM stated while waiting for the ambulance, CR#1 informed RN A she had not been administered her medication. She stated RN A told her because she arrived at the facility so late she would have to wait for her medication to arrive around 3:00am. She stated the RN refused to call 911 stating he needed permission from the DON. FM stated RN A called DON to see if he could call the regular ambulance service and not 911 and was given permission. She stated the ambulance arrived between 3:25am - 3:40am. She stated no medication arrived at 3:00pm for CR#1. On 3.31.26 at 12:29pm during a telephone interview with DON A Stated she was out of the facility when she received the call from RN A. RN a told her that CR#1 had fallen and had bumps and bruises. DON stated CR#1 had also fallen daily at the hospital. DON A stated FM initially issued a complaint regarding CR#1's fall to the facility, which was reported to the state, investigated and unsubstantiated. DON stated CR#1 was so disruptive the roommate requested to leave. DON A stated CR#1's behavior was not documented in the nursing notes and should have been. DON A stated the LVN who received CR#1 should have completed a medication review with the doctor or nurse practitioner. DON A stated at anytime if a family asked the facility to send the resident out there request should automatically sent out. DON A stated RN A said while he completed his Neuros, CR#1 was beginning to show signs of swelling. DON A stated RN A called the on-call nurse. On 3.31.26 at 1:00pm during a telephone interview with CNA A who stated she is no longer employed with the facility. CNA A stated 1/16/26 was busy night for her and CR#1 appeared to need more of her assistance than other residents on the hall. CNA A stated CR#1 would not use her call light but would verbally call for nursing assistance when she needed help CNA A stated this is the night she found CR#1 on the floor. She was on night shift and met CR#1 and her roommate soon after arriving for her shift. CNA A stated CR#1 roommate wanted to ask her a question and during this time CR#1 informed her she did not get water during her evening meal. CNA A stated that she began to give care to the roommate, and the roommate wanted to transfer rooms because she stated CR#1 makes a lot of noises. CNA A stated she politely asked CR#1 if she could quiet it down because the noise was disturbing her roommate. CNA A stated she did not know why CR#1 was making a lot of noise and did not report this to the charge nurse. CNA A stated shortly after leaving the residents' room, she was called back again. CNA A stated she observed CR#1 had moved herself on the bed where her legs were hanging off the side of the bed. CNA A stated she took CR#1 to restroom, which is next to CR#1's bed; then assisted her back to bed. CNA A stated after assisting CR#1 to bed she ensured the call light was on the side table with a cup of water and her phone. CNA A stated prior to her going into CR#1 room she observed RN A was on the phone standing just outside of CR#1's door. CNA A stated CR#1 told her that she was calling the guy who was standing right outside of her door for assistance, but he and was on the phone talking and laughing. The guy was later identified as RN A. CNA A stated CR#1 was cognizant enough to know her needs. CNA A stated she was in another residents room on the same hall. She stated after about 15 minutes she heard CR#1 screaming for help. She stated she left the residents room she was giving care to and went to CR#1's room, which she observed CR#1 on the floor. CNA stated she called out to RN A and didn't get a response. CNA A stated she walked up to the nursing station and informed RN A that CR#1 was on the floor. RN A told her he needed to input information in the computer regarding a resident's medication and would get to her shortly. CNA A stated RN A did not get up right away. CNA stated she returned to CR#1's room and attempted to help her up herself, but CR#1 told her she was too heavy and she needed someone else. CNA A stated about 5 minutes later RN A arrived to CR#1's room and the two of them put resident back in bed then RN A left the room without completing any type of assessments before or after picking CR#1 off the floor. CNA A stated at this time, CR#1 was extremely upset and asked CAN A to help her look for her phone as the outgoing CAN had unplugged it and placed it out of her reach CNA A located the cell phone was able to assist CR#1 in calling her daughter. CNA A stated when CR#1 was on phone with FM she did not observe the swelling. CNA A stated FM arrived about 30 minutes later and wanted to immediately speak with RN A who was not in the building. CNA A stated she located RN A outside in his vehicle on the phone and eating and told him that CR#1's FM was in the facility. CNA A stated RN A did not do vitals prior to the two of them picking CR#1 up off the floor nor did she see RN A check CR#1's vitals afterwards. CNA A stated after FM arrived she was upset because she did not received a call from RN A or anyone in the facility that CR#1 had fallen and sustained a head injury. CNA A stated if RN A had really completed Neuros he would have noticed the swelling on CR#1's head, which is why FM was upset. RN A told FM he did not see the bruise on CR#1's head and at this time RN A began to get defensive and dismissive in his response to FM. RN A told FM that CAN A would not use her call light for assistance; however, CR#1 informed FM, and RN A that her roommate pushed her call light for CR#1 as her call light was located behind the bed.On 3.31.26 at 6:35pm during a telephone interview with RN A he stated he vaguely remembered the incident with CR#1. He stated he remembered CR#1 falling. RN A stated CNA A came and reported to him that CR#1 had fallen. RN A stated he did not remember what position CR#1 was in because it has been a while since the incident occurred. He stated CNA A assisted him in getting CR#1 in the bed. RN A stated he took vitals after putting CR#1 back in the bed. RN A stated he did not do range and motion with CR#1 (assessment evaluation) while CR#1 was on the floor. RN A stated he can't remember if he checked to see if resident was on an anticoagulant before picking her up and putting her in bed. At the time of the incident, he stated he was only on the job for 2-3 months. He stated he did not believe he made any mistakes. He stated he went to the room and checked her vital signs. He stated he completed the vital signs right away, and completed the neuro checks every 15 minutes. RN A stated he recorded on a sticky note or he charted them and he couldn't remember. RN A then stated he reported on both, sticky notes and nursing notes. RN A stated he called the doctor and FM and didn't get an answer from either one, so he called DON A to get authorization and was given permission to send CR#1 out 911. RN A stated the negative of not sending resident out 911 could have been CR#1 could have sustained a brain bleed or stroke. RN stated he believed he did everything he was supposed to do. He stated he followed proper protocol.On 4/13/26 at 2:53PM in an interview with the Admin who stated the expectations of a nurse when a resident experienced a fall, especially an unwitnessed fall, is to do an assessment, neuros, and vital signs before picking resident off the floor. The family and doctor should be contacted immediately afterwards. The negative effect of picking up the resident could cause more injury. The assessment should be complete as soon afterwards. The Admin stated if any family request resident to be sent out to hospital, then send resident out. Admin stated all residents are to be treated with dignity and respect at all times.On 4/13/26 at 3:00pm in a telephone interview with he MD who stated he would have to check his charts to see if he received a message from the facility. He stated if he had received any message his NP would have knowledge of it. He stated he would call his NP and have her return the call with results. On 4/13/26 at 3:46pm in a telephone interview with NP she stated that when a new resident arrived to the facility a text is received from the facility that says, new patient admitted room number so-and-so. she stated that she had not received a call from the facility regarding CR#1 nor had she received a call, message or text from LVN A regarding medication review. NP stated she had not received a call from RN A regarding CR#1's fall with head injury. NP stated on 1/20/26 she received a voicemail from DON A asking if she was notified about CR#1's allegations. NP stated that she was not. On 4/14/26 at 3:09pm in a telephone interview with LVN A, she stated she was working at the time the resident arrived at the facility. She stated the resident came into the facility on a stretcher with her family members accompanying her. She stated she called the doctor to verify the meds. She stated she did not call the pharmacy and that the call to the pharmacy was typically for residents who entered the facility with pain medication (narcotics). When asked if she had gotten a recorder when she called the doctor or left a message. LVN A stated she either spoke with the MD or the NP, but she stated she did not leave a message. LVN A stated her calling the MD or NP should have been documented in her nursing notes. She stated she followed protocol. LVN A stated she would have to look at the nursing notes and can't remember much about the admission process due to the elapsed time. However, she stated all of what she did is in the nursing notes. LVN A stated the adverse effect of not documenting what occurred is It didn't happen. LVN A stated the blood pressure was 164/100 (she could not say if this was a mistake or not) during the time resident was admitted , but no interventions were put in place. She stated she worked the 6:00am - 6:00pm shift and stayed later, which is when resident had arrived at the facility. On 4/14/26 at 3:50pm in a telephone interview with CMA, she stated she was employed as a CMA. She stated when a new resident enters into the facility, the charge nurse calls the doctor to do a medication review and then administer the resident their initial dose of medication. After that process, the CMAs are notified of medication ordered, and what medication is not available in the facility and which medication are waiting to be delivered. She stated all PRN medication is administered by the charge nurses. She stated she does not remember CR#1 because there were so many residents that come to the facility. However, if she came, then the charge nurse should administer the initial dose of medication. She stated there is an issue with nurses ordering medication for residents. She stated when a resident's medication is low enough to be reordered, the CMA would let the nurse know the medication needs to be ordered. She stated sometimes, the resident would be out of the medication, then there is a rush to order.On 4/20/26 at 5:30pm in a telephone interview with the Pharmacy, she stated there were medications ordered on 1/16/26 for CR#1. However, they were returned to stock because they were not picked up after 14 days. She stated there is a store closer to the facility and medications would need to be transferred to the store closest to the facility. However, there is no record of any medication transfer request. She stated the pharmacy does not deliver medication to the patient in the nursing home.Record review of facility's Promoting/Maintaining Resident Dignity policy dated 1/13/23 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignityand respect resident rights.2. During interactions with residents, staff must report, document and act upon information regardingresident preferences.5. When interacting with a resident, pay attention to the resident as an individual.10. Speak respectfully to residents; avoid discussions about residents that may be overheard.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 7 emergency exits (dining room exit doors #1 and #2) reviewed for physical environment.- The facility failed to ensure the area beyond dining room exit door #2 were unobstructed. On 3/31/26 and 4/13/26, there was a large pallet of medical supply boxes on the sidewalk that obstructed the only ramp accessible to the dining room exit door #2. - The facility failed to ensure the area beyond dining room exit door #1 was free of clutter. On 3/31/26, the sidewalk area outside of the door was cluttered with crates, wood furniture, a grill, ice cooler, and trash bin. This deficient practice could place residents at risk of falls, injuries, and confusion during evacuations. The findings included:In an observation on 3/31/26 at 12:04pm, an exit door behind the dining room, dining room exit door #1, was obstructed by items. On the sidewalk just outside the door, the following items were observed: a cooler on wheels, bucket and mop, scrubbing brush, a piece of wood furniture, a grill, 2 crates stacked on top of each other, another mop bucket and a large trash bin on wheels next to the ramp. In an observation on 3/31/26 at 12:11pm, an exit door behind dining room, dining room exit door #2, was obstructed by a pallet of boxes. On the sidewalk just outside the door on the left, there was a pallet of boxes of medical supplies approximately 3 boxes across and 5 boxes tall with three more rows behind it. The sidewalk led to the only ramp. There was approximately one foot of space between the edge of the pallet to the edge of the sidewalk that then drops off (the curb). In an observation and interview on 4/13/26 at 12:10pm, Central Supply Staff A was observed putting boxes away in the central supply closet in the administrative office area. She said she received deliveries on Monday. She said she had 4 pallets of boxes delivered that day. She said she put supplies out at the nurses' stations twice a week. She said she used to have supplies delivered to a shed at the back of the facility. She said the shed was condemned by a governmental entity about 8 months ago. She said now they delivered supplies at the back of the facility. She said she tried to process as much as she could to get the supplies inside. A pallet of boxes was observed outside on the sidewalk next to the dining room exit door #2. She said she could not put all the boxes inside in one day. She said she knew she could not leave supplies outside like that. She stated she recognized that the blocked ramp was a problem. She said she had not been given directions on where to put the supplies, so she did the best she could. In an observation and interview on 4/13/26 at 1:26pm, the Maintenance Director said the medical supply company delivered the supplies and placed them outside of the facility. He said he needed to talk to them because they should not deliver the boxes on the walkway. The surveyor and Maintenance Director observed a pallet of boxes on the sidewalk leading to the ramp outside of dining room exit door #2, and he said the area was obstructed and should not be that way. He said he had a pallet jack and could move the boxes. He said central supply brought the supplies inside as quickly as she could. In an interview on 4/13/26 at 2:58pm, the Administrator said dining room exit doors #1 and #2 were designated as exits because they had an exit sign above the doors. He said the ramp was mainly used for deliveries of food and supplies. He said if the residents or staff could not use the ramp due to an obstruction, they would use another exit door. Record review of the policy's Evacuation: Emergency Preparedness Plan dated 4/2025 read, Any disaster or emergency which directly affects this facility will require a decision either to evacuate residents or not to evacuate residents. Therefore, evacuation because a prime consideration. While gathered in the assembly area, the Facility will conduct a complete audit of all residents, staff and visitors. All people assembled in the area should remain alert for instructions from emergency responders.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice for 3 (Residents #185, #55 and #49) of 5 reviewed for respiratory care. 1. Resident #185's Bi-pap (bilevel positive airway pressure) mask was not covered in a plastic bag when it was not used on 12/16/2025.2. The facility failed to ensure empty portable oxygen tank in Resident #55's room was secure and in a base.3.The facility failed to ensure Resident #49's received 2 liters of oxygen as ordered. This failure could affect residents with oxygen therapy and bilevel positive airway pressure and could lead them to lack of care including possible infection by not following infection control.1. Record review of Resident #185's face sheet, dated 12/19/2025, revealed the resident was a [AGE] year-old male and originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of cellulitis of left lower limb (skin infection to left leg), type 2 diabetes mellitus (not control blood sugars in the body), hypertension (high blood pressure), sleep apnea (when breathing stops and restarts many times while sleeping), and muscle wasting and atrophy (loss of skeletal muscle mass). Record review of Resident #185's admission MDS assessment was In progress because the resident was admitted to the facility on [DATE]. Record review of Resident #185's physician order, dated 12/02/2025, revealed the resident had the order of Apply BIPAP (bilevel positive airway pressure) at 14 IPAP (inspiratory positive airway pressure) / 10 EPAP (expiratory positive airway pressure), every time at bedtime. Observation on 12/16/2025 at 12:11 p.m. revealed Resident #185 was on the bed and talking to his wife at the bedside in his room. Resident #185's Bi-pap (bilevel positive airway pressure) mask connected to a machine was on the nightstand uncovered. During an interview on 12/16/2025 at 12:56 p.m. LVN-B stated Resident #185's Bi-pap (bilevel positive airway pressure) mask was on the nightstand without a plastic bag. Further interview with LVN-B said the resident's Bi-pap (bilevel positive airway pressure) mask should have been covered in a plastic bag when it was not used to prevent possible infection. During an interview on 12/19/2025 at 12:09 p.m. DON stated Resident #185's Bi-pap (bilevel positive airway pressure) mask should have been covered in a plastic bag when it was not used to prevent possible infections. DON said the facility did not have a policy related to specifically covering a mask in a plastic bag when not used, the facility follows standards nursing care, and it was nurse's responsibility. Record review of professional guidelines, titled World Health Organization - Care, cleaning and disinfection of Bi-pap devices (https:// chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.who.int/docs/default-source/coronaviruse/checklists-3_2022.pdf#:~:text=Doff%20and%20discard%20PPE%20and,an%20area%20where%20there%20is), dated 12/22/2025, revealed Ensure cleaned BiPAP/CPAP device is stored in an area where there is low risk of contamination between uses. 2. Record review of Resident #55's face sheet, dated 12/18/2025, revealed Resident #55 was admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, unspecified and chronic respiratory failure with hypoxia. Record review of Resident #55's Quarterly MDS assessment, dated 09/16/2025, revealed the residents' BIMS score was 12 indicating moderate cognitive impairment. Section O indicated oxygen therapy was provided while a resident. Record review of Resident #55's care plan, target date 02/17/2026, revealed Resident #55 had a focus of The resident has altered respiratory status r/t COPD with an intervention of Oxygen at 2L LPM via nasal cannula PRN. Observation and interview on 12/16/2025 at 12:50 PM Resident #55 was observed sitting on her bed with a portable oxygen tank on the back of her wheelchair, a portable oxygen tank in a stand beside the bed and a portable oxygen tank sitting on the floor by the wall of her room. Resident #55 stated the staff had changed her oxygen tank on the back of her wheelchair yesterday and left the empty oxygen tank. Resident #55 stated she wore her oxygen when she got winded and tired but did not wear it all the time. During an interview on 12/16/2025 at 1:08 PM CNA G stated Resident #55 always had her oxygen on and further stated she did not work with the oxygen tanks. CNA G stated the nurse was responsible for the oxygen tanks. Observation and interview 12/16/2025 on 1:12 PM RN I stated someone probably changed Resident #55's oxygen tank and left it. RN I stated it was not safe for the tank not to be in a base and further stated the tank could fall. RN I stated the portable oxygen tank should have been sitting in a base. RN I stated when an oxygen tank was empty it was supposed to be removed from the room. RN I further stated the oxygen tank should be sitting in a base for safety precautions of the residents and the staff. The RN I stated emptied oxygen tanks were separated from the full oxygen tanks and kept secured in the oxygen room. RN I removed the oxygen tank from the floor or Resident #55's room. During an interview on 12/19/2025 at 10:36 AM the DON stated if the oxygen tanks were empty, they should have been returned to the storage room. The DON further stated oxygen tanks should be used in transport or when residents were out of the room. The DON stated portable oxygen tanks should be kept in a stand or wheelchair caddy if in the room and should not be sitting on the floor. The DON stated there was an explosive risk if the oxygen tanks were to fall over and the residents could trip over the tanks. During an interview on 12/19/2025 at 10:54 AM the Administrator stated there was a potential hazard by the oxygen tank sitting on the floor. The Administrator further stated if the oxygen tank was not on a wheelchair or was not in use should not be stored in the room. The Administrator stated the oxygen tank should have been in the holder or the carrier. 3. Record review of Resident #49's face sheet, dated 12/18/2025, revealed she was admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, unspecified, simple chronic bronchitis and other disorders of lung. Record review of Resident #49's Quarterly MDS assessment, dated 09/06/2025, revealed the resident's BIMS score was 13, indicating intact cognition. Record review of Resident #49's O2 Sats Summary dated 12/18/2025, revealed Resident #49 with oxygen values taken and receiving oxygen via nasal canula. Record review of Resident #49's Physician Order Summary, dated 12/16/2025, read, Oxygen administration at 2L/minutes via nasal canula as needed for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, start date 09/10/2025. Record review of Resident #49's care plan, with a revision date of 11/11/2025, revealed there was not a care plan reflecting Resident #49's use or need of oxygen. During an observation and interview on 12/17/2025 at 9:02 AM Resident #49 was observed sleeping in bed wearing her oxygen with oxygen concentrator set to 3 liters. LVN H stated Resident #49 has an order for 2 liters oxygen as needed, however, Resident #49 would adjust the liters sometimes. LVN H entered Resident #49's room and adjusted the oxygen concentrator. LVN H stated as he left the room that the oxygen concentrator was set at 3 liters and he adjusted it to 2 liters. Record review of facility's policy titled Oxygen Safety, implemented 01/26/2024, read Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Policy explanation and Compliance Guidelines: 1. Safety is the responsibility of all staff, residents, visitors and the general public. 4. Oxygen Storage- c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full or empty.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in lockedcompartments for 3 of 6 medication carts (med aide cart in hall 200, med aide cart in 300 hall, and med aide cart for secured hall) observed for medication storage. One unidentified small round white pill was observed in the bottom drawer of the medication cart on 200 hall.Medication aide cart on 200 hall was left unlocked and unattended in an out cove across from the nurses station. Two unidentified small round white pills were observed in the top drawer of the medication cart on 300 hall.One unidentified small round white pill was observed in the bottom drawer of the medication cart for the secured hall.This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.The findings were:Observation of medication aide cart on 300 hall on 12/18/2025 at 5:05 PM revealed one small round white pill and one small red tringle shaped pill in the bottom of a medication drawer. The pills were loose and not labeled with no identifying markers to indicate what it was. Medication cart was locked and secured. Observation of medication aide cart for the secured hall on 12/18/2025 at 5:11 PM revealed one small round white pill in the bottom of a medication drawer. The pill was loose and not labeled with no identifying markers to indicate what it was. Medication cart was locked and secured. Interview with ADON K on 12/18/2025 at 5:14 PM revealed the medication aide (MA) assigned to the medication carts for 300 hall and the secured unit was on break at the time of observations. ADON K stated all medications were to be stored in pill bottles or blister packs and if a pill was dropped it was to be disposed of per facility policy. ADON K stated it was the responsibility of the MA to ensure med carts were clean and all medications were stored in packaging and not loose in the medication cart. ADON stated there was no possible harm to the residents if a pill was loose in the medication cart because medication aides knew not to use loose pills and to dispose of them per facility policy. Observation of medication aide cart on 200 hall on 12/18/2025 at 5:32 PM revealed the medication cart was in the corner across the hall from the nurse's station unlocked and unattended. One small round white pill was observed in the bottom of a medication cart. The pill was loose and not labeled with no identifying markers to indicate what it was. Interview with MA L on 12/18/2025 at 5:33 PM revealed she was behind the nurse's station and her medication cart was within eyesight. MA L stated she was not using her medication cart at the time surveyor observed it unlocked. MA L stated she was not within reach of her medication cart but there were no residents within reach either. MA L stated it was the responsibility of each MA to ensure their medication carts were clean and free from loose pills. MA L was unable to identify how loose pills in the medication cart could have harmed residents. MA L stated residents could have got into the unlocked medication cart and taken meds that were not theirs. MA L stated if a loose pill was found in the medication cart it was to be disposed of according to the facility policy. Interview with MA M on 12/19/2025 at 11:40 AM revealed she was the medication aide assigned to the medication carts for 300 hall and the secured unit on 12/18/2025 when surveyor made observations. MA M stated medication aides were responsible for the cleaning of the carts and ensuring medications were stored per facility policy. MA M stated medications were to be stored in blister packs or medication bottles and labeled with resident's name. MA M stated if a pill was found loose in the cart it was to be disposed of. MA M was unable to identify how loose pills in the medication cart could have harmed residents.Interview with DON and Administrator on 12/19/2025 at 11:53 AM revealed medication aides were responsible to ensure medication carts were secured when not in use. DON stated medications were to be stored in labeled blister packs or bottles. DON stated if a loose pill was found it was to be disposed of. DON and Administrator stated it was the responsibility of the medication aide assigned to the cart to ensure it was clean, everything was stored properly and secured when not in use. DON and Administrator stated residents had the potential to take medications that were not theirs if there was an unlocked medication carts and/or loose pills. Record review of facility policy named Medication Administration, dated 10/01/19, revealed 2. The medication cart is locked at all times when not in use.Policy regarding medication storage was requested from the ADON K on 12/18/2025 at 5:14 PM and requested from the Administrator and DON on 12/19/2025 at 11:53 AM but not provided prior to exit.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftovers to be used later with a temperature in the danger zone were discarded. 2. The facility failed to ensure food was stored 6 inches off the floor. These failures could place residents who ate food from the kitchen at risk of food- borne illness and disease. Observation of the facility kitchen on 12/16/25 at 8:45 AM revealed the following. 1. A pan of white gravy 45.7 degrees Fahrenheit with a temperature in the danger zone.2. A Plastic container of Scrambled eggs 55 degrees Fahrenheit.3. A Pan of hot dogs 50 degrees Fahrenheit with a temperature in the danger zone. 4. A case of canned chicken noodle soup stored on the floor in the storeroom. An interview with the Dietary Food Service Manager on 12/16/25 at 8:45 AM; revealed that the following foods were stored in the refrigerator and were to be used the following day. She stated the leftover food with danger zone temperatures of 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded. She further stated that she will in-service dietary staff on proper handling, storing, and dating leftover food for compliance .Record review of the facility's policies and procedures for Food Safety dated 2018 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 72 hours unless otherwise indicated. For

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #187, #97, and #138) of 33 residents reviewed for infection control practices. 1. MA-F measured Resident #187's blood pressure without cleaning the blood pressure cuff on 12/17/2025. 2. When CNA-A and CNA-G were providing indwelling urinary catheter care to Resident #97, they did not wear gowns. Resident #97 had enhanced barrier precautions, and the sign attached on the door said, Staff must wear gloves and gown for the following high-contact resident care activities such as urinary catheter care. 3. Resident #138's oral suction Yankauer (the tool is used to suction to prevent aspiration) connected to the suction machine was on the floor on 12/16/2025 without covering it with a plastic bag. This deficient practice could place residents at risk for cross contamination and infections.The findings included: 1. Record review of Resident #187's face sheet, dated 12/19/2025, revealed the resident was an [AGE] year old male and admitted to the facility on [DATE] with diagnoses of heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), hypertension (high blood pressures), muscle wasting and atrophy (loss of skeletal muscle mass), and atherosclerotic heart disease of native coronary artery (plaque and blood clots can reduce blood flow through an artery). Record review of Resident #187's admission MDS assessment was in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #187's physician order, dated 12/15/2025, revealed Midodrine Oral Tablet 2.5 milligram - Give 1 tablet by mouth three times a day for hypertension Hold if systolic blood pressure greater than 130. [sic] Observation on 12/17/2025 at 4:20 p.m. revealed MA-F came out from another resident's room with a blood pressure cuff and machine. Further observation on 12/17/2025 at 4:38 p.m. revealed MA-F opened the computer and entered Resident #187's room and measured the resident's blood pressure without cleaning the blood pressure cuff and machine. During an interview on 12/17/2025 at 4:47 p.m. with MA-F stated she measured Resident #187's blood pressure without cleaning the blood pressure cuff and machine that she already used to another resident. The MA-F said she should have cleaned the blood pressure cuff and machine before measuring Resident #187's blood pressure to prevent possible infection, and it was her mistake. 2. Record review of Resident #97's face sheet, dated 12/19/2025, revealed the resident was a [AGE] year old female, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heartbeat), hypokalemia (low potassium level in the blood), muscle wasting and atrophy (loss of skeletal muscle mass), acute kidney failure (kidney lose the ability to remove waste and balance fluids), and heart failure (the heart muscle does not pump blood as well as it should). Record review of Resident #97's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 12 out of 15 which indicated the resident had moderate cognitive impairment and had indwelling urinary catheter. Record review of Resident #97's comprehensive care plan, dated 04/24/2025, revealed Resident has the need for Enhanced Barrier Precautions due to indwelling urinary catheter. For intervention - Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated. Observation on 12/18/2025 at 2:06 p.m. revealed CNA-A and CNA-G were providing indwelling urinary catheter care including perineal care to Resident #97 and put on gloves, but they did not wear gowns for entire procedures. Further observation on 12/18/2025 at 2:10 p.m. revealed there was Enhanced Barrier Precautions sign and personal protective equipment such as gloves and gowns placed on the door. During an interview on 12/18/2025 at 2:14 p.m. with CNA-A and CNA-G stated they did not wear gowns because they forgot. The CNA-A and CNA-G said they should have put on gowns when providing indwelling urinary catheter care to Resident #97 because the resident had Enhanced Barrier Precautions, and catheter care was one of high- contact resident care activities to prevent possible infection. During an interview on 12/18/2025 at 3:44 p.m. with DON said CNA-A and CNA-G should have put on gowns when providing indwelling urinary catheter care to Resident #97 because the resident had Enhanced Barrier Precautions, and catheter care was one of high- contact resident care activities to prevent possible infection. 3. Record review of Resident #138's face sheet, dated 12/19/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnoses of acute respiratory failure (severe shortness of breath), local infection of the skin, cerebral infarction (brain tissue death due to the blood vessel blockage), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #138's admission MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to bed mobility and Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to sit to stand and chair to bed transfer. Record review of Resident #138's comprehensive care plan, dated 12/02/2025, revealed Impaired breathing mechanics, decannulated, requires suctioning orally at times. The resident prefers to suction herself. For intervention - The resident has demonstrated that she can self-orally suction herself and chooses to do so. Replace Yankauer as needed. Clean suction machine per facility protocol. Observation on 12/16/2025 at 11:22 a.m. revealed Resident #138 was on the bed in her room, there was an oral suction machine on the nightstand at the bedside, and the oral suction Yankauer (the tool is used to suction to prevent aspiration) connected to the suction machine was on the floor without covering it with a plastic bag. During an interview on 12/16/2025 at 1:04 p.m. with RN-J stated Resident #138's oral suction Yankauer connected to the suction machine was on the floor without covering it with a plastic bag. RN-J said the resident could suction by herself with the Yankauer, but the facility should have covered the Yankauer with a plastic bag when it was not used to prevent infection. During an interview on 12/19/2025 at 12:09 p.m. the DON said the facility nurses should have covered Resident #138's oral suction Yankauer with a plastic bag when it was not used to prevent infection. Record review of the facility policy, titled Infection prevention and control program, dated on 05/13/2023, revealed . 10. Equipment protocol - All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Reusable items potentially contaminated with infectious materials shall be placed on an impervious clean plastic bag. Record review of the facility policy, titled Enhanced barrier precautions, dated 11/24/2025, revealed Employes targeted gown and gloves use during high contact resident care activities - High-contact resident care activities include: device care or use such as urinary catheter.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 17 residents (Resident #151 and #140) reviewed for resident rights. CNA-A and LVN-B were standing over Residents #151 and #140 while assisting them to eat, rather than sitting next to the residents, on 12/16/2025 at the dining area of the memory care unit. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: Record review of Resident #151's face sheet, dated 12/19/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function), dementia (loss of memory and thinking ability), and Alzheimer's disease (progressive disease that destroy memories and other important mental functions). Record review of Resident #151's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment and required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating. Record review of Resident #151's comprehensive care plan, dated 04/29/2025, revealed The resident is limited assist with one person for meals. Record review Resident #140's face sheet, dated 12/19/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroy memories and other important mental functions), dementia (loss of memory and thinking ability), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #140's annual MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment and required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating. Record review of Resident #140's comprehensive care plan, dated 10/29/2025, revealed The resident requires set up and clean up assistance with one staff to eat. Observation on 12/16/2025 at 12:27 p.m. at the dining area of the facility memory care unit revealed Residents #151 and #140 sat next to each other, CNA-A in front of the residents was standing over Resident #151 and #140 while assisting and sometimes feeding them to eat. Further observation on 12/16/2025 at 12:30 p.m. revealed that LVN-B was also standing over Residents #151 and #140 while assisting them to eat, rather than sitting next to the residents, and CNA-A was helping other residents. During an interview on 12/16/2025 at 12:45 p.m. CNA-A and LVN-B stated they were standing over Residents #151 and #140 while assisting them to eat, rather than sitting next to the residents because they were busy helping residents in the memory care unit. CNA-A and LVN-B said they should have sat next to Residents #151 and #140 while helping them to eat to give respect and dignity. During an interview on 12/19/2025 at 12:09 p.m. with DON said that the facility staff should have sat next to Residents #151 and #140 while helping them to eat to give respect and dignity, and all staff were trained on resident rights. Record review of the facility policy, titled promoting and maintaining resident dignity, dated 01/13/2023, revealed 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 33 residents (Resident #166) reviewed for assessments: Resident #166's quarterly MDS, dated [DATE], identified the resident was receiving hospice care. However, Resident #166's Prognosis of Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded to No, instead of Yes in Section J (health Conditions). This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #166's face sheet, dated 12/19/2025, revealed the resident was an [AGE] year old female, originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck, chronic kidney disease (kidneys have become damaged over time and have a hard time doing all their important jobs), atrial fibrillation (irregular and often very rapid heart rhythm), and dementia (over time destroy nerve cells and damage the brain). Record review of Resident #166's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and in Section O (Special Treatment, Procedures, and Program), the resident was receiving hospice care. However, in Section J (health Conditions), Prognosis of Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded to No, instead of Yes. Record review of Resident #166's comprehensive care plan, dated 11/24/2025, revealed that The resident is currently under the care of Hospice Services. Record review of Resident #166's certification of terminal illness, dated 11/29/25, revealed the resident's physician certified the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. During an interview on 12/19/2025 at 10:30 a.m. MDS nurse RN-C stated Resident #166's quarterly MDS, dated [DATE], indicated the resident was receiving hospice care. However, Resident #166's Prognosis of Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded to No, instead of Yes in Section J (health Conditions). The MDS RN-C said that it was a mistake, and it should have been coded No because Resident #166 was receiving hospice services. MDS RN-C said coding accurately was a MDS nurse's responsibility, and inaccurate MDS assessments might result in improper care to the resident, and the facility did not have policy for MDS accuracy, but following CMS's RAI Manual guidelines. Record review of CMS's RAI version 3.0 Manual, titled J1400: Prognosis, paged J-29, dated 10/2025, revealed Coding instructions - Code Yes if the resident is receiving hospice services.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's care plan included her need for oxygen as needed. This deficient practice placed residents at risk of not receiving proper care and services.The findings were: Record review of Resident #49's face sheet, dated 12/18/2025, revealed she was admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, unspecified, simple chronic bronchitis and other disorders of lung. Record review of Resident #49's Quarterly MDS assessment, dated 09/06/2025, revealed the resident's BIMS score was 13, indicating intact cognition. Record review of Resident #49's O2 Sats Summary dated 12/18/2025, revealed Resident #49 with oxygen values taken and receiving oxygen via nasal canula from 10/18/2025 to 12/18/2025. Record review of Resident #49's Physician Order Summary, dated 12/16/2025, read, Oxygen administration at 2L/minutes via nasal canula as needed for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, start date 09/10/2025. Record review of Resident #49's care plan, with a revision date of 11/11/2025, revealed there was not a care plan reflecting Resident #49's use or need of oxygen. During an observation and interview on 12/17/2025 at 9:02 AM Resident #49 was observed sleeping in bed wearing her oxygen with oxygen concentrator set to 3 liters. LVN H stated Resident #49 has an order for 2 liters oxygen as needed, however, Resident #49 would adjust the liters sometimes. LVN H entered Resident #49's room and adjusted the oxygen concentrator. LVN H stated as he left the room that the oxygen concentrator was set at 3 liters and he adjusted it to 2 liters. During an observation and interview on 12/19/2025 at 10:13 AM MDS RN C was observed reviewing Resident #49's care plan and stated she did not see the oxygen use addressed in Resident #49's care plan. MDS RN C further stated oxygen use would have been something that would have been care planned. MDS RN C stated she looked at the orders and it looked like the oxygen use started 09/10/2025 and she was not sure why it was started back then. MDS RN C stated care plans were to address the needs of residents, the need for monitoring, how to monitor, and the care needed by the residents. MDS RN C further stated by not care planning needs of residents could put the residents at risk of deteriorating and staff would not know how they should care for them. During an interview on 12/19/2025 at 10:27 AM the DON stated nursing should have care planned Resident #49's use of oxygen. Then DON stated the MDS RN would have addressed it when submitting an MDS because they should have reviewed the MDS. The DON stated nursing was responsible for care planning acute issues and changes with a resident. The DON stated the care plan was the communication of the care of the residents, and it pulled to the Kardex (physical or digital summary of patient care details) for the staff to know the care to be provided.The DON stated if needs had not been care planned the staff might not have known the interventions needed. The DON stated it was also important to have care planned Resident #49's behavior of adjusting the oxygen concentrator, due to it would be important so staff would know to check to make sure it was on the ordered setting. Record review of facility's Comprehensive Care Plans policy, revision date, 10/24/2022 read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #22) reviewed for incontinence care. When CNA-D was providing perineal care to Resident #22 on 12/18/2025, CNA-D did not clean the resident's right and left buttock area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.The findings included: Record review of Resident #22's face sheet, dated 12/19/2025, revealed Resident #22 was a [AGE] year old female, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of acute kidney failure (kidney lose the ability to remove waste and balance fluids), hyperkalemia (high potassium level in the blood), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and elevated white blood cell count (high white blood cell in the blood, including infection). Record review of Resident #22's annual MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, and the resident was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to toilet hygiene, sit to stand, and chair to bed transfer. Further record review of the MDS indicated Resident #22 was frequently bladder and bowel incontinent. Record review of Resident #22's comprehensive care plan, dated 01/31/2024, revealed the resident had the care plan of The resident has MIXED bladder incontinence and bowel incontinence related to Dementia, Impaired Mobility. For intervention - Clean peri-area with each incontinence episode. Observation on 12/18/2025 at 9:21 a.m. revealed CNA-D washed her hands with water, put on gloves and gown, opened the old and dirty brief of Resident #22, then cleaned the resident's genital area by separating labia and cleaned left and right groin area. Then CNA-D turned Resident #22 on her side and cleaned the resident's anal area. CNA-D did not clean the resident's left and right buttock area. Further observation revealed CNA-D changed her gloves after sanitizing her hands and put a new and clean brief under the resident, then closed the brief. During an interview on 12/18/2025 at 9:27 a.m. CNA-D acknowledged she did not clean Resident #22's left and right buttock areas. CNA-D said she was very nervous, so she forgot cleaning Resident #22's left and right buttock areas. CNA-D stated she should have cleaned those areas to prevent possible infection. During an interview on 12/18/2025 at 3:42 p.m. DON stated CNA-D should have cleaned Resident #22's left and right buttock areas to prevent possible infection and skin breakdown. Record review of the facility policy, titled Perineal Care, revised 12/2020, dated 10/24/2022, revealed It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection the extent possible and top prevent and assess for skin breakdown.

Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #86) out of 8 residents reviewed for medical records. Resident #86's electronic medication administration record was inaccurate as evidence by indicating Rosuvastatin Calcium Tablet 20 milligram, give 1 tablet via gastrostomy tube one time a day for lipid control, but the physician order said Rosuvastatin Calcium Tablet 40 milligram. This failure placed residents at risk for missed treatment and medications which could result in decline in health and well-being.Findings included: Record review of Resident #86's face sheet, dated 12/19/2025, revealed the resident was an [AGE] year old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of syncope and collapse (passing out), acute kidney failure (kidney lose the ability to remove waste and balance fluids), muscle wasting and atrophy (loss of skeletal muscle mass), and atherosclerotic heart disease of native coronary artery (plaque and blood clots can reduce blood flow through an artery). Record review of Resident #86's admission MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment and was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to most activities of daily life such as sit to stand, chair-to-bed, and toilet transfer and had gastrostomy tube. Record review of Resident #86's physician order, dated 11/15/2025, revealed the resident had the order of Rosuvastatin Calcium Tablet 40 milligram, Give 1 tablet via gastrostomy tube one time a day for lipid control. Record review of Resident #86's electronic medication administration record from 12/01/2025 to 12/31/2025 revealed Rosuvastatin Calcium Tablet 20 milligram Give 1 tablet via gastrostomy tube one time a day for lipid control - Start Date - 11/15/2025. Observation on 12/17/2025 at 8:29 a.m. revealed RN-E administered Rosuvastatin Calcium Tablet 40 milligram one tablet to Resident #86 via gastrostomy tube. During an interview on 12/17/2025 at 8:30 a.m. RN-E said Resident #86's primary care physician gave the order of Rosuvastatin Calcium Tablet 40 milligram, but the electronic medication administration record indicated Rosuvastatin Calcium Tablet 20 milligram. Further interview with RN-E stated she did not know what reason Resident #86's electronic medication administration record was inaccurate, but she thought the facility nurse might have made a mistake when entering this medication to the electronic medical record system when the resident returned to the facility on [DATE] from the acute hospital. During an interview on 12/18/2025 at 3:48 p.m. the DON stated Resident #86's electronic medication administration record was incorrect because the resident's primary care physician order indicated Rosuvastatin Calcium Tablet 40 milligram, Give 1 tablet via gastrostomy tube one time a day for lipid control. The DON said the resident's electronic medication administration record should have been accurate to prevent providing incorrect dosage to the resident, and it was the facility nurses' mistake. The DON had responsibility to oversee residents had accurate medication administration records. Record review of the facility policy, titled Medication Reconciliation, dated 04/10/2023, revealed the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay.

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 12 (Resident #1) reviewed for abuse. - The facility failed to report to the State Survey Agency a suspicious injury of unknown origin suffered when Resident #1 was found on the floor of his room on 07/29/25 with a deep 10 cm (3.9 inch) laceration (a tear or cut in skin and other tissues that causes bleeding) to the top of his head that required hospitalization and 15 staples. This failure could result in the state agency being unaware of alleged incidents of injury of unknown origin. Findings included: Record review of the HHSC TULIP (system to which providers report accidents and incidents) on 09/04/25 revealed, facility staff did not submit a submit a report of Resident #1's suspicious injury of unknown origin (deep 10 cm) laceration to the top of his head that required hospitalization and 15 staples.Record review of Resident #1's Face Sheet dated 08/26/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure, dementia, depression, high cholesterol, acid reflux, arthritis, abnormality in gait (how a person walks) and mobility and repeated falls.Record review of Resident #1's Quarterly MDS dated [DATE] revealed, minimal difficulty hearing, clear speech, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no upper or lower extremity functional limitation in range of motion and the use of a walker. Resident #1 required setup or clean-up assistance with putting on/taking off footwear and was independent for: roll left to right; moving from sitting to lying; moving from lying to sitting; sit to stand; chair/bed-to-chair transfer; toilet transfer; and the ability to walk 150 feet in a corridor or similar space. Resident #1 had 1 fall since the prior assessment that resulted in minor injuries.Record review of Resident #1's undated Care Plan revealed, Focus: ADL self-care performance deficit r/t Impaired balance, impulse control, and desired Independence, Resident #1 does not like to ask for assistance; Intervention: Resident uses rollator for ambulation independently and does not like to request assistance when ambulating or transfers, Res uses rollator for ambulation independently and does not like to request assistance when ambulating or transfers, The resident requires supervision by (1) staff to move between surfaces. Focus: he resident is High risk for falls r/t Gait/balance problems; Goal: The resident will not sustain serious injury through the review date; Intervention: Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Focus: The resident is High risk for falls r/t Gait/balance problems, 5/29/2023: Fall with laceration to Left side of head, transferred to hospital returned with seven sutures to area, 1/07/25 while trying to charge hearing aids - no injury, 1/15/25 fall- no injury noted, Goal: The resident will resume usual activities without further incident; Interventions: 1/15/25 fall educated resident to call for assistance, therapy to screen, 1/7/25- attempted to relocate hearing aids near resident refused and wants items to stay where they are. Nursing staff are to anticipate needs with hearing aid care, 11/12/24: Fall with minor injury (abrasion to right knee)- educate resident on using call light for assistance.Record review of Resident #1's Change of Condition Communication Form dated 07/29/25 at 11:18 AM signed by LVN A revealed, on 07/29/25 the resident had a suspected fall with head laceration & uncontrolled bleeding.Record review of Resident #1's Fall Risk Evaluation dated 07/29/25 at 11:42 AM revealed, low fall risk as indicated by a score of 03.Record review of Resident #1's Provider Progress Note dated 07/29/25 revealed, fall with head laceration. He is being seen today for management of multiple medical issues including fall with head laceration. Patient is found lying on the floor in his room with a head laceration to his scalp that is bleeding. Staff applied pressure for the bleeding and another staff called 911. Patient was lying in his back when assessed and was talking and answering questions. Staff advised not to pick up the patient from the ground as EMS needs to assess him and apply neck brace due to the fall. A dressing was applied to the scalp laceration to keep the area clean as the bleeding had improved. Patient being sent to the hospital for evaluation and treatment and staples will be needed for the head laceration. Fall was unwitnessed as stated by staff. He is not on any blood thinners. He does not think he lost consciousness. Review of Systems- Neurological: no loss of consciousness; skin: laceration to the scalp. Physical Exam- General: elderly male lying on the floor; Skin: Head laceration to scalp; Neurological- alert, oriented, denies headaches. Diagnosis and Assessment: Laceration of scalp without foreign body, initial encounter. Send to the ER for evaluation and treatment due to head laceration from fall.Record review of Resident #1's Progress Notes revealed,- 07/29/25 at 11:13 AM signed by LVN A: Resident left via 911- 07/29/25 at 11:15 AM signed by LVN A: Heard a loud thump at resident's room and observed resident on the floor, on his back. Resident has 1 shoe on and 1 shoe off. Noted resident with head laceration and uncontrolled bleeding. Pressure applied immediately on his head. NP in the facility notified. 911 was called and 2 personnel arrived. RP & ADON made aware. Report given to ER charge nurse.Record review of pictures of Resident #1's injuries revealed,- 07/29/25 at 03:09 PM- a deep sickle shaped laceration to the top of the resident's head. The laceration started at the crown of the head that curved toward the front of his right temple. The entire laceration was behind the resident's hairline and limited to the top of the head.-08/02/25 at 12:39 PM- there were injuries or bruising to the residents face, neck, back of head, or torso. The only other indication of injury outside of the laceration were the 2 circular bruises on the right forearm. Record review of the facility Incident Investigation dated 07/29/25 revealed, LVN A started an incident report for an un-witnessed fall for Resident #1. The report included witness statements from LVN A. The facility constructed a room diagram during an interview with LVN A and CNA A validated the location of Resident #1, the location of the roommates fall mat and the fact that Resident #1's roommate was in bed. Nursing Description: Heard a loud thump at resident's room and observed resident on the floor, on his back. Resident has 1 shoe on and 1 shoe off. Noted resident with head laceration and uncontrolled bleeding. Pressure applied immediately on his head. Resident Description: Resident Unable to give Description. Injury type: Laceration; location- top of the scalp. - LVN A's statement read: Nurse stated she was on the hall and heard a thump. As she approached she heard someone yell help. Upon entering the room, the resident was observed laying diagonally on his back with his head approximately a foot away from the roommates foot of bed and he was bleeding from a laceration noted to his head. Resident had one shoe on and one off. His head was on the floor and his shoulder was halfway laying on the roommates fall mat. During this interview we constructed a drawing to map out the location to clearly understand exactly where he was. Pressure was applied to the laceration while ADON called 911. Resident was getting upset because he wanted to get up, but he was able to be redirected & remained on the floor until EMS arrived to transport to the ER for further evaluation. Resident was unable to explain what happened and he became agitated when asked questions. He could have been walking or just lost balance and fell back, I don't know how he fell. Resident was present in bed and he is unable to get up without assistance. There were no other residents in the room.- CNA A's statement read I was coming from a room and heard someone call help. I saw the nurse approaching from the other end of the hall. We met up together and entered resident's room together to check on resident. He was on the floor and was bleeding from his head. He started saying Help me up and we had to tell him that he was bleeding and we needed him to stay there until the ambulance arrived. The nurse held pressure to his head and I assisted with keeping him calm & still until help arrived. He never said what he was doing or how he fell. He had slept in this morning and refused breakfast. That's not unusual, we typically reheat or offer something when he's ready to get up. The ADON came to the room and I left to check on other patients because she said she would stay with the nurse. As I was leaving the room EMS were arriving. I showed her the room diagram that was constructed during Nurse interview & she validated that it was correct for the positioning of the resident, the location of the roommates fall mat, and that the roommate was in his bed. However, she could not recall the shoes, bedside table placement, or walker location. She said she was just focused on the resident himself and keeping him calm.Notes: 07/30/25- IDT Team reviewed & discussed resident fall and hospitalization. Care plan updated. Resident was up ambulating in room without assistance; walker was by his side. ADON searched area for blood spatter or item with blood on them to identify what resident might have struck his head on; there was no blood found anywhere near him. The only plausible explanation from the shape of the laceration and proximity of the resident's fall; was that he hit his head on the corner of the resident's roommate's bed. Resident has history of agitation and refusal of care along with verbal aggression with staff; staff will utilize behavioral interventions to attempt to assist resident when he'll allow & back off & reapproach when he is upset. Record review of Resident #1's Hospital Records with admission date of 07/29/25 revealed,07/29/25- CT ( medical imaging test that creates detailed images of the body) head without contrast; findings: no evidence of brain bleed, mass, or acute infarct (sudden blockage of blood flow to an organ or tissue leading to cell death); impression: No CT evidence of acute brain abnormality; small right frontal scalp laceration.07/29/25- Chief complaint: Fall; resident arrived to the hospital at 11:46 AM with a 10 cm laceration to the top of his scalp with no active bleeding and blood pressure of 191/79. Patient with a 10 cm scalp laceration repaired with 15 staples in the ER. Neosporin applied compressive wrap ordered. In an interview on 08/26/25 at 11:04 AM, Family Member #1 said Resident #1 admitted to the facility 2 years ago and prior to the fall the resident and his roommate were moved to a new room due to scheduled maintenance of his old room. She said the facility called her on 07/29/25 to notify her that Resident #1 had an unsupervised fall, and he was supposedly found on his back with a huge laceration and no other bruising except 2 spots on his arm. Family Member #1 said while the resident had dementia, he remembered what happened when he had previous falls but, in this situation he could not remember anything. She said Resident #1 had no recollection of the fall, he just remembered waking up in the hospital. Family Member #1 said Resident #1 was verbally aggressive, cursed a lot so she was concerned someone did something to him because on all his previous falls he had some other bruising on his body. An observation and interview 08/26/25 at 12:08 PM revealed, Resident #1 sitting at his bed with a visiting family member with a healed sickle shaped area on the top on the top his heard covered with hair. He could not answer what happened to him, but he was pleasant. Resident #1 was observed with steady balance and slow gait as used his walker to use the bathroom and returned. Resident #1 was able to self-transfer himself in and out of bed with no difficulty. In an interview on 08/26/25 at 1:40 PM, LVN A said on 07/29/25 she and a CNA heard the sound of a fall and then observed Resident #1's laying on his back with his head close to his roommate's bed. She said the resident had one shoe off and his head was bleeding, so staff held pressure to his head and called 911. LVN A said she and the ADON inspected the residents room to identify what the resident could have hit his head on and there wasn't any blood splatter on any furniture, the bedside tables were not close to the resident, there were no items on the floor and Resident #1's head was over a foot away from his roommate's bed. LVN A said there were no fall mats around the residents bed because he was independent and wanted to have as much control as possible so a fall mat was a greater risk than benefit for the resident. She said during the investigation she recreated the incident with nursing administration and they were unable to determine how the injury occurred. In an interview on 08/26/25 at 2:03 PM, the ADON said she heard LVN A yelling so she went into the room and observed Resident #1 lying on the floor. She said when the resident was assessed and asked what happened he said, I don't know what the fuck happened, nothing was hurting and told the staff to get the fuck out. The ADON said the resident had both of his shoes on, and when she inspected the room there wasn't any blood on any surfaces in the room except for the spot Resident #1 was lying. There was nothing on the dresser and she could not identify what the resident possibly have hit his head on. In an interview on 08/26/25 at 2:33 PM, the Administrator said he was responsible for reporting and investigating incidents of abuse, neglect and injuries of unknow origin. He said all allegations of abuse and neglect must be reported but he was only required to report injuries of unknown origin that were suspicious in nature. The Administrator said he used the HHSC provider letter to determine the kind of incidents he reported, and he did not report the laceration to the top of Resident #1's head because after investigation he did not find it to be suspicious because the resident . He said Resident #1 was independent and his roommate could not get out of the bed to harm him. He said Resident #1 did not suffer from any fractures or broken bones so the incident did not require reporting even though the facility was unable to identify how Resident #1 got the laceration on his head. In an interview on 08/28/25 at 03:23 PM, the DON said the facility immediately lunched an investigation following Resident #1's laceration at the top of his head. She said following Resident #1's injury the facility place interventions of increased monitoring to preemptively meet the resident's needs and nursing staff also received in-servicing. In an interview on 08/28/25 at 03:23 PM, CNA A said she provided care to Resident #1 30 minutes prior to his fall. She said she heard someone say help and went she went to the room she saw Resident #1 lying on the floor saying help. CNA A said nursing staff asked Resident #1 what happened, but he was unable to answer. CNA A said Resident #1 was found on his back with his head partially on his roommate's fall mat and the other portion on the floor (over a foot away from the footboard); there was no blood splatter or drops of blood observed anywhere in the room except for where the resident's head lay. In an interview on 09/04/25 at 12:39 PM, the DON said the administrator was the abuse coordinator and a suspicious injury of unknown origin would be anything that could not be explained, bruising in unusual locations like the torso, or a resident with multiple bruises at different stages of healing. She said the facility investigation could not determine how the resident got the laceration on the top of his head, and there was no evidence he hit his head on anything. In an interview on 09/04/25 at 01:22 PM, the Administrator said suspicious injuries were any injuries that could not be explained or something like fingerprint bruising. He said any suspicious injuries of unknown origin, neglect and abuse must be reported within 2 hours. The Administrator said no one saw how Resident #1 got the laceration to his head, there was no evidence he hit any furnishings, and there was nothing on the floor that could have contributed to the floor like water etc. The Administrator said he used deductive reasoning to rule out a suspicious injury of unknown origin. He could not confirm that Resident #1's fall was not due to the injury, or that the fall occurred at the same time the injury occurred, but he said no one was in the hall around the time the resident was found on the floor. He said failure to timely report alleged injuries of unknown origin could place the facility at risk of receiving a citation.Record review of the facility policy titled Incident and Accidents revised 08/15/22 revealed, Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. 3. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. 4. The following incidents/accidents require an incident/accident report but are not limited to: Unobserved injuries. 6. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions.7. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. 14. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.Record revie of the HHSC provider letter titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) revised 08/29/24 revealed, A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Suspicious injuries of unknown source. Reportable Incidents and Timeframes: Do Report: abuse (with or without serious bodily injury) an incident that results in serious bodily injury and that involves any of the following: neglect exploitation mistreatment injuries of unknown source misappropriation of resident property. When to Report: Immediately, but not later than two hours after the incident occurs or is suspected. Do Not Report: an injury that is not suspicious or of unknown source. Injuries of unknown source: Note: an injury should be classified as an injury of unknown source when ALL of the following conditions are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one point in time; or the incidence of injuries over time.

Based on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 14 residents reviewed for ADL care (Residents #1). Facility staff failed to provide personal hygiene care to Resident #1 on 10/31/24. This failure could place residents at risk of not receiving necessary care and assistance when needed.Findings include:Record review of Resident #1's undated face sheet revealed a 73year-old female, originally admitted [DATE] and readmitted [DATE], with diagnoses including cerebral infarction (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen), spinal stenosis (space inside backbone is too small), respiratory failure (not enough oxygen in the body), hypothyroidism (thyroid gland does not make enough hormone).Record review of Resident #1's MDS Quarterly assessment, dated 05/28/25, revealed her cognitive level (BIMS) score was 0 (severely impaired). Section B: Hearing, Speech, and Vision revealed resident#1 is rarely/never understood and rarely/never understands others. Section C: Cognitive Patterns revealed Resident#1 unable to participate in the assessment because of rarely/never understood. Section GG: Functional Abilities revealed resident totally dependent on staff for all for all areas of ADL. Resident#1 was impaired of both sides of the lower extremity and uses a wheelchair. Record review of Resident # 1's care plan, dated 05/21/25, revealed ADLs Functional Status/Rehabilitation Potential: Resident #1 was dependent with all ADLs. Bed mobility with two to three persons assist, for transfers required total assistance with 3 staff, dressing was total assistance with 2 staff, and personal hygiene required 2 staff assist.Problem: The resident has an ADL self-care performance deficit r/t history of cerebral infarction (blood flow to the brain is interrupted, leading to tissue damage), confusion, impaired mobility, wheelchair bound, Adult Failure to Thrive (unexplained weight loss, malnutrition, decreased physical activity, and functional decline). 8/30/2024: Family requesting only bed baths. Date Initiated: 10/7/2022. Revision on 8/30/2024.Goal: The resident will maintain current level of function through the review date. Date initiated: 8/30/2024. Revision on: 8/30/2024. Target date: 8/16/2025.Interventions: Res with low air mattress with bolsters. Date initiated: 1/3/2024. BATHING/SHOWERING: The resident requires total assist by 2 staff with (bathing/showering) 3x a week and as necessary. Date Initiated: 10/07/2022. Revision on: 06/02/2025., BED MOBILITY: The resident requires air mattress and is Extensive assist by 2 staff to turn and reposition in bed and as necessary. Date Initiated: 10/07/2022. Revision on: 08/16/2024. BED MOBILITY: The resident uses enabler for positioning to maximize independence with turning and repositioning in bed. Date Initiated: 05/08/2023. Revision on: 05/08/2023. DRESSING: The resident requires Extensive assist by 2 staff to dress. Date Initiated: 10/07/2022. Revision on: 06/02/2025. NPO diet, NPO texture, NPO (Nothing by Mouth) consistency Date Initiated: 10/07/2022. Revision on: 4/23/2025. PERSONAL HYGIENE: The resident requires Extensive assist by 1 staff with personal hygiene and oral care.Date Initiated: 10/07/2022. Problem: The resident has limited physical mobility r/t Stroke, Weakness. Date Initiated: 01/11/2024. Revision on: 01/11/2024.Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 01/11/2024. Target Date: 08/16/2025Intervention: LOCOMOTION: The resident is totally dependent on 1 staff for locomotion usingwheelchair. Date Initiated: 01/11/2024. Revision on: 01/11/2024. Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date Initiated: 01/11/2024.Provide gentle range of motion as tolerated with daily care. Date Initiated: 01/11/2024. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date Initiated: 01/11/2024. Problem: The resident has a communication problem related to Aphasia, non-verbal, unable to voice needs, able to nod head yes/no to simple yes/no questions at times. Date Initiated: 12/07/2023. Revision on: 12/07/2023Goal: The residents needs will be met on a daily basis through the review date. Date Initiated: 12/07/2023. Revision on: 12/07/2023. Target Date: 08/16/2025.Interventions: Anticipate and meet needs. Date Initiated: 12/07/2023. COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face whenspeaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 12/07/2023. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Date Initiated: 12/07/2023. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Date Initiated: 12/07/2023. Refer to speech therapy for evaluation and treatment as ordered.Date Initiated: 12/07/2023. Speak on an adult level, speaking clearly and slower than normal. Date Initiated: 12/07/2023. Problem: Family made allegations of potential neglect. Date Initiated: 01/06/2025. Revision on: 07/25/2025 Goal: Resident will be provided timely and appropriate care based on needs. Date Initiated: 01/06/2025. Target Date: 08/16/2025.Interventions: 10/31/24: Allegation that CNA did not provide care. Immediately received a full, head to toe, assessment thereafter by a licensed nurse and personal hygiene was provided. There were no new skin issues identified during her physical assessment. Date Initiated: 07/29/2025. 5/5/25: Had a care plan with Hospice, family, and facility to determine best plan of care to address allegation of neglect. Family agreed for res to be up by 10:30am daily with agreement to put back to bed at or before 3PM and provide care by 2 staff at all times. Date Initiated: 01/06/2025. Revision on: 07/25/2025. CNA to notified nurse for any G-tube (small tube in abdomen to deliver nutrition and medication) disconnection needs with ADL care. Date Initiated: 07/25/2025. Record review of the facility Investigation Report (#542162) dated 11/7/2024, revealed the CNA did not provide incontinent care to resident on 10/31/24 during her shift (6a-3p). The findings from the facility's investigation were Unsupported because the resident was not harmed, did not have skin break down, and was cared for by the nurse on duty. In a telephone interview on 8/12/25 at 12:28pm, the FM stated Resident #1 was not changed from 5am-5pm according to the Electronic Monitoring camera footage in her room. The FM stated she reviewed the camera footage for 10/31/24, at 5:00 am until 10/31/24 at 5:18 pm. She stated Resident #1's undergarments and night gown were never changed, she was never taken out of bed, nor was her face washed. The FM stated she called the facility and spoke with the nurse (RN) on duty to find out why these services had not been done by CNA A. The FM stated the RN could not give her a response as to the reason incontinent care was not provided to Resident #1. The FM stated at this time, she requested to speak with the DON or ADON and was informed they were not available to speak with her. FM stated according to the camera, there were two people that entered the room. The FM stated one of the two people who entered Resident #1's room was the Nurse (RN) who administered meds, and the second person was a male that came to take Resident #1's blood and afterwards he walked out. The FM stated there were no nurses or aides that entered Resident #1's room to check on her throughout the day. The FM stated the camera footage from this date as well that was recorded; however, the DON stated she would investigate. The FM stated there are still issues with CNAs not going in to check on Resident #1 and she sent multiple emails to the facility, particularly the DON and Administrator, and the Ombudsman. The FM stated just last week (unable to recall the day or dated) Resident #1 was changed about 4:00pm in the evening and was not changed until 4:00am the next morning. The FM stated 12 hours had gone by. FM stated she has had to call Resident #1's CNAs to put her in proper position. She stated on one occasion they left her in an uncomfortable position with the covers almost covering her head. FM said per care planning meeting, Resident #1 was to be out of bed at 10:30a-11:00a daily for 4 hours. She stated this was discussed in the care plan meetings with facility.During an observation on 08/15/25 at 8:34am, Resident #1 was observed in the wheelchair facing the outside corridor window located in the visitor's area. Resident#1's eyes were closed and appeared to be sleeping. Her physical appearance revealed face washed and clean, dressed in clean clothes with a clean blanket over her lap, and free of marks and bruises. In a telephone interview on 8/15/25 at 4:45pm, CNA A stated she worked a double shift that day (10/31/2024). She stated she assumed she was to work in a certain hall and didn't realize she was working on the wrong hall. She agreed with the provider investigation. She stated she started working at the facility the end of September 2024 and was confused by the schedule. She stated it was an honest mistake and did not provide care 10/31/2024 during her 6:00am-2:00pm shift, which she was responsible for Resident#1's care. CNA A was terminated from the facility for unrelated reasons. In an interview on 8/17/25 at 10:30am, the OMB stated there are some issues with incontinent care not happening in nine hours. The OMB stated this was going on for about a year. The OMB stated the FM is being blown off (concerns dismissed) by facility. The OMB stated the OMB A had been more involved with the facility. The OMB stated she asked the facility to allow her to do resident rights training with facility staff, but the facility declined indicating they will do their own training. She stated the ADON typically responds to the FM and the OMB A's concerns. She believed there was a culture with aides doing whatever they want to without consequences.In a telephone interview on 8/17/25 at 11:12am, OMB Asst said during the care plan meeting a year ago the resident was supposed to be turned every two hours. These issues have been going on for over a year. She stated there has been 2 care plan meetings on Resident #1. The facility has stated they are doing training. The FM has spoken with Admin, DON, and corporate through the corporate hotline. OMB Asst stated the only response the facility gives to concerns are, staff are receiving training. OMB Asst stated she cannot say there was a staffing issue its just there is a staffing accountability. She stated she has not had other complaints from other residents at this time. OMB Asst stated there was not enough supervision from charge nurse on floor and believes there may be a leadership issue where the CNAs don't respect that authority; however, she can't say for sure. OMB Asst stated in the past she has received photos from FM showing Resident#1's neck extended, or wedges not put appropriately in place while she is in the bed. She stated FM has had to call the facility and have CNA's go into Resident#1's room and reposition her. OMB Asst stated Resident #1 is out of bed daily since the care plan meeting. She stated she has not observed Resident#1 soaked in urine. OMB Asst stated she arrives at the facility around 10:30am and observe Resident#1 completely and appropriately dressed.In a telephone interview on 8/19/25 at 12:10 pm with DON - She stated she was not employed at the facility at this time. However, the negative outcome for a resident not being changed or given incontinent care can cause skin breakdown. She stated between CNA's and Nurses a resident should be seen every two hours and repositioned. She stated charge nurses should ensure this by checking the POC on the karmex (CNA documentation) at that beginning of resident shift, middle and end of CNA's shift. [NAME] shift nurse should check the POC between 12:00pm -1:00pm. In an Interview with ADON on 8/19/25 at 1:45pm-She stated she is aware of the issues with Resident #1 not receiving in continent care on the 6am-2:00pm shift. She states the nurse completed a head-to-toe assessment after hearing about this. She stated the facility completed a report, investigation and training was provided to staff regarding this issue. She stated the negative outcome for a resident not receiving incontinent care can cause skin breakdown. In a telephone interview on 8/25/25 at10:43am CNA B, stated she has been working with Resident #1 since January 2025. CNA B stated she has never observed Resident #1 in her chair for hours. She stated she has experience in the past few months that Resident #1 tends to have a bowel movement before getting showers. She stated she has observed Resident #1 with a bowel movement and pamper soiled; however, she is unable to say how long her pamper has been soiled, which is why she never brought this concern to the attention of the facility. In a telephone interview on 8/25/25 at12:37pm CNA C stated she has been working with Resident #1 since March 2025. CNA C stated she has never observed Resident #1 in her chair for hours. However, she has noticed her pamper soiled when she and her partner arrives to give Resident #1 her shower. She stated she has not said anything to the facility because they are giving her a shower anyway, and she cannot say how long Resident #1's pamper has been soiled. Record review of the facility's Activities of Daily Living (ADL) Policy dated based 5/26/23 revealed, the facility will, based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure resident's abilities in ADL's do not deteriorate unless deterioration reaction is unavoidable. Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care;2. Transfer and ambulation;3. Toileting;4. Eating to include meals and snacks; and5. Using speech, language, or other functional communication systems.

Based on interviews and records reviewed, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 3 residents reviewed for quality of care. - The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1's left stump was found with maggots and roaches on 06/07/25. The wound was also found with roaches in addition to the maggots per the findings. CR #1 was transported to the hospital where she later had an above the knee amputation. An Immediate Jeopardy (IJ) was identified on 06/13/25. The IJ template was provided to the facility on [DATE] at 10:51 a.m. While the IJ was removed on 06/15/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk of not receiving necessary medical care, infection, a decline in health, the need for hospitalization and/or death. The findings included: Record review of CR #1's admission Record, dated 06/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying condition that affects metabolism), cardiac arrest (sudden loss of heart function), peripheral vascular disease (disorder that restricts blood flow to the arms, legs, or other body parts), acquired absence of left leg below knee, and infection of amputation stump. Record review of CR #1's MDS Quarterly Assessment, dated 04/10/25, revealed a BIMS score of 15, indicating she was cognitively intact. Further review revealed resident required a helper to complete toileting, shower/bathe, and lower body dressing. Record review of CR #1's care plan report, undated, revealed the resident had a left BKA stump infection, date initiated: 04/27/25, and interventions included to administer antibiotic and antipyretic as per MD orders. Resident was on IV medications for infection of left stump for 6 weeks r/t stump infection, date initiated and revision on 03/28/25. Resident was on antibiotic therapy r/t wound infection. Resident had potential/actual impairment to skin integrity to the left BKA r/t ulcer. Resident was at risk for impaired skin integrity related to non-compliance with treatment to left BKA. Interventions included resident returned from hospital and refused recommended treatment options while admitted , date initiated: 04/04/25, administer medications as ordered, conduct skin inspections / examinations weekly and as needed, encourage resident participation and compliance with plan of care, if resident refuses treatment, discuss with resident / family / IDT to determine why and try alternative methods / interventions to gain compliance, date initiated for these interventions was 06/08/25. Record review of CR #1's physician orders, undated, revealed the following orders: if resident leaves the building or goes outside-apply dressing to wound for protection as needed, every 2 hours as needed, start date: 06/07/2025 . Removed maggots gently on left leg stump, clean with wound cleanser, applied idone [sic], let dry and covered with dry dressing, one time only for stump infection for 1 day, start 06/07/2025 .ceftriaxone sodium injection solution reconstituted 1 GM, inject 1 gram intramuscularly one time a day for skin infection for 3 days, start 06/07/2025, .amoxicillin-pot clavulanate oral tablet 875-125 MG, give 1 tablet by mouth two times a day for wound infection for 1 month, start 06/07/2025 .Left BKA: Cleanse with NS/wound cleanser, pat dry. Apply iodine, leave open to air, one time a day for skin mgmt., start : 03/05/25 .weekly skin evaluation one time a day every Thu, start date 02/06/25 .doxycycline hyclate oral tablet 100 MG, give 1 tablet by mouth two times a day for wound infection for 1 month, start 04/28/25, end 05/28/25 .amoxicillin-pot clavulanate tablet 875-125 MG, give 1 tablet by mouth two times a day for wound infection for 1 month, start 04/28/25, end 05/28/25 . Record review of CR #1's progress notes, dated 06/07/25 at 13:36 (1:36 p.m.), Type: Change of Condition, Author: Nurse A, read in part .Maggots on stump left leg, started 06/07/2025, since started it has gotten: Stayed the same .Removed maggots, clean with wound cleanser, applied idone [sic] let dry and covered with dry dressing .Notifications: [family member] 06/07/2025 1:40 PM, Dr [name] 06/07/2025 1:40 PM . Record review of CR #1's progress notes, dated 06/07/25 at 14:32 (2:32 p.m.), Author: Nurse A, read in part .For [family member's] request res was sent to [hospital name], 911 was called @ 14:00 [2:00 p.m.], arrive @ 14:08 [2:08 p.m.], res was lying on bed, alert, oriented x3, res no complains of pain or discomfort, left stump was already clean and covered by Dr orders, VSNL, SPO2 98% 3L n/c, no distress or SOB . Record review of CR #1's hospital records, dated 06/07/25, read in part .Pt arrives EMS from [nursing facility name] with reports of possible wound infection. Pt had a BKA a couple of years ago. Pt had cardiac arrest in January and was in the hospital for 9 days then went to rehab. While in the hospital the physician stated she needs AKA and pt has refused. Pt has maggots and roaches in the wound according to EMS. Both insects were visualized . During an interview on 06/11/25 at 10:13 a.m., Treatment Nurse B said it was her understanding that Nurse A saw something concerning and grabbed Nurse C and sent the resident to the hospital. She said when the resident was moving around, the maggots were not visible, but when the resident was still and her leg was not moving, they got close and that was when they saw movement on the backside of the wound. She said they notified the physician and when talking with the family they decided to send her out to the hospital. She said she spoke to Nurse A over the telephone on Saturday, 06/07/25, around 4:00 p.m. or 5:00 p.m. and told her to keep her updated. She said the nurse from the hospital called and reported to Nurse A there were maggots in CR #1's stump. She said CR #1's wound treatment was done daily. She said she did not know if the treatment nurse had already performed wound care for the day. She said neither Treatment Nurse B nor Nurse B reported any wound care concerns to her for CR #1 for the month of June 2025. She said CR #1's wound was very hard, scabbed, and had eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds). She said if a wound had maggots, it was a sign of infestation. She said CR #1 had been on long term antibiotics and believed it recently switched to by mouth. She said the eggs could be present in the wound from 0-24 hours but said she did not know what the development was until they transitioned into a fly. During a telephone interview on 06/11/25 at 10:53 a.m., Treatment Nurse C said she did not provide wound care to CR #1 on 06/07/25 nor had she seen her on this day. She said Nurse A told her there might be maggots in CR #1's wound. She said Nurse A and Nurse C said they were going to send CR #1 out to the hospital. She said they wrapped her leg and moved her roommate out of the room. She said the resident was very non-compliant with her dressing and was always tearing it off and would not keep it wrapped. She said the resident was a heavy smoker. She said the life cycle of a maggot was approximately 3-4 days from the time they lay eggs. She said the last time she provided wound care to CR #1 was on Tuesday morning, 06/03/25, and it looked fine. She said the wound was hard like tree bark. During an interview on 06/11/25 at 11:07 a.m., Nurse A said around 10 something in the morning on 06/07/25 CR #1 was outside in the smoking area when one of the staff came to her and told her the resident was outside and was not feeling well. She said she went outside, took her vitals and her BP and O2 were low. She said she took CR #1 back to her room and she and a CNA put her on her bed. She said she contacted the NP, did everything that was ordered, and called the family. She said she did not recall the time, but later when she was checking on CR #1, CR #1 asked her to cover her leg and when she went to cover her leg, she saw more than 5 but less than 10 maggots coming from her left stump. She said the resident did not feel any pain, was verbal, oriented, and alert. She said she went and told ADON B who told her to call the doctor. She said the doctor gave an order to clean area, apply iodine, and cover with dry dressing. She said before cleaning the area, she contacted CR #1's family member who said he would like for her to go to the hospital. She said she did not see any other insects/bugs in the wound. She said when CR #1 was in a resting position, the maggots would come out and when she moved the maggots would go back inside. She said she observed small holes, but the skin was hard. She said she did her rounds around 1:30 p.m. During an interview on 06/11/25 at 11:28 a.m., Treatment Nurse A said he has been working for the facility since October of last year (2024) and working as a Treatment Nurse since 06/02/25. He said he provided wound care to CR #1 on 06/06/25 and the wound was fine. He said he did not see any drainage or maggots. He said the wound was dark and hard. During a telephone interview on 06/11/25 at 11:37 a.m., Nurse C said she was at the nurse's station on 06/07/25 (did not recall the time) when a resident came and said CR #1 was not feeling well. She said she assisted Nurse A take CR #1 back to her room. She said she did not remember what time but approximately 45 minutes later, Nurse A asked her for assistance with wrapping CR #1's leg. She said she saw a little bit of blood and about 5-10 maggots on the underside of CR #1's stump. During a telephone interview on 06/11/25 at 12:06 p.m., the Wound Care Doctor who said CR #1 had really bad peripheral vascular disease and had recommended further amputation, but CR #1 declined. He said she had dry gangrene, and they were waiting for it to progress to wet gangrene because she refused surgery. He said it would take a couple of days to see maggots. He said they could [NAME] underneath if there was no drainage but as they multiply, they could come out. He said CR #1's stump was all one big piece of necrotic, dead, dry tissue. During an interview on 06/11/25 at 1:40 p.m., CR #1, said they were not doing wound care at the facility. She said the Wound Care Doctor would go and see her. She said she did not know she had maggots. She said they had to do surgery. During an interview on 6/11/25 at 1:47 p.m., the Hospital Nurse who said he took care of CR #1 the day after she was admitted , 06/08/25, and saw maggots on the floor. He said her stump was necrotic, black, had gangrene, and maggots were coming out. During an interview on 06/11/25 at 2:05 p.m., the Hospital MD , who said it was unexpected to have a patient to come from a NF with maggots in a wound. He said it also depended on the compliance of the patient. He said it probably takes 3 or so days to develop maggots. He said going outside could cause exposure to other things. He said when they talked to CR #1 about surgery, she said yes and did not hesitate. He said CR #1 had an above knee amputation. During an interview on 06/12/25 at 7:28 a.m., CNA A said she worked 06/07/25 and was assigned to CR #1. She said she first saw CR #1 during her first round around 6:30 a.m.-7:00 a.m. She said she was providing incontinent care, CR #1 was turned towards the wall, lying on her right side, and as she was wiping her, she happened to look down and saw that her wound was leaking blood and saw something moving on the left side of her wound. She said she asked the resident if she was hurting, and CR #1 said yes, her leg was hurting and said CR #1 always said her leg hurt. She said she finished incontinence care and went and told Nurse A she saw something moving and CR #1 said she was hurting. She said Nurse A went to CR #1's room and looked at the wound and then left the room and went back to her cart which was right outside of the room. She said she saw CR #1 after breakfast, approximately around 9:30 a.m.-10:00 a.m., and the resident was in bed and had an IV. She said CR #1 was usually quiet, she would get up for smoke breaks, was not too fond of the food, and slept the majority of the day if she was not up smoking a cigarette. She said she saw her during lunch, and she was the same. CNA A said when she would check on CR #1, she would say she was okay, but she was out of it and would go back to sleep. During an interview on 06/12/25 at 8:12 a.m., the DON who said at first CR #1 would not allow a lot of dressing changes. She said there were times where they could not find her or times where she would be outside smoking and would tell them she was not going back inside for wound care. She said when the wound care doctor would come, they would ask him to see her first in case she refused and that way he could check back before he left. She said the hospital talked to her about having additional surgery back in April of 2025, but CR #1 declined. She said the resident also declined palliative care. She said Nurse A called her around 1:00 p.m. on 06/07/25, and said it was like she saw a worm and when CR #1 moved, it went back in, so she told her to lie still. She said she went and got Nurse C and she had CR #1 lie still and they started coming out. She said Nurse A called the doctor and the family. She said the brother wanted CR #1 to go to the hospital, so they called 911 and sent her out. She said the Physician gave an order to clean, betadine, cover, and contact family. She said her graph was already occluded and would require surgery. During a telephone interview on 06/12/25 at 9:23 a.m., the Physician who said CR #1 would refuse to get dressing changes. He said the nurse called him immediately (he did not recall the exact day and time). He said he gave an order to clean the wound, apply iodine, wrap, and to talk to the family. He said maggots are unexpected and it was not acceptable to see them in a wound, but maggots per se helps clean a wound. He said maggots were not preventable and if they were going to happen, they were going to happen. He said keeping it clean was the only way to prevent but it did not not provide 100% protection. He said there would always be some kind of contamination if a resident was going outside or to other places. He said he did not know the life cycle of a maggot, but it could not be long, maybe 24 to 48 hours. During a follow-up interview on 06/12/25 at 10:06 a.m., Nurse A said on the morning of 06/07/25, around 7:00 a.m., CNA A told her she saw something in CR #1's wound. She said the wound was open to air and that she moved the leg and looked around and did not see anything. She said they were in the process of changing her brief and clothing her so they could transfer her to her wheelchair. During a follow-up interview on 06/14/25 at 8:44 a.m., the Physician who said maggots reflected the dirtiness of the wound. He said he had been telling CR #1 to have the amputation for more than a year. He said he knew she liked to go outside, sit in her wheelchair, the flies could go and smell the wound, and could land on it. He said the wound was already necrotic for a long time. He said he repeatedly talked to her about getting surgery for the past year, he thinks, more or less, and she would refuse. He said the last time he talked to her about surgery was about 3 months ago, her family member was present in the room, she refused, just kept complaining about the pain, and was requesting pain medication. He said her family member verbalized that was the way she was and would probably be better off with hospice because she was not going to agree with any treatment and was suffering with a lot of pain from the wound. He said her wound was dead necrotic tissue and it was a rich medium for infection for the maggots to come in. He said any creatures could smell the dead tissue and go by smell. He said she may not have been refusing the wound care treatment, but she was refusing the surgery. Physician said one of the reasons you leave the wound open to air was to allow the oxygen to reach the wound. During a telephone interview on 06/17/25 at 8:18 a.m., CR #1's family member said there had been refusals from CR #1 from the beginning of January of this year. He said when CR #1 should not be smoking, she would be smoking which probably led to the problem she had. He said she was outside in the heat with an uncovered wound. He said there would be times that he would be sitting outside with CR #1 and flies would land on her wound and he would have to shoo them away. He said he never mentioned it to the facility. He said he had never spoken to the wound care doctor directly. He said a long time ago, he thought about 6 months ago, when CR #1 first entered the facility, he talked to the doctor. He said the doctor did not say anything about her wound. He said he just talked about her status. He said CR #1 had just come off from having a devastating heart attack and the doctor mentioned about her going on hospice, but it would be her choice. He said CR #1 and he decided not to do hospice. He said hospice was always on the table, offered several times, but did not recall when the last time was that the facility brought up hospice again. He said something he did not understand was why the doctor did not send CR #1 to the hospital. He said Nurse A called him and told him there were maggots coming out of CR #1's leg and the doctor said to clean and cover, and that was the end of their conversation. He said he spoke to his significant other and said to her why was CR #1 not in the hospital. He said he called the facility back and spoke to Nurse A and told her to send CR #1 to the hospital. He said he was never contacted by the doctor. He said CR #1 has refused treatment from the doctor, hospital, wound care doctor, and everywhere she has gone. He said CR #1 was a person who was non-compliant and did not accept help from anyone. He said he saw her earlier that week, probably on Thursday, 06/05/25. He said he did not notice anything different with the wound. He said there was no smell coming from the wound. He said the wound was just dark, hard, and looked like a big scab over CR #1's knee. He said the only thing he questioned to himself was why the doctor did not say send CR #1 to the hospital when he heard the word maggots come out of Nurse A's mouth. He said he was baffled. Record review of the facility's Treatment Nurse Job Description, undated, read in part .The treatment nurse will provide quality of care to prevent and promote healing of alterations and skin integrity at each residence as determined by resident assistance and individual plans of care . The Administrator was notified on 06/13/25 at 10:51 a.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 06/13/25 at 8:10 p.m.: June 13, 2025 [Nursing Facility Name] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On June 13, 2025, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The alleged Immediate jeopardy allegations are as follows: Issue: F684 - Quality of Care The facility failed to ensure treatment and care was provided to CR#1 consistent with professional standards of practice. CR#1's left stump was found with maggots on 6/7/25. CR#1 was transported to the hospital where she later had an above the knee amputation. Actions for Resident Involved -Resident CR#1 was discharged to the hospital on 6/7/25. -On 6/7/25, Resident CR#1's room was inspected by Maintenance Director or designee for insects/pests and there were none identified. The room was deep cleaned on 6/8/25. -On 6/7/25, Resident CR#1's beddings and clothing were removed by charge nurse and sent to [NAME] for wash. -On 6/7/25, Maintenance Director or Designee was called by Administrator and serviced room [ROOM NUMBER] for pest control. Identify residents who could be affected: -On 6/7/25, All current residents with wounds were checked and visualized by the Director of Nursing and/or Designee to ensure that there are no signs of insects/pests and that wounds are treated and are covered with dressings as ordered. There were no other findings noted. -On 6/8/25, DON/Designee completed a review of wound care orders and care plan updates. Residents with wound orders with no wound dressings i.e., open to air and/or residents refusing wound care treatments/non-compliance will be referred to physician for review of orders, document and care plan will be updated. -On 6/7/25, ADONs completed room checks to identify presence of pests/insects and there were none noted. Action Taken/ System Change: -On 6/7/25 and 6/13/25, All Facility staff were re-educated by the Administrator or designee on: o Abuse and Neglect Prohibition o Observing and immediately reporting any observation of insects/pests in the facility. -On 6/7/25 and 6/13/25, 100% of licensed nurses were re-educated on the following: o Wound inspection for presence of pests/insects in wounds/impaired skin integrity o Ensure wounds are covered with wound dressings as ordered. o Wound treatments with no wound dressing orders i.e., open to air, will be referred to the physician especially if residents leave the facility or go outside. o Residents refusing wound treatments/wound dressings and non-compliant with wound care will have the physician and RP notified and care plan updated. -Beginning 6/13/25, licensed nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. -Beginning 6/13/25 and ongoing, newly hired licensed nurses will receive this training during orientation prior to providing care to residents. The training will include the above-stated educational components. -New Admissions/Readmissions will be reviewed during morning clinical meetings to ensure that wound treatments are ordered and carried out. Residents refusing wound treatments will be reviewed, ensure that physicians and RPs are notified and care plan updated. -Completion date: 6/13/25 Monitoring: -Beginning 6/13/25 and going forward, the Director of Nursing/Designee will monitor compliance with wound treatments to include wounds are covered with dressings according to physician's orders and to ensure that any change in the wound condition/presence of pests that the physician is notified, and plan of care is updated. -Beginning 6/13/25 and going forward, Director/Designee will review that treatments are performed and documented as ordered to include residents who refuse wound treatments will be re-evaluated, physician and RP will be notified, and care plan is updated. -Beginning 6/13/25, the Director of Nursing or designee will monitor compliance each weekly morning. -On 6/7/2025 and 6/13/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to discuss the immediate jeopardy and review the plan of removal. We respectfully submit this action plan for the removal of Immediate Jeopardy. Sincerely, [Name], Administrator On 06/14/25-06/15/25, surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by the following: Record review of the Abuse & Neglect and Pest Control in-service training report, dated 06/07/25, reflected 146 staff members were reeducated on the facilities Abuse and Neglect Policy and Procedure, as well as observing for and immediately reporting the presence of pest in the facility with examples provided. Reeducation included immediately reporting observations to the Administrator and/or DON, as well as department supervisor. Record review of the Observation of Wounds and Orders in-service training report, dated 06/07/25, reflected 31 licensed nurses were educated on the etiology and appearance of maggots, as well as observing for and immediately reporting the presence of maggots in wounds / open skin conditions. The reeducation included obtaining orders for wounds to be covered with a dressing when residents leave the building, including wounds with orders to leave open to air. Record review of the Abuse & Neglect and Pest Control in-service training report, dated 06/13/25, reflected 130 staff members were reeducated on the facility's Abuse and Neglect Policy and Procedure, as well as observing for and immediately reporting the presence of pest in the facility with examples provided. Reeducation included immediately reporting observations to the Administrator and/or DON, as well as department supervisor. Record review of Observation of Wounds and Orders in-service training report, dated 06/13/25, reflected 31 licensed nurses, LVNs and RNs, were reeducated on observing for the presence of pests/insects in wounds and open skin conditions. The reeducation included immediately reporting any observation of pest/insects and/or abnormality in a wound to the MD and initiating a change in condition. Licensed nurses were also reeducated on following physician orders and informing the MD of any refusals and/or non-compliance related to wounds and wound care. Reeducation also included ensuring wound care orders included covering wounds and consulting the physician whenorders for wounds to be left open to air. Record review of CR #1's progress notes, entered by Nurse A, on 06/07/25, reflected that the beds were stripped, room was checked for any food or perishable products that would attract insects, all bedding and clothing was sent to laundry, and the room would be treated and deep cleaned. Record review revealed an undated typed statement by the Environmental Supervisor that read he deep cleaned CR #1's room on 06/07/25, after she discharged , and he did not see any signs of pests in the room at the time of cleaning or after cleaning the room. Record review of progress notes, dated 06/07/25, reflected the DON or designee checked and visualized all current residents with wounds and none were found to have signs of insects/pests and their wounds were treated and covered with dressing(s) as ordered. Record review of the care plan audit, dated 06/07/25, reflected 48 residents who had a wound identified. Record review of the wound care order audit, dated 06/07/25, reflected 48 residents whose orders were reviewed. Interviews were conducted from 06/14/25 to 06/15/25 with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.). Staff interviewed included the following: Administrator, DON, ADON B, Environmental Supervisor, Maintenance Assistant, Nurses B, D, E, F, G, and H, MA A, CNAs B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P, and Nursing Assistant in Training. All staff interviewed verbalized an understanding of the facility's Abuse and Neglect Policy and Procedure, as well as observing for and immediately reporting the presence of pest in the facility to the Administrator and/or DON, and department supervisor. Licensed nurses verbalized an understanding on wound inspection for presence of pests/insects in wounds/impaired skin integrity, ensuring wounds are covered with wound dressings as ordered, wound treatments with no wound dressing orders, residents who refuse wound treatments/wound dressings and non-compliance with wound care. During an interview on 06/14/25 at 8:19 a.m., Environmental Supervisor said one of the maintenance guys (not sure who) called him and told him the room was ready for deep cleaning. He said he did not recall what time he was notified. He said he checked trash cans, observed the room, dust, broomed, mopped, and after sweeping and cleaning, used DC33, a disinfectant cleaner, on hand to surface areas throughout the room that were commonly touched by residents and staff, i.e. doorknobs, dresser handles, anything hand to surface. He said he wiped down the beds, handrails, sanitized/mopped down the floors. He said he did not find anything that he could recall during the deep cleaning process. He said he believed the deep cleaning occurred on 06/07/25. During an interview on 06/14/25 at 9:18 a.m., the Maintenance Assistant who said he received a call last Saturday, 06/07/25, from the Administrator around 3:00 p.m.-4:00 p.m. and he told him that CR #1's room had a complaint that they had seen some pests or something like that. He said he went to the facility around 6:00 p.m.-6:30 p.m. He said he checked the room from side to side and did not see anything. He said he used some disinfectant wipes, the linens had already been removed, and he wiped down the mattress. He said after that he requested a deep cleaning for the room through the department heads via text. During an interview on 06/14/25 at 10:51 a.m., the DON who said they put their eyes on all the residents with wounds on 06/07/25 and made sure all were checked. She said Treatment Nurse C, ADON A, ADON B, ADON C, and her helped. She said they looked at orders and sites on Saturday, 06/07/25, and on Sunday, 06/08/25, they made sure the care plans were updated and matched the orders and sites. She said CR #1 was the only one who was consistently refusing wound care. She said none of the residents had to be referred to physician for non-compliance of wound care. She said the medical director said if they have a resident that has an order for leave open to air that to PRN cover if they are going to go outside and/or leave the building for right now. She said as of today, all open wounds have an order to be covered. She said it is part of the in-service for new admissions, and/or if they return from a doctor's appointment with a new order to leave open to air they have to call and clarify with the physician to see if they can cover it, and if not then to document. She said the preferred treatment is for the wound to always be covered. She said on 06/07/25 at about 3:30 p.m. Nurse A and she moved out the other resident from the room, stripped the beds, she checked their drawers and bedside tables for any food or open items, then took all laundry and bedding to laundry and had them rewash everything. She said the Maintenance Assistance came later that evening, around 6:44 p.m., and treated the room. She said the ADONs and her started conducting in-service on 06/07/25 with licensed nursing staff on wound inspection for presence of pests/insects in wounds/impaired skin integrity, ensuring wounds are covered with wound dressings as ordered, wound treatments with no wound dressing orders, residents who refuse wound treatments/wound dressings and non-compliance with wound care. She said if they see any changes to the skin site they do a change in condition, or if a resident is being non-compliant and going outside with an exposed wound then it needed to be documented and notifications needed to be made appropriately and care plan updated by nursing. She said she was running the TAR every morning for missed documentation, refusals, and a full order listing report to ensure that it was a complete order, and a dressing was part of the order. She said they reviewed all new admission charts, and they would ensure that the orders had dressings in place or ask for clarification at that time. She said if they were identified as a refusal, she would ensure documentation was done and the wound would be reassessed at that time. She said it was part of the morning clinical meeting to review all residents a[TRUNCATED]

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 including hand hygiene procedures to be followed by staff involved in direct resident contact for 2 (Resident #1 and Resident #2) of 6 residents reviewed for infection control. 1.-The facility failed to ensure proper hand hygiene and infection control procedures, when LVN A applied clean dressing without washing/sanitizing her hands or changing her gloves during Resident #1's catheter care on 06/05/2025. 2.-The facility failed to ensure proper hand hygiene and infection control procedures, when RN B initiated catheter care for Resident #2 without washing/sanitizing her hands prior to donning gloves at the start of care. RN B failed to remove her gloves and wash/sanitize her hands throughout Resident #2's catheter care on 06/05/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #1s face sheet dated 06/05/2025 reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with a primary diagnosis of Acute Cystitis without Hematuria (a bacterial infection of the bladder, without blood in the urine), and secondary diagnosis of infection and inflammatory reaction due to indwelling urethral catheter (a hollow tube inserted through the urethra into the urinary bladder to drain urine.) Record review of Resident #1's Entry Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's admission MDS assessment was not due for completion. Record review of Resident # 1's undated care plan revealed the following: Problem: The resident has a suprapubic catheter r/t(related to) benign prostatic hyperplasia without lower urinary tract symptoms. Goal: The resident will show no s/sx (sign and symptoms) of urinary infection through review date. The resident will be/remain free from catheter-related trauma through review date. Interventions: Suprapubic cath (catheter) care q (each) shift and PRN (as needed). Record review of Resident #2's face sheet dated 06/03/2025 reflected Resident #2 was a [AGE] year-old male admitted on [DATE] with a primary diagnosis of Flaccid Hemiplegia Affecting Left Dominant Side (a condition where the left side of the body, experiences paralysis with limp, floppy muscles due to neurological damage). Record review of Resident #2's quarterly MDS assessment, dated 04/01/2025, revealed a BIMS (Brief Interview for Mental Status) score of 13 out of 15 which suggests intact cognitive function. Record review of Resident # 2's undated care plan revealed the following: Problem: The resident has a suprapubic catheter and is at risk for infection/trauma Goal: The resident will be free of catheter related trauma through review date. Interventions: Suprapubic cath care q shift and PRN. In an observation on 06/05/2025at 10:13 am with LVN A as she performed suprapubic catheter care on Resident #1. LVN A washed her hands, donned (process of putting on protective gear) a gown, and applied clean gloves. LVN A cleaned the table with sani-wipes, removed gloves, washed hands, and then applied new gloves. LVN A applied Normal Saline to a cup with 4x4 gauze inside, then cleaned around the site from the inside to the outside with one 4 x 4 gauze at a time, and then took a 4x4 gauze and cleaned the foley line from starting from the entrance site and going outwards a few inches. LVN A applied a new, clean dressing without sanitizing her hands or changing her gloves. In an observation on 06/05/2025at 10:29 am with RN B as she performed suprapubic catheter care on Resident #2. RN B put clean gloves on and put 4x4 gauzes into a cup without first sanitizing or washing her hands. RN B then donned a gown and new gloves without first sanitizing or washing her hands. RN B then picked up a trash can with the same gloves and proceed to remove the old dressing. RN B assessed the site which looked red and crusty. RN B removed her gloves and applied new gloves without sanitizing or washing her hands. RN B cleaned the site from the inside to the outside with one 4x4 gauze each time and then the actual catheter line starting with the closest end to the site and going outward. RN B then applied a clean dressing without washing/sanitizing her hands or changing gloves. In an interview on 06/05/2025 at 11:15 am with RN B, she said she forgot to wash/sanitize her hands before starting Resident #2's catheter care and by not doing so infection could happen. RN B said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing also, and that could cause an infection. RN B said washing/sanitizing hands was to prevent infection. RN B said that she had been trained on infection control prior to entrance. In an interview on 06/05/2025 at 11:17am with LVN A, she said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing during Resident #1's catheter care. LVN A said the reason for changing gloves was to prevent cross contamination. LVN A said the reason for washing/sanitizing hands was to prevent germs. In an interview on 06/05/2025 at 11:15am with RN B, she said she forgot to wash/sanitize her hands before starting Resident #2's catheter care and by not doing so infection could happen. RN B said she forgot to change her gloves and wash/sanitize her hands before putting on a clean dressing also, and that could cause an infection. RN B said washing/sanitizing hands was to prevent infection. LVNA said that she had been trained on infection control prior to entrance. In an interview on 06/05/2025 at 11:29 with the DON, she said there wasn't a specific procedure for suprapubic catheter care, it was done with routine Activities of Daily Living (ADL) care, and not specific site care. She said that it was her expectation that nursing staff wash/sanitize their hands first prior to care. She said that the nurse should then apply gloves, remove the dirty dressing, take off the dirty gloves, wash/sanitize hands, and apply clean gloves. She said that the nurse should then use 1 4x4 gauze soaked with normal saline, at a time and clean from the inside to the outside of the stoma site. She said that the nurse should use 1 4x4 gauze to wipe at a time and clean the drainage tube starting closest to the stoma and going outwards. She said that the nurse would remove the dirty gloves, wash/sanitize their hands, apply clean gloves, and then apply the clean dressing. She said that by not washing/sanitizing hands and changing gloves could cause an infection control issue. Record review of the facility's policy titled Hand Hygiene dated 10/24/2022 read in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all location within the facility. Definitions: Hand hygiene is a general term for leaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to , the attached hand hygiene table . Hygiene table, CDC(Center for Disease Control) recommendations for hand hygiene, Prior to direct contact with residents, Before donning sterile gloves for procedures, after contact with a resident's skin, after contact with blood or body fluids, and after removing gloves .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmaceutical services. RN A failed to request a refill of Resident #1's prescribed Testosterone medication (administered every two weeks) timely and resulted in a missed dose on 03/25/2025 until one week later (04/01/2025). This failure placed residents at risk of experiencing worsening symptoms/conditions, pain, and possible infection from missed doses of prescribed medication. Findings include: Record review of Resident #1's face sheet dated 04/03/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), quadriplegia (paralysis in all four limbs), neuralgic amyotrophy (multifocal inflammatory neuropathy that usually affects the upper limbs), neuromuscular dysfunction of bladder (urinary bladder problems due to nerve damage or injury), and essential hypertension (a chronic cardiovascular disease that causes abnormally high blood pressure for unknown reasons). Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact); Resident #1 did not exhibit behaviors related to hallucinations, delusions, behavioral symptoms, or rejection of care; Resident #1 was wheelchair bound (motorized); Resident #1 was dependent on staff for oral hygiene, toileting hygiene, showers, dressing, and personal hygiene; Resident #1 had an indwelling catheter; Resident #1 was always incontinent of bowel; and Resident #1 occasionally experienced pain. Record review of Resident #1's care plan revised on 03/14/2025 revealed the following care areas: * The resident has an ADL self-care performance deficit related to Multiple Sclerosis, HTN, depression (a group of conditions associated with the elevation or lowering of a person's mood): Goal included: The resident will maintain current level of function in ADL's. Interventions included: Resident with low air mattress with bolters. Resident may use enabler as indicated for bed mobility. Transfers: The resident requires mechanical lift with x 2 staff assistance. Bathing/Showering: The resident requires total assistance with 2-person assistance with bath/shower 3x per week and as necessary. Toilet Use: The resident requires extensive assistance of 1 person for incontinence care. * The resident has potential for exhibiting attention for sexual inappropriate behaviors towards females. Goal included: The resident will have no evidence of behavior problems. Interventions included: If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Record review of Resident #1's physician's orders for March 2025 revealed: * Testosterone Cypionate 200 mg/ml to inject 1.25 ml IM every 2 weeks in the morning, every 2 weeks on Tuesday for hypogonadism (a failure of the gonads, testes, or ovaries, to function properly). Order date: 09/10/2024. Start date: 09/24/2024. Record review of Resident #1's Mar for March 2025 revealed: * Testosterone Cypionate 200 mg/ml to inject 1.25 ml IM every 2 weeks in the morning, every 2 weeks on Tuesday for hypogonadism. Start date: 09/24/2024. D/C Date: 04/01/2025. The medication was administered as prescribed on 03/11/2025 by RN A. The medication was not given on 03/25/2025. RN A indicated to see the resident's progress notes for the reason why it was not administered. Record review of Resident #1's MAR for April 2025 revealed: * Testosterone Cypionate 200 mg/ml to inject 1.25 ml IM every 2 weeks in the morning, every 2 weeks on Tuesday for hypogonadism. Start date: 04/01/2025. This medication was administered on 04/01/2025. Record review of Resident #1's nursing progress notes for March 2025 revealed: * On 03/25/2025, at 11:45 a.m., RN A wrote, Testosterone Cypionate 200 mg/ml to inject 1.25 ml IM every 2 weeks in the morning, every 2 weeks on Tuesday for hypogonadism pending for pharmacy delivery. Observation and interview with Resident #1 on 04/03/2025 at 10:00 a.m. revealed he was alert, oriented, and ambulated via motorized wheelchair. He stated RN A did not give him his prescribed testosterone injection two weeks ago until yesterday (04/02/2025, but it was administered on 04/01/2025). He said RN A told him there were no more refills on the injection, so he had to call the pharmacy. He said on the night after he missed the dose, a night nurse told him the medication was available in the building, but nobody offered to give him the injection until 04/02/2025 (it was administered on 04/01/2025). He said he never felt any different from not getting the injection. In an interview with RN A on 04/03/2025, at 11:30 a.m., he stated Resident #1 missed a dose of Testosterone last week because the nurse who administered the last dose did not reorder the medication. He said he did not know who gave Resident #1 the last dose of Testosterone (on 03/11/2025), but then on his shift (on 03/25/2025), there was no medication available to administer. He said he told Resident #1 he would call the pharmacy and get the medication. He said the pharmacy delivered the medication Wednesday night (03/26/2025), but since Resident #1 took the medication every other week, he did not get it until the next Tuesday (04/01/2025). He said usually, he would reorder medication when a resident had one dose left. He said you would not wait to reorder until you administer the last dose of medication because you may not have it in time for the next dose. He said which ever charge nurse saw that the medication was running low should reorder the medication. He said he normally reordered medication through their computer system. He said any negative affects of missing a medication dose would depend on the medication. He said he did not know why Resident #1 was prescribed Testosterone because he was already aggressive. He said he did not think Resident #1 would experience any negative affects from not taking a dose of Testosterone. In a follow-up interview with RN A on 04/03/2025, at 12:30 p.m., he stated, Oh yeah, I remembered what happened. He said he was the last nurse who administered Resident #1's Testosterone. He said he saw it was Resident #1's last dose on 03/11/2025 and he reordered it through the computer system. He said since it was not a daily medication, he did not remember to check on it until it was time to give it again on 03/25/2025. He said he had to call the pharmacy, and then they sent the medication. He said from now on, he will order the medication and call the pharmacy on the same day. In an interview with the DON on 04/03/2025, at 12:40 p.m., she stated she knew the ADON had to reorder the Testosterone because there were no more refills, but she did not know when RN A tried to reorder it and found out that there were no more refills. She said she would contact the pharmacy to find out when RN A placed the order because there was no documentation in Resident #1's progress notes to show when it was done. In an interview with the DON and ADON on 04/03/2025, at 1:30 p.m., the DON said the pharmacy representative told her if any order was made by phone, they did not have a record of it. The ADON said she called the pharmacy on 03/25/2025 to reorder the medication and it was received in the facility and signed for on 03/26/2025, at 1:23 a.m. The DON said she asked RN A about the incident, and he told her he tried to administer the injection the next day on 03/26/2025, but Resident #1 refused. The DON said she had not spoken to RN A about it that day (04/03/2025), but she could not recall the day she spoke with him about it. The DON said RN A had a text message in his phone to Resident #1's NP asking if it was okay to administer the medication on 03/26/2025 (this text nor the answer from the NP were provided during the investigation), but there was no documentation about it in Resident #1's chart. The DON said Resident #1 told her RN A did not offer him the injection on 03/26/2025. The DON said the medication was discontinued on Resident #1's MAR and then restarted the next Tuesday to get him back on the two-week routine. The DON said RN A told her everything was done (the medication was reordered) by phone. The DON said RN A did not tell her he tried to reorder the medication electronically. The ADON said RN A could have pushed the button to reorder the medication through the computer system but since Testosterone was a controlled substance, only she (an ADON) or the DON could have reordered it. The DON said this medication should have been reordered when the last dose was given since it was administered every 14 days. The DON said she was not sure why Resident #1 received Testosterone because he was aggressive. She stated Resident #1 did not experience any negative effects when he missed the dose of medication. An attempt was made to contact Resident #1's NP on 04/03/2025, at 1:43 p.m. A voicemail message was left but the call was not returned prior to the survey exit. Record review of the facility's policy titled, Ordering and Receiving Medications from Pharmacy, revised on 10/01/2019 revealed, . It will be the responsibility of the facility to re-order the medication to avoid any lapse in therapy . 6. Refill Medication Ordering - Maintenance Reorders: . B. The refill order is used for ordering maintenance medications. All refills must be ordered before the last dose is administered. Reorder medications 3 to 4 days in advance of need to assure an adequate supply is on hand .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being in accordance with the comprehensive assessment and plan of care for two of eleven residents (Resident #7 and #9) reviewed for care and services to address pain. -Resident #7, who had a stage IV pressure sore to his sacrum (large wedge shaped vertebra at the inferior end of the spine), was not assessed for pain prior, during or after the wound dressing change. -The facility failed to evaluate Resident #7 for pain per facility's policy during admission, quarterly or during change in condition. Resident #7's pain was not adequately controlled. - The facility failed to adequately control Resident #9's pain. This failure affected two resident and could place the other two residents receiving wound care at the 200 hallway at risk for experiencing pain unnecessarily. Findings include: Record review of Resident #7's face sheet revealed Resident #7 was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's care plan reviewed 9/16/15 revealed in part: Resident #7 was at risk for skin breakdown. Further record review revealed that care plan was not updated indicating that Resident #7 had a stage IV pressure sore with interventions in place to assess and treat for pain. Resident #7 did not have a pain care plan. Record review of Resident #7's Significant change in status assessment MDS dated [DATE] revealed Resident #7 required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #7 was always incontinent of bowel and bladder. Resident #7 was coded as not on any scheduled pain medication regimen and had not received any PRN pain medications. The resident had also not received non-medication intervention for pain. Indicators of Pain or Possible Pain in the last 5 days revealed that Resident #7 was coded as having no signs of non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements of postures observed. Resident #7 had one Stage IV pressure ulcer that was acquired at the facility. The Stage IV pressure ulcer measured 6.0 cm x 3.0 cm x 0.0 cm. (LxWxD). Record review of electronic assessments revealed no pain assessments during admission, quarterly or during change in condition. Further record review revealed that Resident #7 was admitted to hospice care on 2/1/2016. Record review of the wound assessment sheet for Resident #7 dated 3-1-2016 revealed the Stage IV pressure sore was located on the sacrum and measured 6.0 cm. x 3.0 cm. x Non-measureable depth. (LxWxD). Further record review revealed that pressure sore was acquired at the facility on 1/8/2016. Record review of Resident #7's summary of Physician's order dated 3/1/2016 to 3/31/2016 revealed the following orders in part: - clean sacrum with normal saline, pat dry, apply Santyl to wound bed, cover with water proof dressing every day and as needed loose/soiled in the morning. -[MEDICATION NAME] ([MEDICATION NAME], narcotic) 20 mg/ml give 0.5 ml every 4 hours as needed for pain. -[MEDICATION NAME] (narcotic) Tablet 7.5 - 325 mg ([MEDICATION NAME]-[MEDICATION NAME]) Give one tablet by mouth two times a day for pain. - [MEDICATION NAME] Tablet 7.5 - 325 mg ([MEDICATION NAME]-[MEDICATION NAME]) Give one tablet by mouth every 6 hours as needed for pain (give prior to wound care treatment). Observation on 3/03/2016 at 9:30 a.m. during incontinent care, Resident #7 was noted with a square dressing to his sacral area that was completely soaked with dark brown/red colored drainage. The dressing was peeling off from the top exposing the large circular pressure sore that was noted with an adjacent open area to the left upper part of the pressure sore. Resident #7's brief was noted with a large area of red and dark brown drainage where the wound was located and there was a foul odor coming from the dressing. The underneath pad where Resident #7 was laying on was noted with a large circular red area at the direction where the sacral pressure sore was located. Resident #7 had also an open area to his right upper buttocks that was not protected with a dressing and an open area to his left lower back that was not protected with a dressing either. Further observation revealed that Resident #7 grimaced his face and moaned while he was being turned to his side by C.N.A. DD. Resident #7 was then assisted to his back and C.N.A DD said that she was going to call the wound care nurse so she could change the soiled dressing before proceding with incontinent care. In an interview on 3/3/2016 at 9:42 a.m. with the Wound care nurse A, she stated that she had already done wound care to Resident #7 before breakfast at around 7:30 a.m. and further said but I can do it again, he has an unstageable pressure sore to his sacrum, he has no other wounds to his buttocks area. Observation on 3/3/2016 at 9:50 a.m. during wound care to Resident #7's pressure sore to his sacrum, Resident #7 moaned when Wound care nurse A removed the dressing to his sacral pressure sore and continued moaning while the Wound care nurse A cleaned the wound base with a gauze. Further observation revealed that the wound base had 3 areas of approx 1.0 x 1.0 c.m of yellow slough and the rest of the wound base was red and the surrounding skin to the pressure sore was red. Wound care nurse continued with wound care while Resident #7 moaned on and off. C.N.A. DD was assisting the Wound care nurse. Interview at that time, surveyor asked the Wound care nurse A if Resident #7 would usually moaned during wound care and she responded yes, I usually give him a pain pill 20 to 30 minutes before wound care, but it is not time now for pain medication. Wound care nurse A continued saying that earlier during wound care to Resident #7's sacral pressure sore, he did not have the open areas to his right buttocks, or the open area on top of the sacral pressure sore or the open area to his left lower back. Wound care nurse A further said while measuring the open areas Resident #7's left lower back open area was 1.5 x 0.8 c.m., the open area to his right buttocks was 2.3 x 0.8 c.m. and the open area to the top left adjacent to the sacral pressure sore was 3.0 x 1.0 c.m. all of these open areas are new, they were not there this morning during wound care. Further observation and interview revealed that Resident #7 continued to moan and grimaced his face at end of wound care/incontinent care and while being assisted to his back by Wound care nurse A and C.N.A. DD. Resident was positioned on his back with his knees and hips bent. An interview with Resident #7 was attempted on 3/3/16 at 10:24 am; however, the resident was non-responsive to the questions, he kept looking at surveyor while grimacing his face. In an interview on 3/3/2016 at 11:55 a.m. with MA F, she stated that Resident #7 had orders for schedule pain medication [MEDICATION NAME] (narcotic) at 8:00 a.m. and 5:00 p.m. and that she did not give the medication because the medication was not available in her drawer but that the nurse had given his PRN [MEDICATION NAME] at 7:00 a.m. In an interview on 3/3/2016 at 2:00 p.m. with LVN D, she stated that she gave [MEDICATION NAME] PRN to Resident #7 at 7:00 a.m. because he was in pain. In an observation and interview on 3/3/2016 at 2:05 p.m. with C.N.A. DD, she stated that Resident #7 would usually moan during care or when he was moved because of his pain. She further said that she believed that the nurses were aware of his pain. Further observation revealed that as C.N.A DD turned Resident #7 to his side facing the door, he softly moaned and grimaced his face. C.N.A. DD continued saying I worked with Resident #7 yesterday and he had the open areas to his right buttocks and his left lower back, they were smaller, I told the Wound care nurse A about those areas and I saw her putting something but was not sure what, but the areas looked smaller yesterday. Today they are bigger. In an interview on 3/3/2016 at 2:50 p.m. with the Wound care nurse A, she stated that she would assess the residents with pressure sores for pain at the beginning of the shift in the morning if they complained of pain the day before. She further said that she would assess non-verbal residents for pain by looking for changes in their behavior such as combativeness, moaning, grimacing and that those were indicators that the residents were in pain. When asked if she noticed that Resident #7 was moaning during wound care to his sacral stage IV pressure sore, Wound care nurse A responded Yes, I did notice it. I checked with the nurse and she had given his pain medication at 7:00 a.m. I would usually call the MD if I see that the current pain medication is not working so the MD could revise the pain medications. When asked if she called Resident #7's MD about his pain management, Wound care nurse A responded No, I did not call the MD, but I did let the nurses know that he was in pain but she had already given his medication at 7:00 a.m. Resident #9 Record review of Resident #9's face sheet revealed Resident #9 was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's care plan reviewed 1/25/16 revealed in part: Resident #9 is at risk for skin breakdown as evidenced by limited mobility and incontinence. -Goal: Resident #9 will not show signs of skin breakdown in 90 days with a target date of 4/25/2016. Interventions: Assist resident in repositioning as tolerated, utilize positioning devices as appropriate to prevent pressure over bony prominences. Record review of Resident #9's Admission assessment MDS dated [DATE] revealed Resident #9 required extensive assistance for bed mobility, dressing, personal hygiene and bathing and required total assistance from staff for toilet use. She was always incontinent of bowel and had an Indwelling catheter. Resident #9 was identified at risk of developing pressure ulcers and did not have a pressure sore. Further record review revealed that Resident #9 was not on a turning/repositioning program. Record review of electronic Braden Scale for Predicting Pressure Sore Risk assessments dated 2/3/2016 revealed Resident #9 had a score of 17 indicating mild risk. Record review of Resident #9's telephone orders dated 3/3/2016 revealed orders that read: -Apply Zinc to coccyx with every incontinent care and as needed. Observation and interview on 3/03/2016 at 8:50 a.m. revealed Resident #9 was lying in a regular mattress on her back. Further observation and interview, Resident #9 stated I have a bed sore on my buttocks, is sore, it's been there for about a month. When asked if staff would come to turn her and reposition her, Resident #9 stated No, I have to tell them, my buttocks gets really sore. Resident #9 continued saying that she still did not have incontinent care done and that she believe that her brief probably needed to by changed. In an interview on 3/3/2016 at 9:03 a.m. with C.N.A. OO, she stated that she did not know anything about Resident #9 and that she would usually work on the other side of the facility. She further stated that she still did not do incontinent care to Resident #9 and that she could do incontinent care at that time. Observation on 3/3/2016 at 9:10 a.m. during incontinent care revealed that Resident #9's coccyx bone area noted with a large circular dark reddened area approx 8.0 x 8.0 c.m with an open area in the middle of approx 3.0 x 2.0 c.m. wound base was red. Further observation at that moment revealed that after C.N.A. OO finished providing pericare to Resident #9, she preceded to position her to her back. Resident #9 immediately told C.N.A. OO turn me on my side please because my buttock's sore hurts . C.N.A. OO then assisted Resident #9 to her side facing the door. In an interview on 3/3/2016 at 10:25 a.m. with the Wound care nurse A, she stated that nurses had reported in the morning that the family member of Resident #9 had come to the facility the day before and had yelled at them because she had discovered a pressure sore to Resident #9's buttocks area and that the family member had taken pictures of the pressure sore. The Wound care nurse A further said that nobody made any reports of Resident #9's having a pressure sore before this morning and that she had already assessed the pressure sore and that it was a Stage 2 pressure sore that measured 3.0 x 2.0 c.m. with shattered edged. She continued saying that she had just gotten wound care orders this morning. In an interview on 3/3/2016 3:47 p.m. with the DON, she stated that pain assessments were supposed to be completed in the computer. Further interview and observation, DON looked at the computer and said I can not locate any pain assessment for Resident #7. The DON continued flipping thru Resident #7's chart and said I don't see any pain assessments for Resident #7 and they were not filed with medical records either . The DON continued saying that residents are assessed for pain before wound care and if residents were on pain during wound care, the nurse is supposed to stop the wound care and medicate the resident appropriately or call the MD. The DON further said that if residents are not able to verbalize pain, then the staff is supposed to monitor for signs of non-verbal clues for pain such as grimacing or moaning they have to make sure the patients are comfortable and come back later . The DON then said that pain assessments were supposed to be completed upon admission, then quarterly or if changes in pain. She further said that is a group effort to complete and monitor the pain assessments and not one person was responsible. In a second interview on 3/3/2016 at 4:30 p.m. with the DON, she stated that the facility protocol to prevent and treat pressure sores was to turn and reposition residents and further said we have to make sure that residents who cannot turn by themselves, we turn them and reposition them and even that they are in air mattresses, they still need to be turn and reposition. Is a team effort to monitor that residents are turn and reposition. The expectation is that if the C.N.A's sees any new changes in skin condition, to report it to the nurses right away, we had recently implemented a skin sheet, C.N.A's are supposed to know about those sheets and the nurses are supposed to get orders as soon as possible. The Wound care nurse A told me that Resident #7 had a couple of new open wound and that they were shearing areas. Record review of the facility policy and procedure Pain Management revised 01/02/2014 revealed in part: .Patients will be evaluated as part of the nursing assessment process for presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. Purpose: To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain and to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. 3.- An individualized, interdisciplinary care plan will be developed and include pharmacological and non-pharmacological approaches. 10.- The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Contact the physician/mid-level provider to report finding and obtain revised treatment orders, if indicated, review the non-pharmacological approaches for effectiveness and revise the care plan as indicated . Record review of the facility undated policy and procedure with title Skin/wound management revealed in part: Pain management: Manage pain per pain assessment. Evaluate before, during and after dressing changes. Daily monitoring of an ulcer during a dressing change includes: Wound pain, if present, is being adequately controlled. The facility's wound report dated 3/1/2016 indicated 4 residents with pressure sores that required wound care in the 200 hallway.

Based on observation, interview and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstratres that they were unavoidable, and failed to provide the necessary treatment and services to promote the healing of pressure ulcers and prevent new sores from developing for two residents (Resident #7 and Resident #9) of eleven residents reviewed for skin breakdown. -The facility failed to assess Resident #7's level of risk for pressure ulcer development at admission and quarterly per facility's policy and he acquired a Stage IV pressure sore to his sacrum (large wedge shaped vertebra at the inferior end of the spine) 5 months after admission to the facility. -The facility failed to develop a care plan to Resident #7's Stage IV pressure sore with specific interventions to alleviate and prevent further wound development and he then developed open wounds to his left lower back, sacral area above the Stage IV pressure sore and right upper buttocks area which were not appropriately assessed and reported to the MD according to facility policy. -The facility failed to routinely turn and reposition Resident #7 and Resident #9 to prevent worsening of the pressure sores or the development of new pressure sores. -Resident #9 acquired a Stage II Pressure Ulcer to the coccyx (tail bone) and wound treatment orders were not obtained until family intervention. These failures affected 2 residents and placed an additional 78 residents that were receiving preventive skin care at risk to develop new pressure sores for a decline in health, not receiving adequate treatment and delayed healing and/or worsening of pressure sores. Findings included: Resident #7 Record review of Resident #7's face sheet revealed Resident #7 was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's care plan reviewed 9/16/15 revealed in part: Resident #7 is at risk for skin breakdown. Further record review revealed that care plan was not updated indicating that Resident #7 had a stage IV pressure sore with interventions in place to assess and treat for pain. Resident #7 did not have a pain care plan. Record review of Resident #7's Significant change in status assessment MDS dated [DATE] revealed Resident #7 required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #7 was always incontinent of bowel and bladder. Resident #7 was coded as not on any scheduled pain medication regimen and had not received any PRN pain medications. The resident had also not received non-medication intervention for pain. Indicators of Pain or Possible Pain in the last 5 days revealed that Resident #7 was coded as having no signs of non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements of postures observed. Resident #7 had one Stage IV pressure ulcer that was acquired at the facility. The Stage IV pressure ulcer measured 6.0 cm x 3.0 cm x 0.0 cm. (LxWxD). Record review of electronic records revealed that Resident #7 did not have a Braden Scale assessment (to assess the patient's level of risk for development of pressure ulcers) during admission, quarterly or during change in condition. Record review of electronic assessments revealed no pain assessments during admission, quarterly or during change in condition. Further record review revealed that Resident #7 was admitted to hospice care on 2/1/2016. Record review of the wound assessment sheet for Resident #7 dated 3-1-2016 revealed the Stage IV pressure sore was located on the sacrum and measured 6.0 cm. x 3.0 cm. x Non-measurable depth. (LxWxD). Further record review revealed that pressure sore was acquired at the facility. Further review revealed the pressure sore was acquired at the facility on 1/8/2016. Record review of Resident #7's summary of Physician's order dated 3/1/2016 to 3/31/2016 revealed the following orders in part: - clean sacrum with normal saline, pat dry, apply Santyl to wound bed, cover with water proof dressing every day and as needed loose/soiled in the morning. Further record review revealed no wound care orders for the open wounds to his left lower back, sacral area above the Stage IV pressure sore and right upper buttocks area. In an Observation and interview on 3/03/2016 at 9:25 a.m. revealed Resident #7 was on an air loss mattress on his back. Further observation and interview revealed that Resident #7 was non-verbal to surveyor. C.N.A D.D. said she was going to do incontinent care to Resident #7. Observation on 3/03/2016 at 9:30 a.m. during incontinent care, Resident #7 was noted with a square dressing to his sacral area that was completely soaked with dark brown/red colored drainage. The dressing was peeling off from the top exposing the large circular pressure sore that was noted with an adjacent open area to the left upper part of the pressure sore. Resident #7 ' s brief was noted with a large area of red and dark brown drainage where the wound was located and there was a foul odor coming from the dressing. The underneath pad where Resident #7 was laying on was noted with a large circular red area at the direction where the sacral pressure sore was located. Resident #7 had also an open area to his right upper buttocks that was not protected with a dressing and an open area to his left lower back that was not protected with a dressing either. Further observation revealed that Resident #7 grimaced his face and moaned while he was being turned to his side by C.N.A. DD. Resident #7 was then assisted to his back and C.N.A DD said that she was going to call the wound care nurse so she could change the soiled dressing before preceding with incontinent care. In an interview on 3/3/2016 at 9:42 a.m. with the Wound care nurse A, she stated that she had already done wound care to Resident #7 before breakfast at around 7:30 a.m. and further said but I can do it again, he has an unstageable pressure sore to his sacrum, he has no other wounds to his buttocks area. Observation on 3/3/2016 at 9:50 a.m. during wound care to Resident #7 ' s pressure sore to his sacrum, Resident #7 moaned when Wound care nurse A removed the dressing to his sacral pressure sore and continued moaning while the Wound care nurse A cleaned the wound base with a gauze. Further observation revealed that the wound base of the sacral pressure sore had 3 areas of approx 1.0 x 1.0 c.m of yellow slough and the rest of the wound base was red and the surrounding skin to the pressure sore was red. Wound care nurse continued with wound care while Resident #7 moaned on and off. C.N.A. DD was assisting the Wound care nurse. Interview at that time, surveyor asked the Wound care nurse A if Resident #7 would usually moaned during wound care and she responded yes, I usually give him a pain pill 20 to 30 minutes before wound care, but it is not time now for pain medication. Wound care nurse A continued saying that earlier during wound care to Resident #7's sacral pressure sore, he did not have the open areas to his right buttocks, or the open area on top of the sacral pressure sore or the open area to his left lower back. Wound care nurse A further said while measuring the open areas Resident #7's left lower back open area was 1.5 x 0.8 c.m., the open area to his right buttocks was 2.3 x 0.8 c.m. and the open area to the top left adjacent to the sacral pressure sore was 3.0 x 1.0 c.m. all of these open areas are new, they were not there this morning during wound care. Further observation and interview revealed that Resident #7 continued to moan and grimaced his face at end of wound care/incontinent care and while being assisted to his back by Wound care nurse A and C.N.A. DD. Resident was positioned on his back with his knees and hip bended. An interview with Resident #7 was attempted on 3/3/16 at 10:24 am; however, the resident was non-responsive to the questions, he kept looking at surveyor while grimacing his face. The resident was lying on his back. Observation on 3/3/2016 at 12:37 p.m. revealed Resident #7 was still in the same position on his back with his knees and hips bent. Resident #7 was non-verbal to surveyor. Observation on 3/3/2016 at 1:57 p.m. revealed Resident #7 was still on his back with his knees and hips bent. In an interview on 3/3/2016 at 2:05 p.m. with C.N.A. DD, when asked if Resident #7 was on a turning and repositioning schedule, C.N.A. DD responded I don't know if he is on a turning schedule but I am supposed to turn and reposition residents every 2 hours. When asked if she had already turned and repositioned Resident #7, C.N.A. DD responded let me go and get a pillow first. Further interview and observation, C.N.A. DD grabbed a pillow and walked towards Resident #7's room and said the pillow will be for his back, let me turn him now. C.N.A. DD further said that Resident #7 would usually moan during care or when he was moved because of his pain. She further said that she believed that the nurses were aware of his pain. Further observation revealed that as C.N.A DD turned Resident #7 to his side facing the door, he softly moaned and grimaced his face. C.N.A. DD continued saying I worked with Resident #7 yesterday and he had the open areas to his right buttocks and his left lower back, they were smaller, I told the Wound care nurse A about those areas and I saw her putting something but was not sure what, but the areas looked smaller yesterday. Today they are bigger. Further interview at that time with C.N.A. DD, she stated that she was not aware of any forms that needed to be completed when reporting new skin problems to the nurses and said that whenever they see a new skin problem, they would make the reports verbally. In an interview on 3/3/2016 at 2:50 p.m. with the Wound care nurse A, she stated that she would assess the residents with pressure sores for pain at the beginning of the shift in the morning if they complained of pain the day before. She further said that she would assess non-verbal residents for pain by looking for changes in their behavior such as combativeness, moaning, grimacing and that those were indicators that the residents were in pain. When asked if she noticed that Resident #7 was moaning during wound care to his sacral stage IV pressure sore, Wound care nurse A responded Yes, I did noticed it. I checked with the nurse and she had given his pain medication at 7:00 a.m. I would usually call the MD if I see that the current pain medication is not working so the MD could revise the pain medications. When asked if she called Resident #7's MD about his pain management, Wound care nurse A responded No, I did not call the MD, but I did let the nurses know that he was in pain but she had already given his medication at 7:00 a.m. Further interview at that time, Wound care nurse A said that residents are supposed to be turned and repositioned every 2 hours to prevent and treat pressure sores. She further stated that the facility policy was that when new skin conditions were reported that the MD needed to be contacted as soon as possible for new orders and update the care plan. Wound care nurse A continued saying that she was not in charge of monitoring the C.N.A's for turning and reposition the residents and that it was the job of the charge nurses on the floor. She continued saying that she was not involved in updating the care plans of the residents including care plans for pressure sores and that she was not in charge of completing Braden Scale assessment (to assess the patient ' s level of risk for development of pressure ulcers) or pain assessments either, that she believed the charge nurses were supposed to complete them. In an interview on 3/3/2016 3:47 p.m. with the DON, she stated that pain assessments and Braden Scale assessment (to assess the patient's level of risk for development of pressure ulcers) were supposed to be completed in the computed. Further interview and observation, DON looked at the computer and said I cannot locate any pain assessment or Braden Scale assessments for Resident #7. The DON continued flipping thru Resident #7's chart and said I don't see any pain assessments or Braden Scale assessments for Resident #7 and they were not filed with medical records either. The DON continued saying that residents are assessed for pain before wound care and if residents were on pain during wound care, the nurse is supposed to stop the wound care and medicate the resident appropriately or call the MD. The DON further said that if residents are not able to verbalize pain, then the staff is supposed to monitor for signs of non-verbal clues for pain such as grimacing or moaning they have to make sure the patients are comfortable and come back later. The DON then said that pain assessments and Braden Scale assessments were supposed to be completed upon admission, then quarterly or if changes in pain or new skin conditions. She further said that is a group effort to complete and monitor the pain and Braden Scale assessments and not one person was responsible. Further interview with DON at that time, she stated that care plans were supposed to be updated by the MDS and monitored by the DON and continued saying from today on, we will be very specific and will talk in the morning meetings about wound care so the MDS nurse can update the care plans during the meetings. In an interview on 3/3/2016 at 4:08 p.m. with LVN D, she stated that she was the charge nurse for Resident #7 but that she was not really monitoring if he would get turn and repositioned every 2 hours and further said If the C.N.A ' s call me for something, I can help but I don't really monitor the turning. Resident #9 Record review of Resident #9's face sheet revealed Resident #9 was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's care plan reviewed 1/25/16 revealed in part: Resident #9 is at risk for skin breakdown as evidenced by limited mobility and incontinence. -Goal: Resident #9 will not show signs of skin breakdown in 90 days with a target date of 4/25/2016. Interventions: Assist resident in repositioning as tolerated, utilize positioning devices as appropriate to prevent pressure over bony prominences. Record review of Resident #9's Admission assessment MDS dated [DATE] revealed Resident #9 required extensive assistance for bed mobility, dressing, personal hygiene and bathing and required total assistance from staff for toilet use. She was always incontinent of bowel and had an Indwelling catheter. Resident #9 was identified at risk of developing pressure ulcers and did not have a pressure sore. Further record review revealed that Resident #9 was not on a turning/repositioning program. Record review of electronic Braden Scale for Predicting Pressure Sore Risk assessments dated 2/3/2016 revealed Resident #9 had a score of 17 indicating mild risk. Record review of Resident #9's telephone orders dated 3/3/2016 revealed orders that read: -Apply Zinc to coccyx with every incontinent care and as needed. Observation and interview on 3/03/2016 at 8:50 a.m. revealed Resident #9 was lying in a regular mattress on her back. Further observation and interview, Resident #9 stated I have a bed sore on my buttocks, is sore, it's been there for about a month. When asked if staff would come to turn her and reposition her, Resident #9 stated No, I have to tell them, my buttocks gets really sore. Resident #9 continued saying that she still did not have incontinent care done and that she believe that her brief probably needed to by changed. In an interview on 3/3/2016 at 9:03 a.m. with C.N.A. OO, she stated that she did not know anything about Resident #9 and that she would usually work on the other side of the facility. She further stated that she still did not do incontinent care to Resident #9 and that she could do incontinent care at that time. Observation on 3/3/2016 at 9:10 a.m. during incontinent care revealed that Resident #9's coccyx bone area noted with a large circular dark reddened area approx 8.0 x 8.0 c.m with an open area in the middle of approx 3.0 x 2.0 c.m. wound base was red. Further observation at that moment revealed that after C.N.A. OO finished providing pericare to Resident #9, she preceded to position her to her back. Resident #9 immediately told C.N.A. OO turn me on my side please because my buttock's sore hurts . C.N.A. OO then assisted Resident #9 to her side facing the door. In an interview on 3/3/2016 at 10:25 a.m. with the Wound care nurse A, she stated that nurses had reported in the morning that the family member of Resident #9 had come to the facility the day before and had yelled at them because she had discovered a pressure sore to Resident #9's buttocks area and that the family member had taken pictures of the pressure sore. The Wound care nurse A further said that nobody made any reports of Resident #9's having a pressure sore before this morning and that she had already assessed the pressure sore and that it was a Stage 2 pressure sore that measured 3.0 x 2.0 c.m. with shattered edged. She continued saying that she had just gotten wound care orders this morning. In a second interview on 3/3/2016 at 4:30 p.m. with the DON, she stated that the facility protocol to prevent and treat pressure sores was to turn and reposition residents and further said we have to make sure that residents who cannot turn by themselves, we turn them and reposition them and even that they are in air mattresses, they still need to be turn and reposition. Is a team effort to monitor that residents are turn and reposition. The expectation is that if the C.N.A's sees any new changes in skin condition, to report it to the nurses right away, we had recently implemented a skin sheet, C.N.A's are supposed to know about those sheets and the nurses are supposed to get orders as soon as possible. The Wound care nurse A told me that Resident #7 had a couple of new open wound and that they were shearing areas. Record review of the facility's policy and procedure revised on 12/08/2014 with title Skin Integrity Management revealed in part: .The implementation of an individual patient ' s skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. -Practice Standards: Complete risk evaluation on admission, weekly for the first month, quarterly and with significant change in condition, Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Review care plan weekly and revise as indicated . Record review of the facility' undated policy and procedure with title Pressure Ulcer prevention guidelines revealed in part: .Encourage frequent repositioning/weight shifting. Position body with pillows and foam support devices. Turn individual at oblique angles to avoid pressure over bony prominences. Risk factors: Impaired/decreased mobility function: Individualized positioning and repositioning schedule Record review of the facility policy and procedure Pain Management revised 01/02/2014 revealed in part: .Patients will be evaluated as part of the nursing assessment process for presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. Purpose: To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain and to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals. 3.- An individualized, interdisciplinary care plan will be developed and include pharmacological and non-pharmacological approaches. 10.- The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Contact the physician/mid-level provider to report finding and obtain revised treatment orders, if indicated, review the non-pharmacological approaches for effectiveness and revise the care plan as indicated . Record review of the facility undated policy and procedure with title Skin/wound management revealed in part: Pain management: Manage pain per pain assessment. Evaluate before, during and after dressing changes. Daily monitoring of an ulcer during a dressing change includes: Wound pain, if present, is being adequately controlled The facility's CMS dated 3/3/2016 revealed 80 residents receiving preventive skin care.

Based on interview, and record review, the facility failed to consult with the resident's physician when a change of condition occurred for 1 of 6 residents ( CR #1 ) who were reviewed for changes in conditions. -CR #1's physician was not notified of changes in condition, including poor intake, pain and lethargy. CR #1 admitted to the hospital on [DATE] and had to have a feeding tube placed. CR #1 had a significant weight loss. This failure affected 1 discharged resident and placed 151 current residents at risk of not having their responsible party, interested family members or physicians aware of a change in their medical condition and psychosocial well-being. Findings include: complaint # 0 Record review of CR # 1 Face Sheet revealed the [AGE] year old was originally admitted to the facility on [DATE] and had the following diagnoses; Alzheimer ' s disease, hypertension, diabetes, stroke, [MEDICAL CONDITIONS], and dementia with depression. CR # 1 discharged from the facility on 3/18/2014. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident required supervision with bed mobility, transfers, walking, locomotion, toileting, dressing and eating. CR #1 was always continent of bowel and bladder, and had a BIMS score of 2 (severe cognitive impairment). Record review of CR #1's weight record revealed on 1/31/14 her weight was 134.9 pounds. Record review of CR #1's SBAR communication form dated 2/26/14 revealed starting on 2/25/14 the resident was having vomiting, dizziness and was disoriented. CR #1 had increased confusion, needed more assistance with ADLs, decreased mobility, fall and had vomited three times with dry heaves and complaints of abdominal pain. Record review of CR #1's Licensed Nurses Progress Note dated 2/26/14 at 3:30 PM revealed "transferred to (local hospital) per MD. Experiencing N/V and disoriented per yesterday fall. C/o pelvic pain, unable to rate." Record review of CR #1's Departmental Notes dated 2/27/14 at 4:34 PM revealed the resident readmitted from the hospital and complained of abdominal pain. Record review of CR #1's weight record revealed on 2/28/14 her weight was 128.6 pounds. Record review of CR #1's PRN Medication Administration Record [REDACTED]. Record review of CR #1's Departmental Notes dated 3/2/14 at 3:37 PM revealed the following; "...Alert. No distress observed at this time ... Had had no bowel movement. Refuses to eat. Has been drinking liquids. Remains very weak. Does no (sic) want to get out of bed. Will continue to monitor." Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/4/14, no time documented, CR #1 pain was a 6 (severe pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's weight record revealed on 3/6/14 her weight was 128.4 pounds. Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/8/14, no time documented, CR #1 pain was a 6 (severe pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/10/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's Physical Therapy Note dated 3/10/14 read, in part, "... patient threw up towards the end of treatment session. Returned back to her room and nurse notified..." Record review of CR #1's Occupational Therapy notes dated 3/10/14 read, in part, "... patient complained of nausea, however, requested treatment short session secondary to vomiting. Nursing informed..." Record review of CR #1's medical record revealed no nursing documentation on 3/10/14. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician orders [REDACTED]. Record review of CR#1' s License ADL sheet for March 2014 revealed on 3/12/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s March 2014 Daily Pain Assessment revealed on 3/12/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's Licensed Nurses Progress Notes dated 3/13/14 at 12:00 AM revealed "administered suppository for hemorrhoids..." Record review of CR #1's Licensed Nurses Progress Notes dated 3/13/14 at 2:00 PM revealed " Up in room but states feeling back pain and N&V. Assessment done and pain medication given [MEDICATION NAME] routine meds no effective for day. Also given [MEDICATION NAME] 12.5 and request from Dr ... for an increase of [MEDICATION NAME] 25 mg ... " Record review of CR #1 ' s physician telephone orders revealed on 3/13/14 for " Vomiting and dizziness " and the resident had a history of [REDACTED]. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s Physical Therapy Note dated 3/13/14 read, in part, " ... attempted several times through the day, but patient was not feeling good. Patient has reported that she has threw up (sic) in the past days and still does not feel good ... " Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/13/14 percent eaten was recorded as follows; breakfast 50%, lunch 50%, dinner 5%. Record review of CR #1 ' s Departmental Notes dated 3/14/14 at 11:56 AM revealed " Medication given for N&V and pain of headache then up and taken to therapy per wheel chair no longer ambulatory. Speech is slow and slurred but still able to communicate needs. " Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/14/14 percent eaten was recorded as follows; breakfast 50%, lunch 50%, dinner 5%. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s weight record revealed on 3/14/14 her weight was 122.8 pounds. Record review of CR #1 ' s physician orders [REDACTED]. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/15/14 percent eaten was recorded as follows; breakfast 25%, lunch 25%, dinner 25%. Record review of CR #1 ' s medical record revealed no nursing documentation on 3/15/14. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/16/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s March 2014 Daily Pain Assessment revealed on 3/16/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1 ' s March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s medical record revealed no nursing documentation on 3/16/14. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/17/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s Physical Therapy Note dated 3/17/14 read, in part, " ... " I ' m weak. " ...responsible party ... present during treatment session and reported that patient had gotten worse in the last 4 weeks since the fall ... " Record review of CR #1 ' s Departmental Notes, skilled notes, and Nurses Notes revealed there were no additional notes or assessments of the resident on 3/15/14 or 3/16/14. Further review on 3/17/14 at 4:27 PM there was a Departmental note which read " readmitted back to WHCC at 4:34 PM, 2/27/2014 under the care of Dr ... Discharge medications reconciled, admission care done. On low sodium diet, and no activity restrictions. Kept comfortable in bed, charge nurses to monitor for unsuallities (sic). " There was no other documentation regarding the resident ' s medical status on 3/17/14. Record review of the facility ' s Concern/Grievance Report for CR#1 dated 3/17/14 revealed the following concerns; family request medications be reviewed by pharmacist, family requests doctor to see resident, family requests dietician meet with resident. Continued review of this form revealed on 3/18/14 nursing called the nurse practitioner because family insisted resident go to the hospital, who gave the order to discharge to the hospital. Record review of the facility ' s Interdisciplinary Plan of Care Review Form dated 3/17/14 revealed under summary of conference discussion, " concerns about medications affecting her appetite, lethargic, still nauseated, not eating. We will do a pharmacy review, run lab work, dietician review. Facility will communicate with daughter the results. " In an interview on 6/3/14 at 1:40 PM, RN A stated she had attended a care plan meeting for CR #1 on 3/17/14, and the family had questions regarding CR #1 ' s change in condition. RN A stated after the meeting, she had told her staff to watch the resident for changes. When asked if she knew if the physician was aware of her status, RN A stated she did not know and it was the floor nurses who notify the physician. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/18/14 percent eaten was recorded as follows; there was no documentation of percent eaten, and Hospital was written for the entries for breakfast, lunch and dinner. Record review of CR #1 ' s Physical Therapy Note dated 3/18/14 read, in part, " ... Patient continues to require max ... cues to initiate and stay on task. Very sleepy and unable to keep eyes open. Able to follow 1 step commands with increase time. Also continues with pocketing of food/liquid, speech therapist eval ' d patient ... " Record review of CR #1 ' s Occupational Therapy Note dated 3/18/14 read, in part, " ... patient ' s eyes are constanly (sic) closed during the entire treatment session ... " Record review of CR #1 ' s physician orders [REDACTED]. Record review of CR #1 ' s Speech Therapy evaluation and plan of treatment dated 3/18/14 read, in part, " ... patient requires medical eval and neurological assess etiology of vomiting and dizziness and change in status. Patient not able to tolerate po (by mouth) feedings at this time and is nauseated and vomiting. " In an interview on 6/3/14 at 8:40 AM, SLP stated CR #1 was evaluated for a change in status in her swallowing and because she had not been eating. SLP stated CR #1 was not alert, complained of nausea and vomiting and could not participate in the evaluation. SLP stated she notified nursing the resident needed medical attention. Record review of CR #1 ' s physician orders [REDACTED]. Telephone order from NP: Transfer patient to (local hospital) per family request for treatment and evaluation. " Record review of CR #1 ' s SBAR, undated revealed the following; Situation; impaired speech, weakness, difficulty swallowing started on 3/18/14. Background; decreased consciousness, new or worsening behavioral symptoms, needs more assistance with ADLs, slurred speech, trouble swallowing, nausea and vomiting. Resident noted with weakness, impaired speech, difficulty swallowing. Record review of CR #1 ' s Discharge Nurse ' s Notes dated 3/18/14 at 5:00 PM revealed Resident observed with weakness, impaired speech, vomiting, difficulty swallowing food. Record review of the facility ' s Departmental Notes dated 3/24/14 read in part, " Late Entry for 3/21/14. Weight down 4.36 %, 5.6 pounds times 8 days. Current weight 122.8 pounds. Resident receives regular diet with small meat portions, House Shakes three times daily. Resident eating meals in room. Weakly weights to continue throught 4/11/14 " In an interview on 5/29/14 at 12:05 PM, LVN A stated she was one of the nurses who took care of CR #1. LVN A stated CR #1 was not eating well, and complained of her stomach hurting. When asked if the physician was notified that CR #1 was not eating and had complaints of pain, LVN A stated there were not any nurses notes, physician progress notes [REDACTED].#1 ' s status until 3/18/14. At 3:55 PM, LVN A stated she had looked through CR #1 ' s medical record and could not find the physician had been notified or nursing documentation of CR #1 ' s medical status and of the poor intake after 3/13/14. In an interview on 6/3/14 at 12:15 PM, the DON stated it was not documented in CR #1 ' s medical record the physician was notified that the resident had not been eating well. When asked when the physician should be notified or if staff should be documenting the residents medical status, the DON stated it would depend on how sick the person was. In an interview on 6/3/14 at 12:55 PM the DM stated the last time CR #1 was seen by the dietician was on 12/17/2013. At 1:20 PM, the DM stated CR #1 triggered for a significant weight loss on 3/14/14 and went to the hospital on [DATE]. Record review of the local hospital discharge summary signed by the physician on 3/28/14 revealed the resident admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Continue review revealed under history of present illness " ...Her acute [MEDICAL CONDITION] secondary to dehydration was treated with IV fluids ...She was found to have profound dysphagia, was unable to tolerate any oral hydration ... " Record review of the local hospital progress note dated 3/28/14 revealed CR #1 ' s weight on 3/20/14 was 51.364 kg (113 pounds) and on 3/21/14 weight of 52.864 kg (116 pounds). Record review the local hospital Operative Report dated 3/28/14 revealed CR #1 had a feeding tube placed with the preoperative [DIAGNOSES REDACTED]. Record review of the facility ' s policy Physician Notification of Change in Resident Condition, revised 11/2005, read in part, " ...It is the policy of this Center to notify the physician and inform the resident and resident ' s responsible part of a significant change in the resident ' s physical, mental, psychological status, including accidents and when there is a need to alter treatments significantly ... Purpose; To keep the physician, resident and resident ' s responsible party informed of changes in the resident ' s condition so that timely interventions can be obtained ... Definition " Change of Condition " related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan ...Procedure ... 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident and the resident representative. 4. Example of changes may include, but not limited to: ... Gastrointestinal problems ... weight loss-appetite changes ... 7. The licensed nurse will document the assessment and information given to the physician in the medical record. 8. All attempts to notify the physician and the resident representative will be noted in the resident ' s medical record ... 10. If unable to reach the attending physician, call the alternate physician ... 15. Assessment and documentation will continue once each shift for a minimum of 72 hours (or until stable) to monitor the resident ' condition and response to treatment. " According to CMS 672 the census was 151.

Based on interview and record review the facility failed to ensure 1 of 6 residents (CR #1) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: -CR #1 had poor intake, complaints of pain. and lethargy which were not addressed. CR #1 discharged to a local hospital with severe dehydration, hernia and required a feeding tube placement because she was unable to swallow. This failure affected 1 discharged resident and placed 151 residents at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings include: complaint # 0 Record review of CR # 1 Face Sheet revealed the [AGE] year old was originally admitted to the facility on [DATE] and had the following diagnoses; Alzheimer ' s disease, hypertension, diabetes, stroke, [MEDICAL CONDITIONS], and dementia with depression. CR # 1 discharged from the facility on 3/18/2014. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident required supervision with bed mobility, transfers, walking, locomotion, toileting, dressing and eating. CR #1 was always continent of bowel and bladder, and had a BIMS score of 2 (severe cognitive impairment). Record review of CR #1's weight record revealed on 1/31/14 her weight was 134.9 pounds. Record review of CR #1's SBAR communication form dated 2/26/14 revealed starting on 2/25/14 the resident was having vomiting, dizziness and was disoriented. CR #1 had increased confusion, needed more assistance with ADLs, decreased mobility, fall and had vomited three times with dry heaves and complaints of abdominal pain. Record review of CR #1's Licensed Nurses Progress Note dated 2/26/14 at 3:30 PM revealed "transferred to (local hospital) per MD. Experiencing N/V and disoriented per yesterday fall. C/o pelvic pain, unable to rate." Record review of CR #1's Departmental Notes dated 2/27/14 at 4:34 PM revealed the resident readmitted from the hospital and complained of abdominal pain. Record review of CR #1's weight record revealed on 2/28/14 her weight was 128.6 pounds. Record review of CR #1's PRN Medication Administration Record [REDACTED]. Record review of CR #1's Departmental Notes dated 3/2/14 at 3:37 PM revealed the following; "...Alert. No distress observed at this time ... Had had no bowel movement. Refuses to eat. Has been drinking liquids. Remains very weak. Does no (sic) want to get out of bed. Will continue to monitor." Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/4/14, no time documented, CR #1 pain was a 6 (severe pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's weight record revealed on 3/6/14 her weight was 128.4 pounds. Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/8/14, no time documented, CR #1 pain was a 6 (severe pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's March 2014 Daily Pain Assessment revealed on 3/10/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's Physical Therapy Note dated 3/10/14 read, in part, "... patient threw up towards the end of treatment session. Returned back to her room and nurse notified..." Record review of CR #1's Occupational Therapy notes dated 3/10/14 read, in part, "... patient complained of nausea, however, requested treatment short session secondary to vomiting. Nursing informed..." Record review of CR #1's medical record revealed no nursing documentation on 3/10/14. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's physician orders [REDACTED]. Record review of CR#1' s License ADL sheet for March 2014 revealed on 3/12/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s March 2014 Daily Pain Assessment revealed on 3/12/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1's March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1's Licensed Nurses Progress Notes dated 3/13/14 at 12:00 AM revealed "administered suppository for hemorrhoids..." Record review of CR #1's Licensed Nurses Progress Notes dated 3/13/14 at 2:00 PM revealed " Up in room but states feeling back pain and N&V. Assessment done and pain medication given [MEDICATION NAME] routine meds no effective for day. Also given [MEDICATION NAME] 12.5 and request from Dr ... for an increase of [MEDICATION NAME] 25 mg ... " Record review of CR #1 ' s physician telephone orders revealed on 3/13/14 for " Vomiting and dizziness " and the resident had a history of [REDACTED]. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s Physical Therapy Note dated 3/13/14 read, in part, " ... attempted several times through the day, but patient was not feeling good. Patient has reported that she has threw up (sic) in the past days and still does not feel good ... " Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/13/14 percent eaten was recorded as follows; breakfast 50%, lunch 50%, dinner 5%. Record review of CR #1 ' s Departmental Notes dated 3/14/14 at 11:56 AM revealed " Medication given for N&V and pain of headache then up and taken to therapy per wheel chair no longer ambulatory. Speech is slow and slurred but still able to communicate needs. " Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/14/14 percent eaten was recorded as follows; breakfast 50%, lunch 50%, dinner 5%. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s weight record revealed on 3/14/14 her weight was 122.8 pounds. Record review of CR #1 ' s physician orders [REDACTED]. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/15/14 percent eaten was recorded as follows; breakfast 25%, lunch 25%, dinner 25%. Record review of CR #1 ' s medical record revealed no nursing documentation on 3/15/14. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/16/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s March 2014 Daily Pain Assessment revealed on 3/16/14, no time documented, CR #1 pain was a 4 (moderate pain) on a scale of 1-10. Record review of CR #1 ' s March 2014 PRN Medication Administration Record [REDACTED]. Record review of CR #1 ' s medical record revealed no nursing documentation on 3/16/14. Record review of CR #1 ' s PRN Medication Administration Record [REDACTED]. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/17/14 percent eaten was recorded as follows; breakfast refused, lunch refused, dinner refused. Record review of CR #1 ' s Physical Therapy Note dated 3/17/14 read, in part, " ... " I ' m weak. " ...responsible party ... present during treatment session and reported that patient had gotten worse in the last 4 weeks since the fall ... " Record review of CR #1 ' s Departmental Notes, skilled notes, and Nurses Notes revealed there were no additional notes or assessments of the resident on 3/15/14 or 3/16/14. Further review on 3/17/14 at 4:27 PM there was a Departmental note which read " readmitted back to WHCC at 4:34 PM, 2/27/2014 under the care of Dr ... Discharge medications reconciled, admission care done. On low sodium diet, and no activity restrictions. Kept comfortable in bed, charge nurses to monitor for unsuallities (sic). " There was no other documentation regarding the resident ' s medical status on 3/17/14. Record review of the facility ' s Concern/Grievance Report for CR#1 dated 3/17/14 revealed the following concerns; family request medications be reviewed by pharmacist, family requests doctor to see resident, family requests dietician meet with resident. Continued review of this form revealed on 3/18/14 nursing called the nurse practitioner because family insisted resident go to the hospital, who gave the order to discharge to the hospital. Record review of the facility ' s Interdisciplinary Plan of Care Review Form dated 3/17/14 revealed under summary of conference discussion, " concerns about medications affecting her appetite, lethargic, still nauseated, not eating. We will do a pharmacy review, run lab work, dietician review. Facility will communicate with daughter the results. " In an interview on 6/3/14 at 1:40 PM, RN A stated she had attended a care plan meeting for CR #1 on 3/17/14, and the family had questions regarding CR #1 ' s change in condition. RN A stated after the meeting, she had told her staff to watch the resident for changes. When asked if she knew if the physician was aware of her status, RN A stated she did not know and it was the floor nurses who notify the physician. Record review of CR#1 ' s License ADL sheet for March 2014 revealed on 3/18/14 percent eaten was recorded as follows; there was no documentation of percent eaten, and Hospital was written for the entries for breakfast, lunch and dinner. Record review of CR #1 ' s Physical Therapy Note dated 3/18/14 read, in part, " ... Patient continues to require max ... cues to initiate and stay on task. Very sleepy and unable to keep eyes open. Able to follow 1 step commands with increase time. Also continues with pocketing of food/liquid, speech therapist eval ' d patient ... " Record review of CR #1 ' s Occupational Therapy Note dated 3/18/14 read, in part, " ... patient ' s eyes are constanly (sic) closed during the entire treatment session ... " Record review of CR #1 ' s physician orders [REDACTED]. Record review of CR #1 ' s Speech Therapy evaluation and plan of treatment dated 3/18/14 read, in part, " ... patient requires medical eval and neurological assess etiology of vomiting and dizziness and change in status. Patient not able to tolerate po (by mouth) feedings at this time and is nauseated and vomiting. " In an interview on 6/3/14 at 8:40 AM, SLP stated CR #1 was evaluated for a change in status in her swallowing and because she had not been eating. SLP stated CR #1 was not alert, complained of nausea and vomiting and could not participate in the evaluation. SLP stated she notified nursing the resident needed medical attention. Record review of CR #1 ' s physician orders [REDACTED]. Telephone order from NP: Transfer patient to (local hospital) per family request for treatment and evaluation. " Record review of CR #1 ' s SBAR, undated revealed the following; Situation; impaired speech, weakness, difficulty swallowing started on 3/18/14. Background; decreased consciousness, new or worsening behavioral symptoms, needs more assistance with ADLs, slurred speech, trouble swallowing, nausea and vomiting. Resident noted with weakness, impaired speech, difficulty swallowing. Record review of CR #1 ' s Discharge Nurse ' s Notes dated 3/18/14 at 5:00 PM revealed Resident observed with weakness, impaired speech, vomiting, difficulty swallowing food. Record review of the facility ' s Departmental Notes dated 3/24/14 read in part, " Late Entry for 3/21/14. Weight down 4.36 %, 5.6 pounds times 8 days. Current weight 122.8 pounds. Resident receives regular diet with small meat portions, House Shakes three times daily. Resident eating meals in room. Weakly weights to continue throught 4/11/14 " In an interview on 5/29/14 at 12:05 PM, LVN A stated she was one of the nurses who took care of CR #1. LVN A stated CR #1 was not eating well, and complained of her stomach hurting. When asked if the physician was notified that CR #1 was not eating and had complaints of pain, LVN A stated there were not any nurses notes, physician progress notes [REDACTED].#1 ' s status until 3/18/14. At 3:55 PM, LVN A stated she had looked through CR #1 ' s medical record and could not find the physician had been notified or nursing documentation of CR #1 ' s medical status and of the poor intake after 3/13/14. In an interview on 6/3/14 at 12:15 PM, the DON stated it was not documented in CR #1 ' s medical record the physician was notified that the resident had not been eating well. When asked when the physician should be notified or if staff should be documenting the residents medical status, the DON stated it would depend on how sick the person was. In an interview on 6/3/14 at 12:55 PM the DM stated the last time CR #1 was seen by the dietician was on 12/17/2013. At 1:20 PM, the DM stated CR #1 triggered for a significant weight loss on 3/14/14 and went to the hospital on [DATE]. Record review of the local hospital discharge summary signed by the physician on 3/28/14 revealed the resident admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Continue review revealed under history of present illness " ...Her acute [MEDICAL CONDITION] secondary to dehydration was treated with IV fluids ...She was found to have profound dysphagia, was unable to tolerate any oral hydration ... " Record review of the local hospital progress note dated 3/28/14 revealed CR #1 ' s weight on 3/20/14 was 51.364 kg (113 pounds) and on 3/21/14 weight of 52.864 kg (116 pounds). Record review the local hospital Operative Report dated 3/28/14 revealed CR #1 had a feeding tube placed with the preoperative [DIAGNOSES REDACTED]. Record review of the facility ' s policy Physician Notification of Change in Resident Condition, revised 11/2005, read in part, " ...It is the policy of this Center to notify the physician and inform the resident and resident ' s responsible part of a significant change in the resident ' s physical, mental, psychological status, including accidents and when there is a need to alter treatments significantly ... Purpose; To keep the physician, resident and resident ' s responsible party informed of changes in the resident ' s condition so that timely interventions can be obtained ... Definition " Change of Condition " related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan ...Procedure ... 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident and the resident representative. 4. Example of changes may include, but not limited to: ... Gastrointestinal problems ... weight loss-appetite changes ... 7. The licensed nurse will document the assessment and information given to the physician in the medical record. 8. All attempts to notify the physician and the resident representative will be noted in the resident ' s medical record ... 10. If unable to reach the attending physician, call the alternate physician ... 15. Assessment and documentation will continue once each shift for a minimum of 72 hours (or until stable) to monitor the resident ' condition and response to treatment. " According to CMS 672 the census was 151.