Every finding on record at Valley Grande Manor

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment.The facility failed to ensure their Comprehensive Emergency Management Plan and Emergency Procedure Policy included adequate shelter to protect the elderly and at-risk resident population from the outdoor elements, such as extreme heat conditions. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.The findings included:During an interview on 8/23/26 at 3:35 p.m. the DON said on 8/22/26 at approximately 3:00 pm all 115 residents were evacuated, including the residents from unit, due to a possible fire down the 100 hall. The DON said when she arrived at the facility, staff were already serving water, ice, and popsicles. The DON said staff had completed head counts and were slowly moving residents back into the facility. The DON said the physicians were called and they sent out their NPs to assess the residents. The DON said the residents were assessed and monitored because of the temperatures outside and all residents were currently on 72-hour vital monitoring. The DON said a few IVs were started due to facial flushing. The DON said the residents could not have been outside of the facility for more than 35 minutes but that was a long time for elderly patients. The DON said no one was diagnosed with dehydration and no one was diagnosed or sent to the hospital due to a heat related injury.During a follow-up interview on 8/25/26 at 3:30 p.m. the DON stated that the Administrator was responsible for implementing and updating the facility's annual Emergency Plan. The DON said they discussed the facility's emergency plan during QAPI meetings, morning meetings, and tabletop meetings. The DON said if the Administrator considered updating or changing the emergency plan, he would initiate a meeting and include her in that meeting. The DON said she did not feel the facility's Emergency Plan needed to include providing adequate shelter for residents when evacuating outdoors for an emergency to protect residents from inclement weather. The DON said she felt the facility did everything to ensure residents' safety, and the fire marshal told them they did an excellent job.During an interview on 8/25/26 at 4:50 p.m., the Administrator said he was responsible for implementing, updating, or changing the facility's Emergency Plan or Corporate, as deemed necessary. He said they review it annually, when they did table-tops, or when deemed necessary. The Administrator said anytime the Emergency Plan was reviewed the facility would make modifications needed to improve the plan. The Administrator said he did not feel the Emergency Plan needed to include providing adequate shelter for residents when evacuating outdoors for an emergency to protect residents from inclement weather. The Administrator said he felt sheltering was addressed when all 115 residents were evacuated for possible fire on 8/22/26. The Administrator said the residents were given water, ice, and food. The Administrator said the ambulance was prepped and ready and they brought an emergency bus. The Administrator said they went over everything with chief and he told the Administrator upon arrival that the residents would go back in momentarily. The Administrator said he felt it was all addressed with the fire department, the contracts with the hospital in case they needed to move out. The Administrator said they had contracts with another nursing home to move residents there. The Administrator said there were no residents with dehydration or heat-related injury. The Administrator said he would review the incident with the fire department next week to see if any changes were needed. The Administrator said he did not see the need to change anything because he was told that they did everything well by the fire department. He said he felt they followed all protocols and policies.Record review of the facility's Emergency Procedure - Evacuation policy revised August 2018 reflected: Evacuation will be conducted safely and calmly. Staff will follow established procedures.There were no procedures or guidelines that reflected adequate shelter provided to protect the elderly and at-risk resident population from the outdoor elements, such as extreme heat conditions. Record review of the facility's Comprehensive Emergency Management Plan - Health & Medical Needs (Texas Nursing Homes), reflected:Purpose This section identifies resident medical and service needs (dialysis, oxygen, ventilators/respiratory, hospice, etc.) and ensures those needs arc continuously met during any emergency situation, including shelter-in-place or evacuation.There were no procedures or guidelines that reflected adequate shelter provided to protect the elderly and at-risk resident population from the outdoor elements, such as extreme heat conditions.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation were reported no later than 24 hours to HHSC Complaint and Incident Intake, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury for 1 of 1 facility reviewed for the reporting of abuse, neglect, and exploitation. The facility failed to report to HHSC within the 24-hour reporting period, an emergency incident that occurred at the facility on 8/22/26 which could have posed a threat to the residents' health and safety. This failure could place residents at risk for physical, mental, and/or psychosocial harm.The findings included:Record review of the Facility's Self-Reported Incident sent to HHSC Complaint and Incident Intake reflected the facility had an incident that required the evacuation of all 115 residents due to possible fire on 8/22/2026 at approximately 2:30 p.m. Review of TULIP online portal system on 8/24/26 at 3:40 p.m. reflected the facility reported to HHSC Complaint and Incident Intake on 8/23/2026 4:58 p.m.During an interview on 8/25/26 at 4:50 p.m., the Administrator said emergency situations, such as the evacuation of all 115 residents due to possible fire incident on 8/22/26, should be reported within 24 hours as per LTCR Provider Letter 2024-14. The Administrator said he could not submit the report timely because he was busy taking care of the patients and dealing with families, providers, hospices, and having to report to everyone. He said it had been an intense few days. The Administrator said he finished as much as possible and tried to send out, but then state came in. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised April 2022 reflected: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities .2.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a.The state licensing/certification agency responsible for surveying/licensing the facility;b.The local/state ombudsman;c.The resident's representative;d.Adult protective services (where state law provides jurisdiction in long-term care);e.Law enforcement officials;f.The resident's attending physician; andg.The facility medical director.3.Immediately is defined as:a.within two hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to promote Resident #1's self-determination by not allowing him to choose when he wanted to go to bed. This failure could place residents at risk for their needs and preferences not being met. Findings included: Record review of Resident #1 face sheet dated 07/09/2026 the resident was admitted to the facility on [DATE] with diagnoses which included personal history of transient ischemic attack, and cerebral infraction (a medical classification indicating a patient has previously experienced a mini-stroke or a full stroke, but has fully recovered without ongoing, disabling symptoms), Alzheimer's disease (a progressive and irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). Record review of Resident #1's MDS assessment dated [DATE] indicated his BIMS score was 00 which indicated severe cognitive impairment (a score of 0-7 indicated severe cognitive impairment). He was totally dependent for transfers. Record review of Resident #1's Care Plan dated 05/02/26 indicated he had an ADL self-care performance deficit r/t Alzheimer's. Interventions: Transfer, the resident requires assistance by 1 staff to move between surfaces. Record review of Resident #1's video footage provided by family member with a post date of 7/8/2026 at 04:17 a.m., revealed Resident #1 was on his wheel chair and CNA A and CNA B were trying to convince him to go to bed and Resident #1 was saying that he did not want to lay down. CNA A and CNA B proceeded to transfer Resident #1 against his will. During an observation and interview on 7/8/26 at 5:45 p.m., Resident #1 was in bed. Resident #1 stated he was not able to recall the transfer or was not able to recall if he was refusing going to bed. During an interview on 7/8/26 at 5:45 p.m., Resident 1's family member stated that Resident #1 was put in bed even when he was refusing to go to bed on 7/8/2026 at 4:20 a.m. She stated that it was not fair to put him to bed against his will. Family member said that she had not mentioned it to anyone. During an interview on 7/8/26 at 10:57 p.m., CNA A said Resident #1 was on contact precautions and he wanted to go outside his room. CNA A stated that Resident #1 wanted to go outside the facility. CNA A stated that she had to respect the residents' wishes but she thought it was not safe for him. During a telephone interview on 7/9/26 at 11:28 a.m., CNA B stated that she was not able to recall that resident was transferred without his will. CNA B stated that Resident #1 was confused and he wanted to go outside the facility. CNA B stated that she and CNA A transferred him to bed but she did not remember that Resident #1 was saying that he did not want to go to bed. CNA B stated that by transferring resident to bed after he refused, she was not respecting Resident #1 wishes. During a telephone interview on 7/9/26 at 11:27 a.m., LVN C stated that Resident #1was confused and looking for an exit and Resident #1 was looking for his family member. LVN C stated that she did not know that he was refusing going to bed. LVN C stated that staff needed to respect the residents' wishes. LVN C stated that the negative outcome could be that the resident could get more agitated and aggressive because we were not respecting his rights. During an interview on 7/9/26 at 8:00 p.m., DON stated that she was not aware of this allegation. DON stated that resident's wishes needed to be respected. DON stated that the negative outcome was that staff was not respecting the resident's rights. Record review of facility's policy titled Resident Rights with a revised date December 2016 reflected Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;.e. self-determination;.

Based on observations, interviews, and record review the facility failed to follow their policy regarding storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption of the food and beverages for 1 of 1 Residents (Resident #1) reviewed for personal food storage. The facility did not have completed documentation of temperature checks for Resident #1's personal refrigerator from November 2025 through June 2026. This failure could place residents with personal refrigerators at risk of food borne illness.The findings included: Record review of Resident #1's admission record dated 06/30/2026 reflected a [AGE] year-old female with an initial admission date of 03/19/2020. Diagnoses included chronic obstructive pulmonary disease (a progressive lung condition that causes obstructed airflow and breathing difficulties), chronic respiratory failure (a long-term medical condition in which the lungs cannot properly oxygenate the blood or remove carbon dioxide), and functional quadriplegia (the complete inability to move all four limbs due to extreme physical frailty or a severe medical condition, entirely without physical injury or damage to the brain or spinal cord). Record review of Resident #1's 05/25/2026 Quarterly MDS revealed a BIMS score of 13 which indicated her cognitive function was intact. During an observation on 06/30/2026 at 05:00 p.m., Resident #1's personal refrigerator log revealed the refrigerator's temperature had not been checked since November 2025. During an interview on 06/30/2026 at 05:15 p.m., LVN E stated management checked the Resident #1's refrigerator temperatures. LVN E stated not checking the refrigerator could cause the residents to get sick. During an interview on 06/30/2026 at 05:30 p.m., the DON stated Resident #1's refrigerator temperature should be checked daily. She said per the log sheet, it had not been checked off since November 2025. She said management was responsible for checking the refrigerator temperature daily during their rounds. She said she was the one responsible for checking the refrigerator. She said if the refrigerator temperature was not checked every day, food could spoil and the resident could get sick. During an interview on 07/02/2026 at 04:29 p.m., CNA B stated the nurses were responsible for checking refrigerators in the residents' rooms. He said he did not check them. During an interview on 07/02/2026 at 05:57 p.m., ADON G stated refrigerators were checked by management and nurses. ADON G stated the nurse was the one who logged the temperature of the refrigerator and management was to verify it was done. During an interview on 07/02/2026 at 07:05 p.m., the DON stated the refrigerator logs are done during the room rounds. She said right now she was doing the refrigerator check daily. She said Resident #1's refrigerator was the only resident refrigerator in the facility.

Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident by failing to ensure the timely acquisition and administration of prescribed medications for 1 (Resident #3's) of 3 residents reviewed for pharmacy services.The facility failed to timely acquire and administer an ordered central nervous system (CNS) stimulant medication, Ritalin 20 mg twice daily for Attention-Deficit/Hyperactivity Disorder (ADHD), resulting in an unapproved treatment delay.This failure has the potential to leave residents without critical prescribed therapies to manage their clinical and behavioral symptoms. Record review of Resident #3's admission record, dated 06/30/2026, reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), End Stage Renal Disease (the final, permanent stage of chronic kidney disease where the kidneys no longer function on their own), Bipolar Disorder (a mental health condition that causes extreme mood swings), and Autistic Disorder (a developmental disorder that affects communication, behavior, and social interaction). Record review of Resident #3's electronic health record initial MDS assessment dated [DATE] revealed it was still in progress. Record review of Resident #3's initial care plan assessment revealed it had not been completed.Record review of Resident #3's physician order summary report dated 06/30/2026 revealed an active order entered with a start date of 06/26/2026 for: 'Ritalin Oral Tablet 20 MG (Methylphenidate HCl) Controlled Drug Give 1 tablet by mouth two times a day for ADHD.' A review of the resident's clinical record confirmed that as of 06/30/2026, the medication had not been administered, resulting in a five-day treatment delay of nine consecutive scheduled doses.Record review of Resident #3's June 2026 Medication Administration Record (MAR) revealed that from 06/26/2026 through 06/30/2026, the facility failed to execute the signed physician's order. Each of the nine scheduled doses of Ritalin 20 mg was signed off by nursing staff with a Code 9, indicating other, see progress notes, confirming that zero doses were administered to Resident #3.Record review of Resident #3's Orders - Administration Note on 06/26/2026 at 09:06 a.m., written by LVN I, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic]Record review of Resident #3's Orders - Administration Note on 06/26/2026 at 04:01 p.m., written by LVN I, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic]Record review of Resident #3's Orders - Administration Note dated 06/27/2026 at 10:26 a.m., written by LVN I, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic]Record review of Resident #3's Orders - Administration Note dated 06/27/2026 at 07:56 a.m. written by LVN I, revealed Ritalin Oral Tablet 20 MG pending approval. Record review of Resident #3's Orders - Administration Note dated 06/28/2026 at 09:06 a.m., written by LVN I, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic] Record review of Resident #3's Orders - Administration Note on 06/28/2026 at 04:00 p.m., written by LVN K, indicated Ritalin Oral Tablet 20 MG pend delivery. [sic] Record review of Resident #3's Orders - Administration Note on 06/29/2026 at 08:55 a.m., written by LVN J, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic] Record review of Resident #3's Orders - Administration Note on 06/29/2026 at 09:06 a.m., written by LVN C, revealed Ritalin Oral Tablet 20 MG Resident out for dialysis. Record review of Resident #3's Orders - Administration Note on 06/29/2026 at 17:37 p.m., written by LVN C, revealed Ritalin Oral Tablet 20 MG Pending script.Record review of Resident #3's Orders - Administration Note on 06/30/2026 at 10:52 a.m., written by LVN J, revealed Ritalin Oral Tablet 20 MG pend delivery. [sic]Record review of Resident #3's June 2026 MAR revealed Ritalin 20 mg was not administered twice daily from 06/26/2026 through 06/30/2026.During a phone interview on 07/02/2026 at 02:18 p.m., with Resident #3's physician stated he was not aware that Resident #3 had not received his Ritalin due to its pending from pharmacy. He said the negative effect of Resident #3 not receiving his Ritalin would be he would not be able to concentrate. During an interview on 07/02/2026 at 05:00 p.m., LVN C stated if an ordered medication was unavailable, the protocol was to call the physician for a prescription. He stated that if he needed further assistance, he would contact the ADON or DON. He stated that if a resident missed a medication dose, he would call the physician and notify the DON. During an interview on 07/02/2026 at 06:00 p.m., ADON G stated that floor nurses must contact the PCP to verify all admission orders. He stated if an ordered medication was not immediately available from the pharmacy, staff were required to check the automated medication dispensing system, obtain a retrieval code from the pharmacy, and have two nurses pull the medication. ADON G stated if the medication was unavailable in the automated medication dispensing system, staff must immediately notify the physician to obtain a hold or alternative order. He stated that an order for twice-daily Ritalin was written on 06/26/2026 for Resident #3, but there had been miscommunication with the pharmacy regarding the Ritalin order and the resident had not received the medication for five days. ADON G stated the facility protocol required staff to document physician notification whenever medication was unavailable or doses were not administered. During an interview on 07/02/2026 at 07:01 p.m., the DON stated she was responsible for reviewing new admissions and ensuring that newly admitted residents' orders were correct. She stated that facility nurses were trained to input admission medication orders directly into the electronic health record. She stated the nurses updated and verified all medication orders with the attending physician when a resident was admitted to the facility. The DON stated if a scheduled/controlled medication was ordered, staff must notify her and the physician to obtain explicit approval. The DON stated there was a five-day delay in obtaining the scheduled Ritalin order for Resident #3 because the facility had to fax the prescription hard copy to the pharmacy. The DON stated that there was no negative clinical outcome for Resident #3 not receiving the medication for five days.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen was administered at the correct setting of 2 liters per minute on 06/30/2026 and at 4 liters on 07/01/2026 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #1's admission record dated 06/30/2026 reflected a [AGE] year-old female with an initial admission date of 03/19/2020. Diagnoses included chronic obstructive pulmonary disease (a progressive lung condition that causes obstructed airflow and breathing difficulties), chronic respiratory failure (a long-term medical condition in which the lungs cannot properly oxygenate the blood or remove carbon dioxide), and functional quadriplegia (the complete inability to move all four limbs due to extreme physical frailty or a severe medical condition, entirely without physical injury or damage to the brain or spinal cord). Record review of Resident #1's 05/25/2026 Quarterly MDS revealed a BIMS score of 13 which indicated her cognitive function was intact. Record review of Resident #1's person-centered care plan, initiated date 04/27/2026 reflected Resident #1 used oxygen therapy related to ineffective gas exchange, COPD. Date Initiated: 03/08/2024. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Date Initiated: 05/07/2026 LVN RN. OXYGEN SETTINGS: O2 @ 2L/min via Nasal Canula continuously to maintain SPO2 > 90% Date Initiated: 03/08/2024 Revision on: 06/30/2026 LVN RN. Record review of Resident #1's order summary dated 06/30/2026, reflected oxygen at 2 Lpm via nasal cannula continuously to maintain O2 above 90% for shortness of breath every shift with an order date of 04/08/2026. During an observation and interview on 06/30/2026 at 05:00 p.m., Resident #1's oxygen level on the oxygen concentration machine was at 3 Lpm via nasal cannula. Observation of Resident #1 revealed the resident was in bed with the head of the bed elevated. No signs of respiratory distress were noted. Resident #1 stated her O2 was supposed to be set on 4 Lpm. During an interview and observation on 06/30/2026 at 05:15 p.m., LVN E stated Resident #1 was supposed to be on 4 Lpm O2. LVN E adjusted the O2 to 3.5 Lpm. During an interview on 06/30/2026 at 05:30 p.m., the DON stated Resident #1 was to be getting 4 Lpm of oxygen via nasal cannula. She stated the O2 was set on 3.5 Lpm and she adjusted the setting to 4 Lpm. She stated that if the O2 was not at the correct setting, the doctor's order was not being followed. She said that the resident could become short of breath. She said they did in-services on O2 but did not remember when the last one was. Record review of Resident #1's physician order dated 07/01/2026 revealed RESPIRATORY: O2 at 4 L/MIN VIA N/C TO MAINTAIN SPO2 ABOVE 90%.During an observation on 07/02/2026 at 03:00 p.m., revealed Resident #1's O2 set at 3.5 Lpm. Resident #1 had no signs of respiratory distress noted. During an observation and interview on 07/02/2026 at 03:05 p.m., LVN F was in Resident #1's room to check the O2 setting. LVN F said the O2 setting was at 3.5 Lpm. She said if the physician's orders were not followed, the resident could become short of breath, and they would not be following the doctor's orders. During an interview on 07/02/2026 at 05:57 p.m., ADON G said O2 machines were set with the ball meter being in the middle of the line. He said they should be eye level with the ball meter when setting the machine. He said the negative effect of an incorrect setting on the O2 machine could be that a resident may have their oxygen levels drop and have hypoxia (low oxygen). He said if the order said 4 Lpm, it should be set on 4 Lpm. He said 3.5 Lpm was not good enough. Record review of the facility's Oxygen Administration Policy 2001 MED-PASS, Inc., Revised October 2010 revealed, PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation1.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and #3) of 5 residents observed for infection control issues in that: 1. The facility failed to ensure LVN E performed hand hygiene before and after medication administration for Resident #1. 2. There was no signage observed outside of Resident #3's room indicating enhanced barrier precautions prior to entering room. These failure could place residents, employees, and visitors at risk of communicable diseases. Findings included: 1. Record review of Resident #1's admission record dated 06/30/2026 reflected a [AGE] year-old female with an initial admission date of 03/19/2020. Diagnoses included chronic obstructive pulmonary disease (a progressive lung condition that causes obstructed airflow and breathing difficulties), chronic respiratory failure (a long-term medical condition in which the lungs cannot properly oxygenate the blood or remove carbon dioxide), and functional quadriplegia (the complete inability to move all four limbs due to extreme physical frailty or a severe medical condition, entirely without physical injury or damage to the brain or spinal cord), and type 2 diabetes mellitus (a chronic condition where the body cannot use insulin properly or make enough of it). Record review of Resident #1's 05/25/2026 Quarterly MDS revealed a BIMS score of 13 which indicated her cognitive function was intact. Resident #1 was dependent on a helper performing all the effort for toileting, showers, and personal hygiene. Record review of Resident #1's Care Plan dated 04/27/2026 revealed, FOCUS: (Resident #1) has Diabetes Mellitus at risk for hypo/hyperglycemia. Date Initiated: 01/12/2026. INTERVENTIONS/TASKS: Administer Tirzepatide subcutaneous (into the fat under the skin) solution as ordered. Monitor for side effects and effectiveness. Date Initiated: 06/30/2026 Revision on: 06/30/2026 LVN RN Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 01/12/2026 LPN RN. Record review of Resident #1's Order Summary dated 06/30/2026 revealed, Tirzepatide Subcutaneous Solution Auto-injector 2.5 MG/0.5ML (Tirzepatide) Inject 2.5 mg subcutaneously in the afternoon every Tue for TYPE 2 DIABETES MELLITUS related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA. During observation on 06/30/2026 at 05:44 p.m., LVN E administered an injectable medication to Resident #1 without washing her hands or using hand sanitizer before putting on gloves and did not wash her hands or use hand sanitizer after administration of the medication. During an interview on 06/30/2026 at 05:49 p.m., LVN E said she did not perform hand hygiene before or after administering the medication to Resident #1. LVN E stated she should have performed hand hygiene before and after administering injectable medication to Resident #1. LVN E said the importance of hand hygiene was to prevent contamination and infection. She said they were in-serviced monthly on infection control which included handwashing and the use of hand sanitizer. During an interview on 06/30/2026 at 05:30 p.m., the DON stated handwashing or hand sanitizer should occur before and after administration of medications. She said a negative effect of not using hand sanitizer or washing of hands before and after medication administration could cause infection or cross-contamination of either the resident or the staff. During an interview on 07/02/2026 at 05:56 p.m., ADON G, stated staff are provided with in-service trainings every two weeks on infection control. ADON G stated the last infection control training was held a few weeks ago and the in-services are usually conducted by himself or by the DON. ADON G stated that the most effective technique for infection control was to practice hand washing. ADON states it is also very important for employees to use enhanced barrier protection. This includes the use of gowns, gloves and face masks. ADON states that donning and doffing are also very important. ADON states that employees are to wash their hands for 20 seconds. ADON G stated if the facility did not practice infection control it could affect the staff as well as the residents. ADON G stated diseases like scabies could be spread if infection control such as hand hygiene was not practiced. During an interview on 07/02/2026 at 07:06 p.m., the DON stated staff are provided with monthly in-service trainings on infection control. The DON stated that the staff were directed to practice proper hand hygiene. The DON stated that staff must demonstrate to DON and ADON how to properly wash their hands, which included washing their hands for 20 seconds or longer. The DON stated situations which required proper hand hygiene include before and after providing care to a resident. The DON stated staff are also expected to wash their hands prior to going into a resident's room and after exiting room. The DON stated a negative outcome of not practicing hand hygiene included the spread of infection through germs. 2. Record review of Resident #3's admission Record dated 06/30/26 revealed a [AGE] year-old male with an admission date of 06/25/26. Resident #3 had a diagnoses of Acquired Absence of other Genital Organ(s) (loss of reproductive organs due to surgical removal or disease), Type 2 Diabetes Mellitus (high blood sugar levels in body) without complications, and Dependence on Renal Dialysis (filtering waste and excess fluid from blood). Record review of Resident #3's care plan dated 06/30/26 revealed resident #3 had a potential/actual impairment to the skin integrity of the penis r/t surgical wound due to history of penectomy. Resident #3 also had potential/actual impairment to skin integrity of the heel r/t DFU initiated date 06/30/26. Record review of Resident #3's medication administration record revealed Resident #3 had active orders for Gentamicin Sulfate External Ointment 0.1%, apply daily for penile wound and Muplrocin External Ointment 2% apply daily for left heel wound. Observation on 06/30/26 at 9:37am of Resident #3's room revealed no signage indicating Resident #3 was on Enhanced Barrier Precautions (EBP). During an interview on 06/30/26 at 2:30pm LVN C said Resident #3 was on EPB due to wounds. LVN C said there was supposed to be signs posted on Resident #3's door so anyone who had entered his room would have known to practice EBP. He said he didn't know why there was nothing posted, he said Resident #3 was admitted to the facility a few days ago. LVN C said if the residents have something contagious the staff or anyone can pass it on to someone else if they don't use proper precautions or the residents can be at risk of also getting a disease, getting sick. During an interview on06/30/26 at 4:54pm the DON said Resident #3 was supposed to have signage of EBP outside his room. She said Resident #3 was receiving dialysis weekly and also had wounds. The DON said they needed to do a better job to make sure signage was in place for anyone on EBP. She said nothing could have happened to the resident because his wounds were covered and staff uses standard precautions for wound care. Observation on 06/30/2026 at 05:44 p.m., LVN E administered an injectable medication to Resident #1 without washing her hands or using hand sanitizer before putting on gloves and did not wash her hands or use hand sanitizer after administration of the medication. During an interview on 06/30/2026 at 05:49 p.m., LVN E said she did not perform hand hygiene before or after administering the medication to Resident #1. LVN E stated she should have performed hand hygiene before and after administering injectable medication to Resident #1. LVN E said the importance of hand hygiene was to prevent contamination and infection. She said they were in-serviced monthly on infection control which included handwashing and the use of hand sanitizer. During an interview on 06/30/2026 at 05:30 p.m., the DON stated handwashing or hand sanitizer should occur before and after administration of medications. She said a negative effect of not using hand sanitizer or washing of hands before and after medication administration could cause infection or cross-contamination of either the resident or the staff. During an interview on 07/02/2026 at 05:56 p.m., ADON G, stated staff are provided with in-service trainings every two weeks on infection control. ADON G stated the last infection control training was held a few weeks ago and the in-services are usually conducted by himself or by the DON. ADON G stated that the most effective technique for infection control was to practice hand washing. ADON states it is also very important for employees to use enhanced barrier protection. This includes the use of gowns, gloves and face masks. ADON states that donning and doffing are also very important. ADON states that employees are to wash their hands for 20 seconds. ADON G stated if the facility did not practice infection control it could affect the staff as well as the residents. ADON G stated diseases like scabies could be spread if infection control such as hand hygiene was not practiced. During an interview on 07/02/2026 at 07:06 p.m., the DON stated staff are provided with monthly in-service trainings on infection control. The DON stated that the staff were directed to practice proper hand hygiene. The DON stated that staff must demonstrate to DON and ADON how to properly wash their hands, which included washing their hands for 20 seconds or longer. The DON stated situations which required proper hand hygiene include before and after providing care to a resident. The DON stated staff are also expected to wash their hands prior to going into a resident's room and after exiting room. The DON stated a negative outcome of not practicing hand hygiene included the spread of infection through germs. 2. Record review of Resident #3's admission Record dated 06/30/26 revealed a [AGE] year-old male with an admission date of 06/25/26. Resident #3 had a diagnoses of Acquired Absence of other Genital Organ(s) (loss of reproductive organs due to surgical removal or disease), Type 2 Diabetes Mellitus (high blood sugar levels in body) without complications, and Dependence on Renal Dialysis (filtering waste and excess fluid from blood). Record review of Resident #3's care plan dated 06/30/26 revealed resident #3 had a potential/actual impairment to the skin integrity of the penis r/t surgical wound. Resident #3 also had potential/actual impairment to skin integrity of the heel r/t DFU initiated date 06/30/26. Record review of Resident #3's medication administration record revealed Resident #3 had active orders for Gentamicin Sulfate External Ointment 0.1%, apply daily for penile wound and Muplrocin External Ointment 2% apply daily for left heel wound. Observation on 06/30/26 at 9:37am of Resident #3's room revealed no signage indicating Resident #3 was on enhanced barrier precautions (EBP). During an interview on 06/30/26 at 2:30pm LVN C said Resident #3 was on EPB due to wounds. LVN C said there was supposed to be signs posted on Resident #3's door so anyone who had entered his room would have known to practice EBP. He said he didn't know why there was nothing posted. He said Resident #3 was admitted to the facility a few days ago. LVN C said if the residents had something contagious the staff or anyone could pass it on to someone else if they did not use proper precautions or the residents could be at risk of also getting a disease, getting sick. During an interview on06/30/26 at 4:54pm the DON said Resident #3 was supposed to have signage of EBP outside his room. She said Resident #3 was receiving dialysis weekly and also had wounds. The DON said they needed to do a better job to make sure signage was in place for anyone on EBP. She said nothing could have happened to the resident because his wounds were covered and staff uses standard precautions for wound care. 1. Record review of the facility's Handwashing/Hand Hygiene Policy (MED-PASS, Inc Revised August 2019) revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation 2 .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications. i. After contact with a resident's intact skin. m. After removing gloves. 2. Record review of facility's policy titled Enhanced Barrier Precautions date revised 04/2024 revealed; Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.

Based on interviews and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 5 residents (Resident #3) reviewed for consent for antipsychotic medications in that: Resident #3 was prescribed and administered Risperidone (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: Record review of Resident #3's admission record dated 07/01/2026, revealed a [AGE] year-old male with an admission date of 06/25/2026. Resident #3's diagnoses included bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels) and autistic disorder (a lifelong neurodevelopmental condition that affects how a person communicates, interacts with others, perceives the world, and learns). Record review of Resident #3's Entry MDS, dated [DATE], was not completed. Record review of Resident #3's Physician's orders and start date 06/26/2026 revealed risperiDONE Oral Tablet 2 MG (Risperidone). Give 1tablet by mouth two times a day for bipolar disorder. Record review of Resident #3's care plan, revealed it was not completed. Record review of Resident #3's June 2026 MAR revealed Resident #3 was administered risperiDONE Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth two times a day for bipolar disorder from 06/26/2026 at 04:00 p.m. through 08:00 a.m. on 07/02/2026. Record review of Resident #3's medical record on 07/02/2026, revealed there was no signed consent for the antipsychotic risperidone. During an interview on 07/02/2026 at 04:54 p.m., LVN C said for antipsychotics they needed the RP signature consent. He said the antipsychotic could not be administered before consent was given. During an interview on 07/02/2026 at 05:27 p.m., LVN D stated before they would put in an order for an antipsychotic, they had to have the consent signed. LVN D stated she would not give the antipsychotic before the consent was signed. She stated she had never given an antipsychotic without the consent being signed and would not know the negative effect. During an interview on 07/02/26 at 07:05 p.m., the DON stated antipsychotics needed signature consent. She said there was no RP signature on Resident #3's consent for the antipsychotic. The DON stated she had verbal consent from the RP. There was no documentation in the electronic medical record that RP verbal consent was given. She said it was very difficult to get the RP's signature because RPs were not at the facility every day. Record review of facility's Resident Rights policy (2001 MED-PASS, Inc. Revised December 2016) revealed: Policy Interpretation and Implementation1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment.

Based on interviews, and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #3) of 3 residents reviewed for baseline care plan completion.The facility failed to complete a baseline care plan for Resident #3 within 48 hours of his admission.This failure could place newly admitted residents at risk of not receiving effective, person-centered care.Findings included:Record review of Resident #3's admission Record dated 06/30/26 revealed a [AGE] year-old male with an admission date of 06/25/26. Resident #3 had a diagnoses of Type 2 Diabetes Mellitus (high blood sugar levels in body) without complications, and Dependence on Renal Dialysis (filtering waste and excess fluid from blood).Record review on 06/30/26 at 8:45am of Resident #3's electronic medical record under assessment tabs revealed no baseline care plan was initiated.During an interview on 06/30/26 at 10:25am, Resident #3 said he had just been at the facility a few days and did not remember having a meeting with the staff since he had been admitted .During an interview on 06/30/26 at 6:04pm the DON said the IDT was responsible for completing care plans for residents. She said the base line care plans were supposed to have been done within 48 hours of when a resident was admitted to the facility. She said a baseline care plan was supposed to have been done for Resident #3. She said it was an oversite. The DON said there was no negative impact on Resident #3 because all residents care was discussed during morning meetings.Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, date revised December 2016 revealed:Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 of 4 resident rooms in the secured unit (Resident room [ROOM NUMBER]) reviewed for environment.1. The facility failed to ensure Resident room [ROOM NUMBER], was thoroughly cleaned and sanitized.2. The facility failed to properly cover a shattered window in Resident room [ROOM NUMBER].This deficient practice could place residents at risk of living in an unsanitary environment and a diminished quality of life due to an unclean and unfunctional environment. Findings include:1. An observation on 6/9/26 at 9:01am of Resident room [ROOM NUMBER] revealed scraps of torn paper on the floor along the floorboards of two walls. The room also revealed a bedside table next to the bed. The bedside table had spilled milk, pieces of scrambled eggs, and a dirty napkin on it. Under the bedside table, there were pieces of scrambled eggs and a dirty napkin on the floor. The bed had crumbs of food and unknown stains. The resident of Resident room [ROOM NUMBER] was not in the room during the time of the observation. In an observation on 6/9/26 at 9:08am, the resident for Resident room [ROOM NUMBER] is non-interviewable. In an interview on 6/9/26 at 9:11am, LVN A stated she was the nurse for the secured unit. LVN A stated that the mess in Resident room [ROOM NUMBER] looked like it was from breakfast. LVN A stated housekeeping had not made their round to the secured unit yet. LVN A stated housekeeping usually arrived later in the morning, before noon. LVN A stated she could have called housekeeping to clean up the room but hadn't because the morning had gotten busy. LVN A stated she would call housekeeping to clean the room now. LVN A stated it was important to keep Resident room [ROOM NUMBER] clean because the resident in Resident room [ROOM NUMBER] deserved to have a clean room and maintain his dignity. LVN A stated Resident room [ROOM NUMBER] not having been cleaned could have posed a risk for falls or insects.In an observation on 6/9/26 at 9:41am, Resident room [ROOM NUMBER] was clear of clutter and trash. There was no mess on the floor or around the bed. The bed was properly made with no crumbs on the sheets. In an observation on 6/9/26 at 9:47am, Resident room [ROOM NUMBER] was noted to be clean. There was no trash on the floor. The bed was folded correctly and there were no crumbs on the sheets. In an observation on 6/9/26 at 10:01am, Resident room [ROOM NUMBER] was noted to be clean of trash. The trash can had been emptied. The bedside table had been cleaned and there was nothing on top of it. The bed was nicely made with no crumbs on the sheets. In an observation on 6/9/26 at 10:53am, Resident room [ROOM NUMBER] reviewed it still had not been cleaned. There were scraps of torn paper on the floor along the floorboards of two walls. The room also revealed a bedside table next to the bed. The bedside table had spilled milk, pieces of scrambled eggs, and a dirty napkin on it. Under the bedside table, there were pieces of scrambled eggs and a dirty napkin on the floor. The bed had crumbs of food and unknown stains. The resident of Resident room [ROOM NUMBER] was not in the room during the time of the observation.In an interview on 6/9/26 at 11:18am, the Housekeeping Supervisor stated he had four housekeepers assigned to the facility. The Housekeeping Supervisor stated that all housekeepers start in the dining room and then attend to their assigned halls. The Housekeeping Supervisor stated that the housekeeper that was assigned to the secured unit, would start with another hall first and then end in the secured unit. The Housekeeping Supervisor stated if a nurse calls him that a room needed cleaning, that room was prioritized and the housekeeper would attend to it right away. The Housekeeping Supervisor stated that starting tomorrow, the housekeeper assigned to the secured unit would start in the secured unit first and then go to their other assigned hall. The Housekeeping Supervisor stated it was important the rooms were kept clean because of resident safety and their well-being. The Housekeeping Supervisor stated it was also important because of infection control and hygiene.In an interview on 6/11/26 at 11:40am the Administrator stated that housekeeping usually went in the morning and the afternoon to clean Resident room [ROOM NUMBER]. The Administrator stated the resident in Resident room [ROOM NUMBER] would sometimes get aggressive and would not allow the housekeeper to clean the room. The Administrator stated distraction was used to allow for cleaning, however housekeeping did clean the room.Record review of the facility's policy on Cleaning and Disinfecting Residents' Room revised in August 2013 revealed, General Guidelines1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. An observation on 6/9/26 at 9:01am of Resident room [ROOM NUMBER] revealed that the only window in the room, was covered entirely by a sheet of drywall. It was noted that the sheet of drywall was placed on the windowsill and screwed onto the wall.In an observation on 6/9/26 at 9:08am, the resident for Resident room [ROOM NUMBER] is non-interviewable. In an interview on 6/9/26 at 9:11am, LVN A stated that the resident of Resident room [ROOM NUMBER], had broken the window over the weekend. LVN A stated that the resident of Resident room [ROOM NUMBER] was not moved to another room because the resident required a single occupancy room and there was not one available. In an interview on 6/9/26 at 10:30am, the Maintenance Director stated the window for Resident room [ROOM NUMBER] did not break but had shattered. The Maintenance Director stated it happened over the weekend on Sunday, 6/7/26. He stated the Maintenance Assistant responded to call but had notified him of the incident. The Maintenance Director stated only drywall was on hand to cover the window at the time of the incident. The Maintenance Director stated there was a requirement for covering windows and there had to be an opening of 4 from the bottom to allow for ventilation and light. The Maintenance Director stated he was not aware the Maintenance Assistant had not left the 4 opening. He stated he did not know when the window would be repaired. The Maintenance Director stated he had not obtained an estimate or invoice for replacement because he was waiting on the Administrator to tell him to do so. The Maintenance Director stated that as of today, he had not been updated on the replacement for the window by the Administrator. Record review on 6/9/26 at 10:45am revealed there were no estimates on the repair or replacement of the window. In an interview on 6/9/26 at 12:36pm, the Maintenance Assistant stated he responded to the call over the weekend to repair the window in Resident room [ROOM NUMBER]. He stated when he saw the window, the window was shattered with pieces of glass on the floor. The Maintenance Assistant stated he cleaned up the glass and called the Administrator. He stated the Administrator told him to cover the window with drywall. The Maintenance Assistant stated he set the sheet of drywall on the windowsill and screwed it to the wall. He stated he did not leave the 4 off the windowsill for ventilation because he thought glass could fall from the breakage and hurt someone. The Maintenance Assistant stated he notified the staff at that time to leave the door open to allow for ventilation.In an interview on 6/11/26 at 11:40pm, the Administrator stated he was notified over the weekend about the broken window in Resident room [ROOM NUMBER]. He stated he had the Maintenance Assistant take care of it. The Administrator stated he asked the Maintenance Assistant to cover the window with drywall until the window could be replaced. He stated that on the day of the incident, he was not aware of when the window would be replaced. The Administrator stated that the resident of Resident room [ROOM NUMBER] was not moved into another room because the resident required a single occupancy room. He stated there were no single occupancy rooms available at the time of the incident. The Administrator stated that at this time, the window had already been replaced.The Administrator stated there was no environmental policy for window covering or maintenance.Record review of the facility's policy on Resident Rights revised on December 2016 revealed, 1. a. A dignified existence

Based on interviews and record reviews, the facility failed to ensure the resident's right to be informed, in advance, of the care to be furnished for 1 of 3 residents (Resident #1) reviewed for consent for secured unit placement.Resident #1 was placed in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders) without prior consent based on information of the benefits, risks, and options available.This failure could affect residents by placing them at risk of not being informed of treatment options.The findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), depression, anxiety and hypertension (high blood pressure).Record review of Resident #1's medical record on 03/20/26, did not reveal a consent for placement into the secured unit.Record review of Resident #1's progress note dated 03/11/26 revealed a change in condition for shortness of breath.In an interview on 03/20/26 at 12:05 pm, LVN B stated she was the usual nurse for the secured unit. LVN B stated Resident #1 was placed in the secured unit last week because the resident needed to be closely monitored. Resident #1 had an episode of shortness of breath and required oxygen. LVN B stated she was not working at the time Resident #1 was placed on the secured unit however, the DON was the one that handled the placement. LVN B stated that when a resident was placed in the secured unit, a consent was required.In an interview on 03/23/26 at 2:53 pm the DON stated Resident #1 had been placed in the secured unit on the night of 03/11/26 because she had a change in condition. Resident #1 had an episode of shortness of breath and needed to be monitored closely. DON stated there were more staff in the secured unit to monitor Resident #1. DON stated a consent was required to place any resident in the secured unit however one was not obtained for Resident #1. DON stated Resident #1 was in the secured unit overnight on 03/11/26 and was returned to her regular room the following morning. DON stated a consent was still required even though Resident #1 was in the secured unit for a few hours. The DON stated she did not know why consent was not obtained. DON stated not having consent was against the right of the resident.Record review of the facility's Secured Unit admission Criteria dated 3/2026 revealed:4. There will be a consent received for placement in the secured/locked area.

Based on interviews and record reviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 3 residents (Resident #1) reviewed for involuntary seclusion.The facility failed to ensure Resident #1 met criteria to be placed in the secured unit per secured unit criteria on 03/11/26.This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm.The findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), depression, anxiety and hypertension (high blood pressure).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 04 indicating her cognition was severely impaired. MDS revealed Resident #1 did not exhibit potential indicators of psychosis such as hallucinations nor delusions. MDS also revealed Resident #1 had a score of 0 for behavioral symptoms directed towards others and a score of 0 for verbal behavioral systems directed toward others. 0 indicated behavior not exhibited.Record review of Resident #1's Order Summary Report dated 03/20/26 revealed there was no order placed on 03/11/26 for resident to be placed in the secured unit.In an interview on 03/20/26 at 12:05 pm, LVN B stated she was the usual nurse for the secured unit. LVN B stated Resident #1 was placed in the secured unit last week because the resident needed to be closely monitored. Resident #1 had an episode of shortness of breath and required oxygen. LVN B stated she was not working at the time Resident #1 was placed on the secured unit however, the DON was the one that handled the placement.In an interview on 03/23/26 at 2:30 pm, LVN D stated she had worked with Resident #1 for two days, 03/11/26 and 03/12/26. LVN D stated she worked the morning shift of 6:00 am - 2:00 pm on both days. LVN D stated that on 03/11/26, Resident #1 had been in her assigned room with no issues. On 03/12/26, Resident #1 was in the secured unit. LVN D stated she received report in the morning when she arrived to work, that Resident #1 had an episode of shortness of breath overnight and was placed in the unit for closer observation. LVN D stated she was directed by the DON to get Resident #1 from the secured unit and take her back to her room. LVN D stated she took Resident #1 back to her room around 9:00 am on 03/12/26.In an interview on 03/23/26 at 2:53 pm the DON stated Resident #1 was placed in the secured unit because she was having shortness of breath. DON stated there were more staff in the secured unit to monitor the resident. DON stated Resident #1 was placed in the unit around 11:00 pm on 03/11/26 and returned to her assigned room the following morning. DON stated that shortness of breath is not a criteria for a resident to be placed in the secured unit however she thought Resident #1 would be better monitored there. DON stated that a criteria for a resident to be in the secured unit was to have behavioral issues. DON stated Resident #1 did not have behavioral issues.Record review of the facility's Secured Unit admission Criteria dated 3/2026 revealed:admission criteria: The individual must have cognitive impairment. Behavioral assessment: Assessing high risk behaviors; self-harm, harm to others; frequency of behavior

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans.1. The facility failed to ensure Resident #1 was care planned for the use of Lorazepam (a psychotropic medication used to treat anxiety).2. The facility failed to ensure Resident #1 was care planned for the use of the Wander Guard (A discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area).3. The facility failed to ensure Resident #1 was care planned for being placed in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders).These deficient practices could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.Findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), depression, anxiety and hypertension (high blood pressure).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 04 indicating her cognition was severely impaired. MDS revealed an active diagnosis of anxiety disorder along with Resident #1 taking an antianxiety medication for this diagnosis. MDS revealed the presence of a Wander/elopement alarm on Resident #1's self. Record review of Resident #1's Order Summary Report dated 03/20/26 revealed resident had an order for Lorazepam 0.5mg, Give 1 tablet by mouth two times a day for anxiety with an effective date of 02/17/26. Record review of Resident #1's care plan initiated 11/18/24, did not reveal a Focus, Goal, or Interventions for Lorazepam, Wander Guard or for the placement of Resident #1 in the secured unit.An observation on 03/20/26 at 9:16 am, Resident #1 was in her assigned room, and a Wander Guard was noted on her right wrist.In an interview on 3/20/26 at 11:21 am, MDS Nurse A stated she was aware Resident #1 was taking Lorazepam but failed to add the medication to the care plan. MDS Nurse A stated she was aware Resident #1 had the Wander Guard on her right wrist. MDS Nurse A stated she had added the use of the Wander Guard on resident's quarterly MDS but failed to add it to the care plan. MDS Nurse A stated Lorazepam and the use of the Wander Guard should have been implemented into Resident #1's care plan but failed to do so. MDS Nurse A stated the DON was also responsible for implementing or revising care plans.In an interview on 03/20/26 at 12:05 pm, LVN B stated she was the usual nurse for the secured unit. Resident #1 had been in the secured unit last week because the resident needed to be monitored closely. Resident had an episode of shortness of breath and required oxygen. LVN B stated the DON was aware Resident #1 was in the secured unit. LVN B stated she was not responsible for updating care plans. LVN B stated what when there was a new order or a change in condition, the MDS nurse or the DON updated the care plans.In an interview on 03/23/26 at 2:53 pm the DON stated she and the MDS nurse were responsible for implementing and revising care plans. The DON stated she was aware Resident #1 was on Lorazepam for anxiety. The DON stated she was aware Resident #1 had the Wonder Guard in place. The DON stated Resident #1 was in the secured unit last week to be closely monitored. DON stated Resident had an episode of shortness of breath and would be better monitored in the secured unit. The DON stated she was aware the placement of Resident #1 into the secured unit should have been added to Resident #1's care plan. The DON stated she checked care plans weekly to ensure they were up to date but she did not know why these changes were not added. DON stated not updating care plans could result in Resident #1 not receiving the correct interventions to certain health problems.Record review of the facility's Care Plans, Comprehensive Person-Centered Policy dated December 2016 revealed:8. The comprehensive, person-centered care plan will: a. Include measurable objective and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, [NAME], and psychosocial well-being. k. Reflect treatment goal, timetables, and objectives in measurable outcomes13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to obtain a written, signed and dated order from the attending physician for 1 of 3 residents (Resident #1) whose records were reviewed for physician services.The facility failed to obtain a physician's order for Resident #1 to be in the secured unit.This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.The findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), depression, anxiety and hypertension (high blood pressure).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 04 indicating her cognition was severely impaired.Record review of Resident #1's Order Summary Report dated 03/20/26 revealed there was no order placed on 03/11/26 for resident to be placed in the secured unit.In an interview on 03/20/26 at 12:05 pm, LVN B stated she was the usual nurse for the secured unit. LVN B stated Resident #1 was placed in the secured unit last week because the resident needed to be closely monitored. Resident #1 had an episode of shortness of breath and required oxygen. LVN B stated she was not working at the time Resident #1 was placed on the secured unit however, the DON was the one that handled the placement. LVN B stated she was unsure if an order was required for a Wander Guard and that she would need to ask the DON.In an interview on 03/23/26 at 2:30 pm, LVN D stated she had worked with Resident #1 for two days, 03/11/26 and 03/12/26. LVN D stated she worked the morning shift of 6:00 am - 2:00 pm on both days. LVN D stated that on 03/11/26, Resident #1 had been in her assigned room with no issues. On 03/12/26, Resident #1 was in the secured unit. LVN D stated she received report in the morning when she arrived to work, that Resident #1 had an episode of shortness of breath overnight and was placed in the unit for closer observation. LVN D stated she was directed by the DON to get Resident #1 from the secured unit and take her back to her room. LVN D stated she took Resident #1 back to her room around 9:00 am on 03/12/26.In an interview on 03/23/26 at 2:53 pm the DON stated Resident #1 was placed in the secured unit because she was having shortness of breath. DON stated there were more staff in the secured unit to monitor the resident. DON stated Resident #1 was placed in the unit around 11:00 pm on 03/11/26 and returned to her assigned room the following morning. DON stated there was no order for Resident #1 to be placed in the unit. DON stated a doctor's order is required for a resident to be placed in the secured unit. DON stated she did not know why she did not obtain a doctor's order. DON stated it was not required to obtain a doctor's order for a Wander Guard. Record review of the facility's Secured Unit admission Criteria dated 3/2026 revealed:3. A physician order for placement will be obtained for secured unit placement.Record review of the facility's Wandering and Elopements Policy dated March 2019, did not have any information regarding criteria or implementations of the Wander Guard.

Based on observation, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices. The facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records.The facility failed to document a change in condition or progress note to reflect the placement of the Wander Guard (A discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) on Resident #1. The facility failed to document a change in condition or progress note to reflect the placement of Resident #1 in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders).These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), depression, anxiety and hypertension (high blood pressure).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 04 indicating her cognition was severely impaired. MDS revealed the presence of a Wander/elopement alarm on Resident #1's self. Record review of Resident #1's medical chart revealed there was no progress note or change in condition to indicate the resident was placed in the secured unit.An observation on 03/20/26 at 9:16 am, Resident #1 was in her assigned room, and a Wander Guard was noted on her right wrist.In an interview on 03/20/26 at 9:20 am, LVN C revealed she was aware Resident #1 had a Wander Guard on her right wrist. LVN C stated she did not know when the Wander Guard was first placed. LVN C stated she was documenting the assessment of the Wander Guard in the TAR every shift. LVN C stated the DON was the one who initiated the Wander Guard on Resident #1 and therefore the progress notes and change in condition should have been initiated by the DON.In an interview on 03/20/26 at 12:05 pm, LVN B stated she was the usual nurse for the secured unit. LVN B stated Resident #1 was placed in the secured unit last week because the resident needed to be closely monitored. Resident #1 had an episode of shortness of breath and required oxygen. LVN B stated she was not working at the time Resident #1 was placed on the secured unit however, the DON was the one that handled the placement.In an interview on 03/23/26 at 2:53 pm the DON stated she was aware that Resident #1 had a Wander Guard to her right wrist but was unaware who had placed it or when it was placed. The DON stated the change in condition or a progress note should have been documented to reflect the placement of the Wander Guard but did not know why it was not documented. The DON stated that Resident #1 had been placed in the secured unit last week because she had an episode of shortness of breath and needed to be monitored closely. DON stated there were more staff in the secured unit to monitor Resident #1. The DON stated that all nurses should be updating Resident #1's medical chart to reflect anything new in her condition. It was important to document because it ensured that all skilled nurses were aware of Resident #1's health status.Record review of the facility's Charting and Documentation policy dated July 2017 revealed:2. The following information is to be documented in the resident medical record: d. Changes in the resident's condition6. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment date and/or any unusual findings obtained during the procedure/treatment

Based on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #2) The facility failed to protect Resident #2 from misappropriation/exploitation by allowing housekeeping to take money from Resident #2 for housekeeping's own well-being and personal expenses, exact date unknown. This failure could place residents who resided in this facility at risk of misappropriation of property. Findings included: Record review of a face sheet dated 1/30/26 reflected Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included vascular dementia (a decline in thinking, memory, and reasoning skills caused by reduced blood flow to the brain, which damages or kills brain cells), and muscle wasting and atrophy (when muscles waste away). Record review of the MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 4 which indicated Resident #2 had severe cognitive impairment. The MDS assessment reflected Resident #2 required supervision or touching assistance with eating and needed substantial/maximal assistance with staff for toileting, and bathing. Record review of the care plan dated 11/6/19 indicated Resident #2 had impaired cognitive function and impaired thought processes related to dementia. During an interview on 01/29/2026 at 3:00 PM, Resident #2 stated he stated the staff here were all alright and they treated him well. He stated no staff had ever stolen anything from him, but he had given one guy $40.00 recently and he had paid him back only $10.00. He stated it was the housekeeping guy that he gave the money to. He stated he gave the money from his safe. He stated he felt safe in the facility, and he had no concerns. He stated he did get his money back and that the administrator paid him back. Attempts to interview housekeeping person were unsuccessful, two attempts were made to reach him by telephone on 01/30/26 at 10:47 AM and 2:16 PM. No return call was received. In an interview on 01/30/2026 at 7:00 PM, the DON stated that she was not working in the facility when the incident happened. During an interview on 01/30/26 at 7:50 PM, the ADM stated in the case of the self-report for misappropriation of property, on 09/6/25, Resident #2 had informed him that he lent $40 dollars to the housekeeping person, and he had paid him only $10.00 dollars back. He stated he immediately began the investigation and upon interviewing. He stated when he asked the housekeeping person about the money, he admitted to receiving the money. He stated the housekeeping person was suspended immediately and would be terminated. He stated that the facility paid back the $30.00 dollars to Resident #2. He stated they performed safe surveys for other residents. He stated he in-serviced staff on abuse and reporting. He stated that law enforcement was called. Review of the Facility Policy on Abuse Prevention Program with revised date December 2016 revealed: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #1) of 3 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication Zyprexa (Olanzapine- atypical antipsychotic) for Resident #1. This failure could put residents at risks of receiving unnecessary psychotropic medications.Findings include: Record review of Resident #1's admission Record dated 01/29/26 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. The admission record revealed Resident #1 had diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks), vascular dementia (a decline in thinking, memory, and reasoning skills caused by reduced blood flow to the brain, which damages or kills brain cells). Record review of Resident #6's MDS Resident Assessment and Care Screening dated 1/6/26 revealed Resident #1 had a BIMS score of 3 which indicated Resident #1 had severely impaired cognition. The MDS assessment also revealed Resident #1 was on a high-risk drug, an antipsychotic. Record review of Resident #1's care plan dated 1/1/26 revealed that Resident #1 used antipsychotic medications related to Alzheimer's disease. The interventions were to monitor for side effects and effectiveness every shift, and monitor/document/report PRN any adverse reactions to antipsychotic medications. Record review of Resident #1's Physician's Orders revealed an order dated 1/1/26 for Olanzapine Oral Tablet 10 mg, give one tablet by mouth two times per day related to Alzheimer's disease, unspecified. The order did not indicate an end date. Side effect monitoring for Olanzapine every shift with start date of 12/31/25 and behavior monitoring for Olanzapine every shift with start date of 12/31/25. Record review of Resident #1's e-MAR dated revealed the medication Olanzapine oral tablet 10 mg was administered to Resident #1 1/06/2026 through 1/05/2026. During a phone interview on 1/30/26 at 1:00 p.m., Pharmacist stated Alzheimer's disease was not an appropriate diagnosis for an antipsychotic medication. Pharmacist stated that antipsychotic for a resident with Alzheimer's disease could cause death. During an interview on 1/30/26 at 6:02 p.m., ADON stated the negative outcome for ordering an antipsychotic medication for Alzheimer's disease on Resident #1 could cause death, that was why was not recommended on residents with Alzheimer's or Dementia. During an interview on 01/30/26 at 7:50 pm, the DON stated Resident #1 was on olanzapine medication. While the DON looked at her computer screen, the DON read out loud Resident #1's Olanzapine order. The DON stated the indication of Alzheimer's disease was allowed due to Resident#1 came with that order from the hospital. Record review of Facility's policy titled Antipsychotic Medication Use with a revised date December, 2016 revealed: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (wound care cart) of 7 medication carts. The facility failed to ensure that the wound care cart was secured and lock when it was left unattended by LVN A. These failures could place residents at risk of injury to other residents if medication left unsecured were consumed. Findings included: During an observation on 01/29/2026 at 02:20 PM revealed the wound care medication cart was left unlocked outside room [ROOM NUMBER]. During the observation LVN A came out of the room and surveyor informed her wound care medication cart was unlocked and LVN A secured the cart by locking it. During an interview on 01/29/2026 at 02:25 PM with LVN A revealed she was responsible for the wound care medication cart that was left unlocked. She stated she was expected to lock the wound care medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. She stated he had left the cart unlocked because she just forgot. During an interview on 01/30/2026 at 04:18 PM with the DON stated her expectation was for staff to lock it when they walk away from the medication cart . DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. Record review of undated facility policy Storage of Medications: revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #4) of 5 residents reviewed for care plans.The facility failed to develop a comprehensive person-centered care plan for Resident #4 to address the use of a fall mat.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Record review of Resident #4's face sheet dated 10/21/25 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: dementia (decline in cognitive abilities), generalized muscle weakness, other lack of coordination, mood disorder (impacts emotional state), type 2 diabetes (high levels of sugar in blood), and chronic kidney disease. Record review of Resident #4's fall risk evaluation dated 10/02/25 reflected a score of 13 which indicated a high risk. Record review of Resident #4's MDS assessment dated [DATE] reflected Resident #4 had a BIMS score of 2, which indicated severe cognitive impairment. Record review of Resident #4's care plan, dated 10/21/25, reflected, [Resident #4] was at risk for falls related to gait balance problems, incontinence, unaware of safety needs, and wandering. Date initiated: was 03/20/23. Interventions included: call light within reach, encourage the use of call light for assistance, and ensure resident was wearing appropriate footwear. [Resident #4] had an actual fall on 07/28/25 with a laceration to back of head. Date initiated: was 07/28/25. Interventions included: continue interventions on the at-risk plan, monitor for signs/symptoms of pain or new injury for 72 hours, and neuro checks as ordered. [Resident #4] had a witnessed fall on 09/09/25 with a minor skin tear to left elbow. Date initiated: was 09/09/25. Interventions included: monitor for signs/symptoms of pain or new injury for 72 hours, therapy to evaluate, and treatment per orders. [Resident #4] had an unwitnessed fall on 10/02/25 with no apparent injury. Date initiated: was 10/02/25. Interventions included: determine/address causative factors for fall, monitor signs/symptoms of pain or new injury for 72 hours, neuro checks as ordered, and offer activities to distract resident. Resident #4's care plan did not reflect the use of a fall mat. On 10/22/25 at 2:15 PM, an attempted interview and observation with Resident #4, revealed she was not interviewable. Resident #4 did not answer baseline questions or questions related to the incident. Resident #4 laid in bed with the call light within reach. Resident #1 was observed with good personal hygiene, no injury, and not in distress. The bed was at its lowest position. A fall mat was in place next to the right side of the bed. On 10/23/25 at 11:15 AM, in an interview with the ADON, she said Resident #4 had several falls and was at risk for falls. The ADON said she was not sure if Resident #4 had a fall mat or when it was implemented. The ADON said if it was part of the interventions for falls, the fall mat should have been care planned. The ADON said it was important to have the fall mat care planned so staff were aware of the intervention and ensured the fall mat was in place. The ADON said the team ensured the interventions were implemented and care planned. On 10/23/25 at 1:05 PM, in an interview with the DON, she said Resident #4 was at risk for falls. The DON said she did not know if Resident #4 had a fall mat. The DON said if Resident #4 had a fall mat, the fall mat should have been care planned. The DON said it was important to have the fall mat care planned so that staff were aware that Resident #4 needed to have it in place to possibly prevent injury or harm. Record review of Care Plans, Comprehensive Person-Centered Policy dated December 2016, reflected:Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will:g. incorporate identified problem areas.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #4, Resident #11, and Resident #13) of 10 residents reviewed for MDS assessment.Resident #4's quarterly MDS assessment dated [DATE] failed to indicate Resident #4 had falls on 07/28/25 that resulted in major injury, on 09/09/25 that resulted in minor injury, and on 10/02/25 that resulted with no injury.Resident #11's quarterly MDS assessment dated [DATE] failed to indicate Resident #11's behavior of physical aggression that occurred on 09/23/25.Resident #13's quarterly MDS assessment dated [DATE] failed to indicate Resident #13's behaviors of delusions and refusal of care that occurred on 09/16/25.Resident #13's quarterly MDS assessment dated [DATE] failed to indicate Resident #13 had a fall that resulted in minor injury that occurred on 10/13/25.This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate assessments.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1.The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. 4.The facility failed to ensure Resident #5 was free from abuse when Resident #88 entered Resident #5's room and attempted to pull Resident #5 from her wheelchair on 06/22/25. 5.The facility failed to ensure Resident #95 was free from abuse when Resident #88 went up to Resident #95 and attempted to remove her from her wheelchair. Resident #88 shook Resident #95 and then slapped her on the side of her head on 06/28/25. An IJ that occurred in the past was identified. The IJ began on 01/24/25 and removed on 06/28/25. The facility took action to remove the IJ before survey began. While the IJ was removed on 06/28/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on abuse/neglect. This failure has the potential to result in serious injury or death as a result of abuse and neglect. 1. Record review of Resident #88's Face Sheet dated 07/24/25 revealed she was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions), anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality, often involving symptoms like hallucinations and delusions), and major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident #88's quarterly MDS dated [DATE] revealed Resident #88 was usually understood by others and usually was able to understand others. She had a BIMS score of 02 which indicated severe cognitive impairment. Resident had physical behavioral symptoms directed toward others (hitting, kicking, scratching, grabbing), verbal behavioral symptoms directed toward others (screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting, pacing, rummaging or verbal symptoms like screaming, disruptive sounds). Record review of Resident #88's comprehensive care plan revised on 05/28/25 revealed Resident #88 has been physically aggressive (hitting staff or other resident) r/t dementia: 01/24/25 - Resident became physically aggressive toward another resident The care plan included the following interventions:-When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly and approach later. Record review of Resident #88's Physician's Order Summary for July 2025 revealed orders for: --Gabapentin oral capsule 100 mg, give two capsules by mouth three times a day related to emotional lability, order date 06/09/25.Haldol Decanoate intramuscular solution 50 mg/ml, inject 50 mg intramuscularly monthly starting on the 10th and ending on the 10th every month for agitation, order date 07/06/25 and start date on 07/10/25.Latuda oral tablet 20 mg, give 1 tablet by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms, order date 06/11/25 and start date 06/12/25.Zyprexa oral tablet 5 mg (Olanzapine), give 5 mg by mouth two times a day related to unspecified psychosis, order date 06/13/14 and start date 06/14/25. Record review of Resident #88's progress notes dated from 06/28/25 to 07/25/25 revealed Resident #88 was put on a continuous one-to-one monitoring until Resident #88 was admitted to a facility in San [NAME]. Record review of Resident #71's Face Sheet dated 07/24/25 indicated she was [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), anemia (a problem in which the blood does not have enough healthy blood cells to carry oxygen to throughout the body), and hypertension (when the blood pressure in the blood vessels is too high). Record review of Resident #71 quarterly MDS dated [DATE] indicated Resident #71 was understood by others, and was able to understand others, did not have any behaviors, and had a BIMS score of 05 which indicated she had moderate cognitive impairment. Record review of facility's Provider Investigation Report dated 01/24/25 revealed Incident date and time: 01/24/25 at 4:00 pm. Nurse Aide saw Resident #88 go hit Resident #71's in the back of the head and pull her hair. Record review of the Provider Action Taken Post Investigation dated 01/24/25: Head to toe assessment performed on 01/24/25 for Resident #71 revealed no other visible injuries noted. Employees were in-serviced on resident-to-resident abuse and resident de-escalation techniques. Social Services did resident safe interviews. Resident behaviors care planned. Staff will keep both residents apart when in close proximity or when doing social activities. Care Plans for both residents updated. Observation of 07/21/25 at 9:32 am revealed Resident #88 in bed on her side with the lights off and a CNA in the room. Resident #88 was still in her pajamas and shoes on. Resident #88 did not respond to greeting and questions regarding incident with Resident #71. In an interview on 07/21/25 9:57 am CNA K said Resident #88 was able to walk and wandered throughout the building, but they had to shadow her to prevent aggressive behaviors toward other residents. If resident was on her own, she would fight with other residents. CNA K said Resident #88 cried a lot and the other residents became impatient with her and then she became aggressive. CNA K said when resident was on her own in her room, she was ok. CNA K said if they gave her colors and pages to color, she would do it. 2. Record review of Incident Report dated 04/05/25 revealed Resident #88 hit Resident #71 on her back and took some coloring pages from her. Resident #88 was separated from Resident #71. Head to toe evaluation of both residents by LVN revealed no injuries to either resident. Record review of Resident #88's care plan was revised on 04/08/25 to include incident on 04/05/25 with aggressive behavior with interventions to monitor for sundowning behavior, continue sertraline100 mg daily (antidepressant), follow up counseling and psych recommendations and monitor behavior. Record review of Psychiatric Progress Note dated 04/24/25 by NP revealed Resident #88 was tearful, confused and wanted to go home to see her mother and father. Patient has many altercations with female residents. The NP last saw Resident #88 on 04/24/25. 3. Record review of Resident #82's Face Sheet dated 07/24/24 revealed Resident #82 was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of unspecified dementia (progressive or persistent loss of intellectual functioning), muscle wasting and atrophy, and muscle weakness. Record review of Resident #82's Quarterly MDS dated [DATE] revealed Resident #82 was usually understood by others, and usually understands others, BIMS of 03, and does not have behaviors and was able to ambulate independently. Record review of Resident #82's care plan dated 06/05/25 revealed Resident #82 has a behavior problem (labile moods) r/t dementia. On 06/04/25 Resident had altercation withanother female resident (#88) and grabbed the other female (88) by her shirt and other resident (#88) lost her balance and fell. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness. Explain/reinforce why behaviors are inappropriate and/or unacceptable. Record review of Resident #99's Face Sheet dated 06/10/25 revealed Resident #99 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy, anxiety disorder, and major depressive disorder. Record review of facility's Provider Investigation Report revealed Incident Date/Time: 06/04/24 at 7:45 pm. Resident #88 was attempting to grab another female resident (#99) and Resident #82 started yelling at Resident #88 to stop harassing the other resident. Resident #88 then went towards Resident #82. Resident #82 grabbed Resident #88 by her shirt and Resident #88 was not able to keep her balance and fell landing on her right lateral side. Nurse aide ran toward altercation but was not able to stop Resident #88 from falling. Resident #88 suffered a small cut to her right eyebrow, no other visible injuries noted. Resident #88 sent to ER for further evaluation per physician's orders. Record review of Health Status Note dated 06/04/25 at 11:09 pm revealed Resident #88 returned from the ER with swelling to right eye and light purple discoloration due to fall. Dermabond was applied to laceration for closure. CT was negative. Resident will be on neuro checks due to fall. Bed at lowest position with call light within reach. Record review of facility's Provider Investigation Report revealed Incident Date/Time:06/07/25 at 8:29 am. Resident #88 was in the dining room and attempted to assist Resident #5 in the wheelchair. Resident #5 said she did not want the assistance. Resident #88 became aggressive and pulled Resident #5's hair. The residents were separated and both Residents were taken to their rooms. Both Residents were assessed by LVN N. After the altercation Resident #88 was taken to the nurse's station for the remainder of the shift.Investigation Summary: After investigation it was determined Resident #82 attempted to stop Resident #88 from harassing another resident and Resident #88 lunged at Resident #82. Resident #82 grabbed Resident #88 by the shirt and Resident #88 lost her balance. The NP, family and the police were notified of the incident. Provider action taken post-investigation: Performed resident interviews and Follow-up with the psych NP as needed. In an interview on 07/21/25 at 12:54 pm Resident #82 said she did not fight with anyone, and she did not recall any incidents when another Resident tried to hit her. Resident #82 said she kept to herself and participated in her own activities. In an interview on 07/22/25 at 4:28 pm CNA J said she was walking toward the nurse's station when she saw Resident #82 pull Resident 88's shirt and push her toward the floor. CNA said Resident #88 must have done something to Resident #82 because Resident #82 did not usually fight. CNA J said the CNA in front of her ran toward Resident #88 and then asked her to get the nurse. CNA J said she went to look for the nurse, but he was providing care to a resident, and he asked CNA J to get the nurse from the back hall. CNA J said she went to get LVN N and then LVN N went and attended to Resident #88. Observation on 07/23/25 at 12:55 pm revealed Resident #88 was walking up A [NAME] Wing. CNA S was holding Resident #88's hand as they ambulated through the hallway. 07/23/25 1:25 pm CNA S said he had been on a one to one with Resident #88 since 07/22/25 through 07/25/25. CNA S said Resident #88 was on a one-to-one monitoring for the 2-10 shift. CNA S said he went everywhere Resident #88 went. CNA S said if Resident #88 became aggressive with another resident, he would intervene and if necessary, would get between the two residents so she would not hit the other resident. He would redirect Resident #88 toward another direction and keep walking with her. 4. Record review of Resident #5 Face Sheet dated 06/10/25 revealed Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia (weakness to one side of the body) and hemiparesis (weakness to one side of the body), muscle wasting and atrophy, and unspecified dementia. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was sometimes understood by others, usually understood others, had a BIMS of 08 indicating she had moderate cognitive impairment and did not have any behaviors and required substantial/maximal assistance with her ADLs. Record review of facility's Provider Investigation Report dated 06/22/25 revealed Incident date and time: 06/22/25 at 7:20 pm. Nurse Aide saw Resident #88 go into Resident #5's room. Nurse Aide followed her into the room. Nurse Aide saw that Resident #88 was attempting to get Resident #5 out of her wheelchair while she was in it. Resident #5 shoved/pushed Resident #88 with her right hand (arm in splint) causing Resident #88 to re-open her wound to her right eyebrow. Nurse Aide immediately separated residents. Head to toe assessments performed by LVN R for both residents. Resident #88 re-opened wound to right eyebrow, no other visible injuries noted. Notified MD/RP/Administrator. Reported to police. Self-report to HHSC.Resident #88 had Latuda (aggression) increased on 06/12/25 to BID and Zyprexa (antipsychotic) 5mg BID on 06/14/25. Provider Action Taken Post-investigation: 06/22/25 Charge nurse placed her WOW in front of resident's room throughout the rest of shift and 10-6 shift. 5.Record review of Resident #95's Face Sheet dated 07/24/25 revealed Resident #95 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, muscle wasting and atrophy, muscle weakness, and Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement). Record review of Resident #95's quarterly MDS dated [DATE] revealed Resident #95 is usually understood by others, usually able to understand others, has a BIMS of 00 meaning she has severe cognitive impairment and does not have any behaviors. Record review of Resident #95's comprehensive care plan dated 07/29/20 revealed Resident #95 requires staff assistance with ADLs due to diagnosis of Parkinson's at risk for decline in ADL function. Record review of Resident #95's progress note dated 06/28/25 at 10:50 am revealed late entry: Resident A came up to resident during service, shook this resident, and slapped resident on the side of the head. Resident A was immediately stopped and separated was sent to her room. Record review of facility's Provider Investigation Report revealed Resident #88 came up to Resident #95 who was sitting in her wheelchair during service, shook resident and slapped resident on the side of her head. Resident #88 was immediately stopped and separated, went back to her room with nurse.Head to toe assessment performed by nurse (Resident #95).Provider Response:Resident (#88) was placed on a one-to-one, family came to stay with her for 1-2 hours. Labs ordered UA to rule out UTI, and CBC, CMP to rule out any infection. Reported it to police with case number 25-16894. Started abuse and neglect in-service. Resident continues on psych services with medication adjustments.Provider Action Taken Post-investigationStarted looking for other facility placement for resident. Given 30-day notice. Safety survey done, continue with 1 to 1 monitoring. Record review of Resident#88's electronic medical record dated 06/28/25 through 07/25/25 revealed Resident #88 was on a one-to-one monitoring all three shifts. A CNA is with Resident #88 at all times. Observation on 07/21/25 at 9:07 am revealed Resident #95 was in her room sitting in her wheelchair. Resident #95 had tremors in her head and hands. Resident #95 was talking to herself. Surveyor attempted to interview Resident #95, but she has garbled speech and was difficult to understand. In an interview on 07/22/25 at 3:25 pm Resident #60 said she was in the dining room when she saw Resident #88 approach Resident #95. Resident #88 was yelling at Resident #95 and then she shook Resident #95. Resident #60 said then she saw Resident #88 slap Resident #95 on the face. Resident #60 said the staff intervened and took Resident #88 to her room. Resident #60 said the police were called and interviewed her, but nothing was done because the police said Resident #88 had dementia. In an interview on 07/22/25 at 5:28 pm CNA L said Resident #88 would walk around the facility. CNA L said Resident #88 was currently on a one-to-one because she was in an altercation with another resident. Resident #88 slapped another resident and was put on a one to one. Before being on a one-to-one Resident #88 would wander into different rooms and they would have to redirect her before she got upset and started a fight with a resident. They have in-services on ANE every month. CNA L said if she witnessed any person abusing a resident she would intervene and then make sure resident was safe. CNA said she would report it to her supervisor. The Abuse Coordinator was the Administrator.In an interview on 07/22/25 at 5:41 pm LVN E said he worked PRN for 2 or 3 months. LVN said he was familiar with Resident #88. LVN said Resident #88 needed a lot of redirections. LVN E said if someone got in her way, she became upset. If it was a person in a wheelchair, Resident #88 would try to push them around because she thought she was helping them. LVN E said they tried to verbally deescalate the situation and redirect Resident #88. Usually if they offered food, drink, or candy it would help redirect Resident #88 from the situation. LVN E said they also had her at the nurse's station with the nurse. Resident would stay a while then would get up again. Resident #88 was currently on a one to one in her room. Resident was allowed to come out and walk around the facility with the sitter following Resident #88. LVN E said they have in-services on abuse/neglect monthly. In an interview on 07/23/25 at 5:00 pm, the Psychiatric NP said she had not seen Resident #88 since April. The NP said she did not know that Resident #88 was on more than one antipsychotic. Surveyor asked NP what the behavioral plan for Resident #88 was and she said they had to rule out medical issues, see if something physiologically was causing the behaviors. The NP said then they could prescribe medications at a medium dose and see how the resident was doing on them. Then they needed to see if the resident's family was supportive of resident taking the medications. The NP said the resident could benefit with psychological counseling.In an interview on 07/24/25 at 4:40 pm the Administrator said his responsibility was to know what was going on in the facility. The Administrator said they had morning meetings, and, in the afternoon, they had stand down meetings. They discussed any concerns regarding resident care or grievances from families. The Administrator said they educated staff on the need to report any and all abuse. They tell staff that they needed to report abuse and if they did not report it then they were just as guilty as the person abusing a resident. They would investigate all incidents and reported any incident that could be considered abuse, neglect, or misappropriation. The Administrator said Resident #88 had been getting aggressive more often and that was the reason they had provided a 30-day discharge notice to the family. Resident #88 has been seen by a psychiatric NP and was put on a one-to-one monitoring since 06/28/25. Record review of Resident #88's 30-day notice of discharge revealed the Notice of Involuntary Transfer or Discharge and Opportunity for Appeal was provided to Resident #88's Responsible Party on 07/07/25. The notice indicated the reason for the notice was This discharge, or transfer is necessary for your welfare because your needs can not be met in this facility, as documented in your clinical record by your physician. 42C.F.R.S483.15(C)(1)(A); 40 Tex. Admin. Code 19.502(b)(1).In an interview on 07/07/25 at 8:56 am LVN A has been employed about three months. LVN A said her responsibilities were to make sure the residents were safe, and their needs were met. LVN A said she would report to the physician any change of condition to the residents and make sure the labs were done and results sent to physician. LVN A said she also supervises the CNAs to make sure they were treating residents kindly and interacting with them gently. They have in-services on abuse/neglect frequently and there was a resident on the other side of the hall that has behaviors and would fight with other residents. They would have an in-service on abuse/neglect after each incident. They had an in-service on abuse/neglect last week. The abuse Coordinator was the Administrator. LVN A said if a resident hit another resident that was considered abuse. LVN A said the residents needed to be separated and assessed for injuries. Then she would document and would report any change in condition to the RP, physician, DON and the Administrator. LVN A said an aggressive resident needs to be monitored frequently. LVN A said she would contact the physician, and they might give orders for an antipsychotic medication, call the RP to inform of the incident and request consent before administering the medication.In an interview on 07/25/25 at 9:56 am CNA M said her responsibilities were to attend to the resident's needs. Whatever the resident needs she would attend to them. CNA M said they would check on a resident with aggressive behavior or wandering into other resident room often. CNA M said they would offer snacks or give Resident #88 activities to do. CNA M said Resident #88 liked to push the residents in the wheelchairs but when resident would refuse the help Resident #88 would get mad. CNA M said they would redirect her by telling her Let's go to the dining room for coffee or let's go do an activity then the resident would go with her. Resident #88 liked coloring, and they would provide coloring pages and crayons. Resident #88 would be taken to the Activity room, and she would sit there to color pages. The nurses also kept her at the nurse's station with them. CNA M said the types of abuse were physical verbal, sexual and when a resident asked them to be showered, or for water and the staff ignored the resident then that was neglect. CNA M said if she saw a resident being abused, she would separate the resident from that person and then she would report it to her supervisor. The Administrator was the Abuse Coordinator. CNA M said she would report the abuse right away. In an interview on 07/25/25 at 10:12 am the SW said Resident #88 needed redirection by distracting resident to do something else. The SW said she would take Resident #88 to her office and gave her a pen, notebook, and a snack. Resident #88 would finish eating the cookie and she would want to get up and leave. The SW said she tried to get resident to write in a notebook, but she would only write for a few seconds and then would get up and walk away. The SW said it was constant redirections. SW said Resident #88 had a short attention span of a few seconds. Resident #88 had difficulty focusing on a task and following directions. Directions had to be broken down in small steps. The SW said the family did attend the care plan meeting via phone and lately in the facility. The last care plan meeting was at the facility. The daughter came in with the Ombudsman. The SW said the daughter was informed of the incidents Resident #88 had with other residents. The family was fine with whatever medications the doctor prescribed. The facility asked that the family to come more often to stay with resident, but they did not come very often. The SW said the DON made a power point in-service on dementia. It addressed the medical and personal effects of dementia and the different types of behaviors. The SW said Resident #88 was sent to the hospital on [DATE] to be cleared medically and then sent to the behavioral center to be stabilized. Resident #88 would then be sent to a long-term care facility in San [NAME] with a memory unit. In an interview on 07/25/25 at 10:54 am the DON said when a resident was identified with behaviors, they would monitor the resident by keeping her close to a nurse or with the DON in her office. They encouraged the resident to be taken to activities and for the family to visit her. The DON said they would ask resident if she wanted to go color. Redirection was used for the resident to do tasks or activities that she liked doing. Maybe make a bed, fold clothes, or color pages. The DON said they needed to be able to find the triggers that sets Resident #88 off. DON said she asked the daughter, but the daughter said Resident #88 did not have any triggers. DON said the daughter was not able to help them find what caused the resident's aggression. She would do an in-service on whatever the incident was about. If it was abuse/neglect or misappropriation she would train staff on it. The DON said she had conducted a presentation earlier this year on dementia and behaviors. The DON said they did train on abuse/neglect monthly and whenever there was an incident. The DON said Resident #88 was discharged to the hospital to clear her medically before she was sent to the Behavioral Center. Record review of her Immediate Discharge Notice dated 07/24/25 with Effective Date of Discharge 07/24/25 and the reason was for the health and safety of resident or others and the location was to a local hospital. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1.The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. 4.The facility failed to ensure Resident #5 was free from abuse when Resident #88 entered Resident #5's room and attempted to pull Resident #5 from her wheelchair on 06/22/25. 5.The facility failed to ensure Resident #95 was free from abuse when Resident #88 went up to Resident #95 and attempted to remove her from her wheelchair. Resident #88 shook Resident #95 and then slapped her on the side of her head on 06/28/25. An IJ that occurred in the past was identified. The IJ began on 01/24/25 and removed on 06/28/25. The facility took action to remove the IJ before survey began. While the IJ was removed on 06/28/25, the facility remained out of compliance at a scope of K and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on abuse/neglect. This failure has the potential to result in serious injury or death as a result of abuse and neglect. The findings were: 1. Record review of Resident #88's Face Sheet dated 07/24/25 revealed she was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions), anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality, often involving symptoms like hallucinations and delusions), and major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident #88's quarterly MDS dated [DATE] revealed Resident #88 was usually understood by others and usually was able to understand others. She had a BIMS score of 02 which indicated severe cognitive impairment. Resident had physical behavioral symptoms directed toward others (hitting, kicking, scratching, grabbing), verbal behavioral symptoms directed toward others (screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting, pacing, rummaging or verbal symptoms like screaming, disruptive sounds). Record review of Resident #88's comprehensive care plan revised on 05/28/25 revealed Resident #88 has been physically aggressive (hitting staff or other resident) r/t dementia: 01/24/25 - Resident became physically aggressive toward another resident The care plan included the following interventions:-When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly and approach later. Record review of Resident #88's Physician's Order Summary for July 2025 revealed orders for: --Gabapentin oral capsule 100 mg, give two capsules by mouth three times a day related to emotional lability, order date 06/09/25.Haldol Decanoate intramuscular solution 50 mg/ml, inject 50 mg intramuscularly monthly starting on the 10th and ending on the 10th every month for agitation, order date 07/06/25 and start date on 07/10/25.Latuda oral tablet 20 mg, give 1 tablet by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms, order date 06/11/25 and start date 06/12/25.Zyprexa oral tablet 5 mg (Olanzapine), give 5 mg by mouth two times a day related to unspecified psychosis, order date 06/13/14 and start date 06/14/25. Record review of Resident #88's progress notes dated from 06/28/25 to 07/25/25 revealed Resident #88 was put on a continuous one-to-one monitoring until Resident #88 was admitted to a facility in San [NAME]. Record review of Resident #71's Face Sheet dated 07/24/25 indicated she was [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), anemia (a problem in which the blood does not have enough healthy blood cells to carry oxygen to throughout the body), and hypertension (when the blood pressure in the blood vessels is too high). Record review of Resident #71 quarterly MDS dated [DATE] indicated Resident #71 was understood by others, and was able to understand others, did not have any behaviors, and had a BIMS score of 05 which indicated she had moderate cognitive impairment. Record review of facility's Provider Investigation Report dated 01/24/25 revealed Incident date and time: 01/24/25 at 4:00 pm. Nurse Aide saw Resident #88 go hit Resident #71's in the back of the head and pull her hair. Record review of the Provider Action Taken Post Investigation dated 01/24/25: Head to toe assessment performed on 01/24/25 for Resident #71 revealed no other visible injuries noted. Employees were in-serviced on resident-to-resident abuse and resident de-escalation techniques. Social Services did resident safe interviews. Resident behaviors care planned. Staff will keep both residents apart when in close proximity or when doing social activities. Care Plans for both residents updated. Observation of 07/21/25 at 9:32 am revealed Resident #88 in bed on her side with the lights off and a CNA in the room. Resident #88 was still in her pajamas and shoes on. Resident #88 did not respond to greeting and questions regarding incident with Resident #71. In an interview on 07/21/25 9:57 am CNA K said Resident #88 was able to walk and wandered throughout the building, but they had to shadow her to prevent aggressive behaviors toward other residents. If resident was on her own, she would fight with other residents. CNA K said Resident #88 cried a lot and the other residents became impatient with her and then she became aggressive. CNA K said when resident was on her own in her room, she was ok. CNA K said if they gave her colors and pages to color, she would do it. 2. Record review of Incident Report dated 04/05/25 revealed Resident #88 hit Resident #71 on her back and took some coloring pages from her. Resident #88 was separated from Resident #71. Head to toe evaluation of both residents by LVN revealed no injuries to either resident. Record review of Resident #88's care plan was revised on 04/08/25 to include incident on 04/05/25 with aggressive behavior with interventions to monitor for sundowning behavior, continue sertraline100 mg daily (antidepressant), follow up counseling and psych recom

Based on record review and interview, the facility failed to ensure residents were free from neglect for 1 (Resident #1) of 5 residents reviewed for abuse/neglect, in that: The facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of emotional distress, fear, decreased quality of life, and further neglect. Findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: 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). -TRANSFER: The resident is dependent on (2) staff for transferring 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). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: -Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 GOALS: -Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 INTERVENTIONS/TASKS: -Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN -GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA -Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 -The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA -BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN -TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN -TRANSFER: The resident requires Mechanical HOYER Lift with (X2) staff assistance for transfers. Date Initiated: 01/14/2021 Revision on: 04/26/2024 CNA RN FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: - The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: - Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021 Record review of x-rays taken on 02/05/25 of right foot and results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of Progress Note on 02/06/25 at 05:11 am written by LVN H revealed, LVN H noticed Resident #1 tossing and turning. LVN H asked Resident #1 if she had any pain. Resident #1 said, Si, me duele mi pie (Yes, my foot has pain). LVN H administered PRN acetaminophen 650mg as ordered. Record review on 02/06/25 Physician's order for Tramadol 50mg tablet Give 50mg tablet by mouth every 4 hours for pain for 14 days. Record review of Progress Note on 02/06/25 at 09:07 am written by LVN B revealed, new order for PRN tramadol 50mg x 14 days and referral to orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles). Record review of Progress Note on 02/06/25 at 03:03 pm MD/NP Progress Note written by PA I revealed Subjective: Fall, sustained right great toe fracture Patient seen today at bedside alert, complaining of right great toe pain. Right great toe fracture: pain medication, supportive care, consider ortho consult. In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was going to transfer her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the mechanical lift, 1- or 2-person assist, not rushing, and being careful. CNA A stated she received an in-service on A/N last month. She said about the A/N in-service, If you don't give the resident anything they ask for, talk to them bad, not change them, it is neglect. CNA A stated she reports A/N to the person in the front but did not know their name. CNA A did not know the name of the abuse coordinator. There was no documentation of the in-service CNA A stated she received from LVN B. In an interview on 06/04/25 at 03:23 pm LVN C stated the nurse was responsible for CNA supervision on whether they are using the correct 1- or 2-person assist. LVN C stated the resident or staff could be injured if only one person was helping a resident who was a 2-person assist. In an interview on 06/04/25 at 03:38 pm CNA D stated she would not do a 2-person assist by herself. She said she would wait for her partner. CNA D stated she would not endanger her resident or herself. In an interview on 06/05/25 at 09:04 am the Administrator stated the facility did not do any in-servicing after Resident #1's fall (02/05/25) because it was a witnessed fall. He said in the case of Abuse or Neglect, they would in-service. The Administrator provided in-service documentation dated 01/31/25 for Abuse & Neglect. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes and the notes showed CNA A had brought Resident #1 back from her shower, who was a 1-person assist for showers, and was waiting on her partner to transfer Resident #1 back to bed. The DON said the fall was not reported because it was a witnessed fall. In an interview on 06/05/25 at 12:45 pm CNA A stated back at that time (February 2025), they were short on staff so several times she had to do a 2-person assist by herself. Record review of the facility's Abuse, Neglect and Exploitation policy (PL 2024-14) dated 08/29/24 reflected: Type of Incident Do report: -An incident that results in serious bodily injury and that involves any of the following: -neglect When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Neglect: HHSC rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain, or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. Record review of the facility's Resident Safety policy, 2001 Med Pass, Inc. Revised July 2017 reflected: Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. 1.The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for shower/bath. 2. The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for transferring. These failures could place residents at risk of not receiving the necessary care and services. Findings include: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: 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). -TRANSFER: The resident is dependent on (2) staff for transferring 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). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: -Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 GOALS: -Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 INTERVENTIONS/TASKS: -Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN -GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA -Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 -The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA -BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN -TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN -TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Date Initiated: 01/14/2021 Revision on: 04/26/2024 CNA RN. FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: - The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: - Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021. Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of x-rays taken on 02/05/25 of right foot and results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was going to transfer her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the mechanical lift, 1- or 2-person assist, not rushing, and being careful. There was no documentation of the in-service CNA A stated she received from LVN B. In an interview on 06/04/25 at 03:23 pm LVN C stated the nurse was responsible for CNA supervision on whether they are using the correct 1- or 2-person assist. LVN C stated the resident or staff could be injured if only one person was helping a resident who was a 2-person assist. In an interview on 06/04/25 at 03:38 pm CNA D stated she would not do a 2-person assist by herself. She said she would wait for her partner. CNA D stated she would not endanger her resident or herself. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes and the notes showed CNA A had brought Resident #1 back from her shower, who was a 1-person assist for showers, and was waiting on her partner to transfer Resident #1 back to bed. In an interview on 06/05/25 at 12:45 pm CNA A stated on the day Resident #1 fell (02/05/25), she had given her a shower by herself. CNA A stated back at that time (February 2025), they were short on staff so several times she had to do a 2-person assist by herself. No Care Plan policy was obtained.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1 ) reviewed for accidents and supervision, in that: 1. The facility failed to ensure Resident #1 received supervision to prevent Resident #1 from eloping from the facility undetected on 04/29/2023. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2023 and ended on 05/01/2023. The facility corrected the non-compliance before the investigation began. This failure could place the residents with exit seeking behaviors and repeated falls at risk for injury or death. The findings were: Record review of Resident #1's face sheet dated 04/24/2023 revealed the resident was a [AGE] year-old male with an admitted [DATE] and a discharge date of [DATE]. The resident's diagnoses included Alzheimer's disease, and dementia. Record review of Resident #1's entry MDS assessment dated [DATE] reflected only section A (identification information) was completed. Record review of Resident #1's initial assessment dated conducted by nursing staff on 04/29/2023 reflected he required limited assistance with bed mobility, and with transfer. For mobility, he required limited assistance with walk in room/self-performance. For mobility walk in corridor, activity did not occur. Record review of Resident #1's incident report dated 04/29/2023 completed by LVN A at 11:40 p.m. reflected: Incident Description: New admission unknown type of behavior. [Resident #1] was seen walking back and forth in B wing north, resident was calm and relax in no distress, no signs of exit seeking. Immediate action: Started checking each room, closet, restrooms, called ADON informed him of situation went outside the building and started searching for resident. All Managers alerted to report to facility. Area searched, 911 notified, police department arrived and provided canine support, family here. Patient found adjacent to facility in church property. Patient taken to hospital for evaluation. Record review of Resident #1's hospital records dated 04/30/2023 reflected [AGE] year-old male with worsening dementia and mood disorder who comes here brought because he actually walked out of the skilled unit he was discharged too yesterday [04/29/2023]. Apparently he spent the night outside of the nursing home. The patient apparently found on the grass where he apparently slept all night. He appears to be definitely much more lethargic then yesterday when he left. He appeared to be shivering a lot and having some dry cough. He was unable to provide history. He was brought here for evaluation after being found. Hospital notes also revealed family refused to allow Resident #1 go back to facility. Hospital records were only from the emergency department, they did not reveal any treatment received or if resident was admitted . Record review of a police report dated 04/30/2023 reflected the police were dispatched to the facility at 1:01 a.m. in reference to a missing person. At approximately 11:00 p.m. to 11:20 p.m., a resident identified as Resident #1 had left the facility. Resident #1 was last seen wearing a black sweater and blue jeans and he suffered from Alzheimer's and dementia. On Sunday April 30, 2023, at 7:47 a.m., the police officer was searching the back parking lot of a local church located next to the facility. The report reflected when I noticed an elderly male subject trapped behind a chain link fence. I then made contact with the male subject and noticed that it was [Resident #1] who had been reported missing. I then had one of the officers cut the chain to the gate and we were able to get [Resident #1] out. An interview on 04/23/2024 at 9:45 a.m., the SW said Resident #1 had been admitted to the facility the evening of 04/29/2023 (Friday) from a local hospital. She said the only assessment done on that day was the initial screening by chare nurse. The SW said the facility did not know if Resident #1 had any exit seeking behaviors at the time he was admitted . She said she received a text at about 3:30 a.m. on 04/30/2023 from the facility's Administrator who requested for her to report to the facility to assist with the search for Resident #1. The SW said she did not see the text message until 04/30/2023 at 5:00 a.m. and at that time called the Administrator who told her she was not needed anymore. The SW said Resident #1 was found in the back yard of a church next to the facility on [DATE] (not sure of the time). An interview on 04/24/23 at 10:21 a.m., the Administrator said he was not able to comment on Resident #1's elopement because he was not employed at the facility at the time. He referred the surveyor to the facility's Regional Director of Operations who he said was more familiar with the incident. In an interview on 04/24/2024 at 10:15 a.m., the Regional Director of Operations said Resident #1 was admitted (did not give date) without a warning that he was an exit seeker. She said Resident #1 was found in the backyard of a church next to the facility the next day. She stated Resident #1 had spent the night outside. She said Resident #1 had not sustain any injuries but was taken to hospital to be evaluated. She said the facility investigated the incident and determined Resident #1 must have exited the building by a side exit door that led to the patio because it was the only door that did not have an alarm. She said that staff and resident used door to go out to the patio. She said what might have happened was one of the residents messed with the door and did not close it right allowing Resident #1 to exit the building. She said they removed the dead bolt and installed magnetic lock/keypad on 05/01/23. An observation/interview on 04/24/2024 at 3:00 pm, the Maintenance Director said after Resident #1's elopement the side door lock was changed. He said the dead bolt was removed and replaced with a keypad, and a code alert was installed. He said if a resident with a wander guard would try to open the side door an alarm would go off and lock the door. The Maintenance Director took a wander guard and attempted to exit the facility's doors and an alarm was activated and doors locked. LVN A said Resident #1 was admitted on the evening (not sure what time) of 04/29/2023 and eloped before 11:00 p.m., on the same day. LVN A said CNA B advised him between 10:45 p.m. and 11:00 p.m. that while she was doing her rounds, she noticed Resident #1 was not in his room. He said he had immediately activated the facility's elopement code (code silver) and the search ensued. LVN A said he advised the CNA's to search every room in the facility while he and other male staff searched outside the building. LVN A said he also called his ADON to let him know Resident #1 was missing and the local police department to report Resident #1 as a missing person. He said he also notified Resident #1's RP. LVN A said at some point all department heads were also called to report to the facility to assist in the search for Resident #1. LVN A said the facility's staff, Resident #1's family, and police department search all night for him city wide. He said his shift ended at 6:00 a.m. and by that time Resident #1 had still not been found. LVN A said he was told by other staff members; Resident #1 was found in the backyard of a church next to the facility. LVN A said all staff were in-serviced on the topic of elopement the next day. An interview on 04/24/2024 at 3:54 pm, CNA B said when she clocked in at 10:00 pm on 04/29/2023, she was given the report by the outgoing CNA that Resident #1 did not walk and that his bed needed to be kept at the lowest position. CNA B said she started doing her rounds and when she got to his room (around 11:00 p.m.) she noticed Resident #1 was not there. CNA B said she started looking for him and also informed LVN A. She said another CNA (did not remember name) told her she had seen a man that she did not recognize walking towards the kitchen. CNA B said she headed towards the kitchen but did not see anybody. She said the facility's staff searched all night but were not able to locate Resident #1 until the next day. CNA B said all staff were in-serviced on their elopement procedures on 04/30/2023. CNA B said the in-service covered what to do when a resident went missing, who they need to notify, and the code used over the intercom to alert all staff a resident is missing. Record review of facility's Elopements policy revised on December 2007 reflected: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation: 1 Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounds area. Record review of facility in-services revealed the following in-services were conducted with staff from all three shifts after the incident: Topic: 04/30/2023 Elopement-staff shall promptly report any resident who tried to leave premises or is suspected of leaving to the charge nurse. Topic: 04/30/2023 and 05/01/2023: all new admissions with diagnosis of dementia will need a wander guard for 72 hours. Topic: 04/30/2023 and 05/01/2023: Nurse's and CNA's are to do a walking round at start and at the end of their shifts. Record review of facility's purchase order dated 05/01/2023 reflected: The only door without an alarm was replaced with a magnetic lock with power supply, an all-weather keypad, and a 24V supply with back-up battery port. Record review of facility's elopement binder reflected all 11 residents who were at risk of wandering had a current face sheet and demographic information in binder. An observation on 04/25/2024 at 11:00 a.m., the surveyor accompanied the DON who verified all 11 residents who were at risk of wandering had their wander guard on. An observation on 04/25/2024 at 3:30 p.m., revealed the Maintenance Director tested all exit doors and ensured the alarm was activated if a resident with a wander guard tried to exit. An interview on 04/24/24 CNA T, B, C, U, V, and G said they had been in-serviced said they had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. They said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. An interview on 04/23/24 LVN W, X, Y, J, S and ADON E said they had been in-serviced said they had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. They said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. An interview on 04/25/24 DON said she had been in-serviced said she had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. She said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 3. Immediately is defined as: a. within two hours of an allegation involving abuses or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of Resident #4's 01/10/24 at 01:00 pm Health Status Note written by LVN N reflected, Note Text: Received call from MD at ER O (emergency room ) to report resident had CT of Head done. CT clear. Resident will be admitted with Dx: bradycardia. Called RP to inform.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was accurately assessed after being discovered with abnormal discoloration to her lower outer left leg on 11/29/2023. Between 11/29/2023 to 12/08/2023, Resident #1 was observed crying and with facial grimacing. Resident #1 was diagnosed with a left ankle fracture. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life and hospitalization . Findings included: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia, and Alzheimer's disease. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected her: Hearing was moderate difficulty Speech clarity was unclear Sometimes understood/understand Vision was moderately impaired BIMS score of 00 (severely impaired) Functional limitation in range of motion: Upper extremity; lower extremity was impaired on both sides. Required substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing, and putting on/off footwear. Dependent for roll left and right, sit to lying, chair/bet-to-chair transfer and tub/shower transfer. Record review of Resident #1's comprehensive care plan reflected she was a 2 person assist with transfer and mobility. Record review of Resident #1's bathing history reflected she was bathed/showered a total of 10 times between 11/29/2023 and 12/08/2023. Record review of Resident #1's skin assessments history reflected there was one done on 12/05/2023 that only addressed her sacral wound. Record review dated 12/09/2023 of Mobile X-Rays on Demand results reflected, Resident #1 had 3 views of left ankle x-rays completed with findings of an acute distal tibial and fibular fractures with no significant displacement to the left ankle. Record review of Resident #1's progress notes from 11/29/2023 to 12/08/2023 did not reflect any documentation on the discoloration first noticed on 11/29/2023 to her outer lower left leg. In a telephone interview on 12/12/2023 at 5:35 p.m., RN BB (complainant) said he was the charge nurse at the ER department where Resident #1 was seen. He said Resident #1 was transferred from nursing facility to be evaluated for a diagnosis of a fractured left ankle. He said he was concerned because Resident #1 was a bedridden resident and unable to say what had happened due to her history of Alzheimer's. He said when he called the nursing facility (he did not get the name of staff who he spoke with) he was told Resident #1 had been crying for 2 weeks and they had no record as to how she had sustained the injury to her left ankle. The Complainant said Resident #1 was admitted to hospital due to an ankle fracture and elevated blood pressure. He said he was not able to describe how Resident #1's ankle looked like or the exact time she was seen at the ER department because he was at home and did not have access to her medical records. He said Resident #1 was seen at the ER department between 6 am-2 pm shift. In an interview on 12/13/2023 at 11:41 a.m., CNA C stated Resident #1 was a bedridden resident and required total assistance with all ADL's. CNA C said Resident #1 as only able to answer yes and no questions. She said on 12/09/2023 she had been assigned to shower residents. She said Resident #1 arrived at the shower room sitting on a shower chair. She said she did not remember if Resident #1 was wearing a heel protector when she first arrived. She said was transferred by CNA's D and E. She said when she started showering Resident #1, she noticed she was whining and had facial grimacing and when she got to her feet, she stated she noticed discoloration to her lower outer left leg and ankle. She said she asked Resident #1 if she was in pain and Resident #1 nodded yes and started to cry. She said as soon as CNA's D and E took Resident #1 back to her room, she went and notified her charge nurse, LVN F of her findings. She said LVN F and herself immediately went over to Resident #1's room where LVN F assessed her. CNA C said about 2 hours later she went back to Resident #1's room to reposition and feed her. She said asked Resident #1 if she was in pain and she nodded yes. CNA C said she went to tell LVN F Resident #1 was still in pain. LVN F told her she had already given her pain medication, called the NP and x-rays had been ordered. In an observation at the hospital on 12/13/2023 at 12:45 p.m. revealed Resident #1 was lying in bed; eyes closed and was receiving a breathing treatment. She had a urinary catheter and was on intravenous therapy. In an interview on 12/13/2023 at 12:55 p.m., hospital RN AA said Resident #1 had been admitted with the diagnosis of a closed left ankle fracture. She said Resident #1 was ready to be discharged they were just waiting for the paperwork to be completed. In an interview at the hospital on 12/13/2023 at 1:00 p.m., Resident #1 whispered she was in pain and complained her left foot was hurting. She kept repeating she was in pain and then closed her eyes. She was not able to answer any questions related to the discoloration of her outer lower left leg. In an interview on 12/13/2023 at 2:35 p.m., CNA E said Resident #1 was a bedridden resident. She said on 12/09/2023 she and her partner CNA D had transferred Resident #1 from her bed to the shower chair. She said Resident #1 was a 2 person assist and required total assistance. She said with the assistance of a gait belt, she, and her partner each put one hand under her shoulder and the other hand under Resident #1's knees and transferred her in a sitting position to the shower chair. CNA E said at no time did Resident #1's feet touch the floor and denied seeing any discoloration to Resident #1's lower outer left leg. She said she did not remember if Resident #1 had a heel protector on her left foot. In a telephone interview on 12/13/2023 at 2:45 p.m., CNA D said Resident #1 was bedridden resident. She said on 12/09/2023 she and her partner CNA E had transferred Resident #1 from her bed to the shower chair with the assistance of a gait belt. She said she and her partner each put one hand under her shoulder and other hand under Resident #1's knees and transferred her in a sitting position to the shower chair. CNA D said Resident #1 did not complain of pain nor cried during the transfer. She said she did not notice any discoloration to Resident #1's left outer foot or ankle. She said she did not remember if Resident #1 was wearing a heel protector at the time of transfer. She stated if she did, it would be CNA's C responsibility to remove it prior to starting the shower. In an interview on 12/13/2023 at 3:51 p.m., CNA G said Resident #1 was bedridden resident and required total assistance with all ADL's. She said she cared for Resident #1 while she was in the COVID unit from November 28, 2023, to December 8, 2023. She said she would sponge bathe Resident #1 because she had pneumonia and was too weak to be transferred to the shower room. She said she did not notice any discoloration to Resident #1's left outer leg. She said Resident #1 wore a heel protector on her left foot the whole time she was in the covid unit. CNA G said Resident #1 never complained of pain or showed any physical signs she was in pain. She said Resident #1 had a pressure ulcer in her coccyx area and was receiving daily wound care. CNA G said as far as she remembered, Resident #1 did not sustain any injury while in the covid unit. In an interview on 12/14/2023 at 8:45 a.m., the NP said she had been Resident #1's NP since before she was admitted to the nursing facility. She said she was notified on 12/09/2023, Resident #1 had swelling and discoloration to her left ankle. She said she also received a picture, LVN F had taken of Resident #1's ankle. The NP said from looking at the picture she was sent, Resident #1's ankle did not look deformed but was swollen and discolored. She said she gave orders for x-rays and when the results came back as acute distal tibial and fibular fractures with no significant displacement to the left ankle, she gave an order for Resident #1 to be sent to the hospital for further evaluation. The NP said she asked LVN F how Resident #1 had sustained the injury and was told they did not know how it had happened. The NP said she was not surprised with the fracture Resident #1 sustained given her frailty and any wrong movement might have caused a fracture. She said, with that being said, she still needs to be handled with care. The NP said that 12/09/2023 was the first time she was notified of Resident #1's discoloration. In an interview on 12/14/2023 at 9:00 a.m., LVN F said on 12/09/2023 she was advised by CNA C that Resident #1 had discomfort to her left ankle. She said she immediately went to Resident #1's room where she did a head-to-toe assessment and compared both her right and left ankle. She said her left ankle/outer left leg looked swollen and had discoloration. LVN F said based on the color of Resident #1's discoloration (bluish, greenish, and yellowish) on outer lower leg and ankle the injury looked days old. She said Resident #1 would complain of pain when her left ankle was moved. LVN F said she gave Resident #1 pain medication and called the NP. She said she also sent the NP a picture of Resident #1's lower left foot and ankle. LVN F said the NP ordered x-rays and to advise of results. LVN F said mobile x-rays were called to the facility and the results showed Resident #1's ankle was fracture. She said when she relayed the results to the NP, she was ordered to send Resident #1 to the ER for further evaluation. LVF said she did not know how Resident #1 sustained the fracture to her left ankle. LVN F claimed Resident #1 was not showered or transferred out of her bed on 12/09/2023. LVN said she followed facility's protocol and documented her findings on Resident #1's medical record (PCC) under progress notes, 24-hour report, SBAR and incident log. In an interview on 12/14/2023 at 5:00 p.m., LVN B said she was the wound care nurse. She said she would provide wound care to Resident #1 on a daily basis. She said she never noticed any discoloration or swelling to Resident #1's outer left leg or ankle. She said Resident #1 had a stage IV pressure ulcer to the coccyx area that required daily care. She said when she would first arrive at Resident #1's room, she would reposition her to her left side (side Resident #1 preferred) and lower the flat sheet to down to Resident #1's knees and started with the wound care. She said she never noticed any discoloration and/or swelling to Resident #1's outer lower leg or ankle. LVN B said Resident #1 would show signs of pain whenever she was performing wound care. LVN B said she would not remove Resident #1's heel protector during wound care to the coccyx area. LVN B said she would also do weekly skin assessments and never noticed any discoloration or swelling to Resident #1's out left leg or ankle. In an interview on 12/14/2023 at 5:18 p.m., CNA H said she saw Resident #1 one time while in the covid hall. She said on 11/29/2023 she remembered LVN B telling RN A that Resident #1 had a yellowing bruise to the top of her left ankle and above the heel protector boot. She said RN A and her went over to Resident #1's room where RN A uncovered her, assessed her, and said oh yes, she has a little bruising but did not remove the heel protector. She said Resident #1 was not complaining of pain during that time. CNA H said RN A gave Resident #1 pain medication and that was all she did. In an interview on 12/14/2023 at 5:30 p.m., RN A said on 11/29/2023 she was assigned to the COVID unit because she had just returned to work due to having Covid herself. She said on 11/29/2023 she was advised by LVN B that while doing wound care she noticed, Resident #1 had a light to medium discoloration to her outer left leg. RN A said she went over to Resident #1's room, assessed her. She described the discoloration as being yellowish in color. She said Resident #1 was wearing a heel protector on her left ankle. She said when she touched Resident #1's lower leg she was very sensitive. She said she thought her sensitivity was due to Resident #1 being Covid positive. RN A said Resident # 1 was crying and had facial grimacing so she decided to give her pain medication and monitor her as that was all I could do. RN A said she was not sure why she did not remove Resident #1's heel protector to assess her ankle. RN A said she documented her finding on PCC under MAR or progress notes. She said, she did not inform the incoming nurse because she took it for granted the incoming nurse would read her notes. RN A said that was the first and only day she worked on the COVID unit and had contact with Resident #1. In an interview on 12/18/2023 at 2:18 p.m., the DON said since Resident #1 was always in pain due to her stage IV coccyx pressure ulcer the nursing staff might have confused Resident #1's fractured ankle pain with her stage IV coccyx pressure ulcer pain. The DON said there were no negative effects on Resident #1's delay to assess, notify the NP, and document on the progress notes the discoloration of her ankle, which was first noticed on 11/29/2023 and later identified on an x-ray as an acute distal tibial and fibular fractures to the left ankle on 12/09/2023. The DON stated there were no negative outcomes because she was being assessed for pain and given pain medication when needed. She said that was all they could do since Resident #1 did not require surgery. In an interview on 12/18/2023 at 2:45 p.m., the NP said she did not order a heel protector for Resident #1 as it was considered part of the basic care the facility would provide. She said she was glad Resident #1 had been wearing one. In an interview on 12/18/2023 at 4:00 p.m., the Administrator said the information he collected during his investigation was conflicting in regard to Resident #1's discoloration. He said RN A told him LVN B advised her that while she was doing wound care, she noticed the discoloration, but LVN B denied ever telling RN A. The Administrator said RN A told him she failed to document her findings, notify the NP, and notify the in-coming nurse. He said he was not able to say if Resident #1 suffered any negative effects because that was a clinical question. Record review of facility's policy on Change in a Resident's Condition or Status revised on February 2021 reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review of facility's Charting and Documentation revised on July 2017 reflected: All services provided to the resident, progress towards the care plan goals, or changes in the residence medical, physical, functional, or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: d. changes in the resident's condition. e. events, incidents or accidents involving the resident. 7. Documentation of procedures and treatments will include care-specific details, including. c. assessment data and/or any unusual findings obtained during the procedure/treatment This was determined to be an Immediate Jeopardy (IJ) on 12/19/2023 at 3:40 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/19/2023 at 3:40 p.m. The following Plan of Removal submitted by the facility was accepted on 12/21/2023 at 4:00 p.m. Immediate action taken On 12/19/2023 the Charge Nurse who failed to notify the physician of the discoloration was terminated. By 12/19/2023 all residents have updated pain assessments completed by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all residents have updated skin observations documents by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all direct care staff have been in-serviced by the DON, the ADON, the MDS, and Treatment Nurse on immediate notification of any skin observation, new onset of pain, and/or change of condition. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. As of 12/19/2023 the DON, the ADON, the MDS, and the Treatment Nurse educated CNA's on notifying the Charge Nurse regarding any new skin issue identified. The CNA will verbally inform Charge Nurse, and Nurses will document skin issue in Point Click Care and CNA's will document new skin issues or injuries in Point Click Care. Monitoring/Supervision As of 12/19/2023 the DON and the ADON review 24-hour report for documentation and pain/skin assessment daily during the morning clinical meetings. DON and ADON will review Point Click Care documentation during morning clinical meeting. As of 12/19/2023 the DON, the ADON, or the MDS will assess all nonverbal bedridden patients twice a week for a month to verify compliance and then monthly x 3 months. Any new direct care employee will be educated on immediate notification of any new skin observation, new onset of pain, and/or change of condition prior to working with residents. All the above-mentioned education/in-services should serve to resolve questions regarding steps taken during a change of condition. In addition to procedures for monitoring and initiating interventions to ensure residents safety. Verification: started on 12/20/2023 at 2:30 p.m. and included: The following observations, record reviews and interviews were conducted to ensure CNA's and licensed staff's understanding of in-service training received by 12/19/2023. Observations on 12/20/2023 and 12/21/2023 of 3 skin assessment conducted by RN I and LVN J. Record review of all direct care staff In-Serviced Sign In Sheet for the topic of: Notification of changes in condition and new skin issues conducted by the DON/ADON reflected 1of 2 RN's (1 is the DON), 19 of 20 LVN's (1 was out of the country), 23 of 23 CNA's and 6 of 6 Med Aides were in-serviced from all shifts. Interviews on 12/20/2023 and12/21/2023 with the following CNA's C, D, E, G, H, K, L, M, N, O, and P. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood they were to notify their charge nurse in case they observed any new skin condition and document their findings in PCC. Interviews on 12/20/2023 and 12/21/2023 with the following LVN's/RN F, I, J, Q, R, S, T, U, V, W, X, Y and Z. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood if a CNA informed them a resident has a new skin observation, new onset of pain and/or change of condition they are to do a head-to-toe assessment, notify their physician, document in PCC, and carry out any new orders. They were to also do a 24-hour report and verbally notify the in-coming nurse to any new discoveries. They also needed to complete an SBAR assessment. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2023 at 4:00 p.m. The facility remained out of compliance at the severity of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental or psychological status for 1 of 3 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #1 was noticed with discoloration to her outer lower leg on 11/29/2023. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents with injuries by placing them at risk of delayed medical treatment, hospitalization , and decline in condition. Findings included: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia, and Alzheimer's disease. Record review of Resident #1's quarterly MDS dated [DATE] reflected her: Hearing was moderate difficulty Speech clarity was unclear Sometimes understood/understand Vision was moderately impaired BIMS score of 00 (severly impaired) Functional limitation in range of motion: Upper extremity was impaired on one side; Lower extremity was impaired on both sides. Required substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing, and putting on/off footwear. Dependent for roll left and right, sit to lying, chair/bet-to-chair transfer and tub/shower transfer. Record review of Resident #1's comprehensive care plan reflected she was a 2 person assist with transfer and mobility. In a hospital observation on 12/13/2023 at 12:45 p.m. Resident #1 was lying in bed, eyes closed and was receiving a breathing treatment. She had a urinary catheter and was on intravenous therapy. In an interview on 12/13/2023 at 12:55 p.m., hospital RN AA said Resident #1 had been admitted with a diagnosis of a closed left ankle fracture. She said Resident #1 was ready to be discharged they were just waiting for the paperwork to be completed. In a hospital interview on 12/13/2023 at 1:00 p.m., Resident #1 whispered she was in pain and complained her left foot was hurting. She kept repeating she was in pain and then closed her eyes. She was not able to answer any questions related to the discoloration to her outer lower left leg. In an interview on 12/14/2023 at 8:45 a.m., the NP said she had been Resident #1's NP since before she was admitted to the nursing facility. She said she was notified on 12/09/2023, Resident #1 had swelling and discoloration to her left ankle. She said she also received a picture, LVN F had taken of Resident #1's ankle. The NP said from looking at the picture she was sent, Resident #1's ankle did not look deformed but had swelling and was discolored. She said she gave orders for x-rays and when the results came back as acute distal tibial and fibular fractures with no significant displacement to the left ankle, she gave an order for Resident #1 to be sent to the hospital for further evaluation. The NP said she asked LVN F how Resident #1 had sustained the injury and was told they did not know how it had happened. The NP said she was not surprised of the fracture Resident #1 sustained given her frailty and any wrong movement might have caused a fracture. She said, with that being said, she still needs to be handled with care. the NP said that 12/09/2023 was the first time she was notified of Resident #1's discoloration. In an interview on 12/14/2023 at 5:00 p.m., LVN B said she was the wound care nurse. She said she provided wound care to Resident #1 on a daily basis. She said she did not noticed any discoloration or swelling to Resident #1's outer left leg or ankle. She said Resident #1 had a stage IV pressure ulcer to the coccyx area that required daily care. She said when she would first arrive at Resident #1's room, she would reposition her to her left side (side Resident #1 preferred) and lower the flat sheet to down to Resident #1's knees and started with the wound care. She said she never noticed any discoloration and/or swelling to Resident #1's outer lower leg or ankle. LVN B said Resident #1 would show signs of pain whenever she was performing wound care. LVN B said she would not remove Resident #1's heel protector during wound care to the coccyx area. LVN B said she would also do weekly skin assessments and never noticed any discoloration or swelling to Resident #1's out left leg or ankle. In an interview on 12/14/2023 at 5:18 p.m., CNA H said she saw Resident #1 one time while in the covid hall. She said on 11/29/2023 she remembered LVN B telling RN A that Resident #1 had a yellowing bruise to the top of her left ankle and above the heel protector boot. She said RN A and her went over to Resident #1's room where RN A uncovered her, assessed her, and said oh yes, she has a little bruising but did not remove the heel protector. She said Resident #1 was not complaining of pain during that time. CNA H said RN A give Resident #1 pain medication and that was all she did. In an interview on 12/14/2023 at 5:30 p.m., RN A said on 11/29/2023 was assigned to the Covid unit because she had just returned to work due to having Covid herself. She said on 11/29/2023 she was advised by LVN B that while doing wound care she noticed, Resident #1 had a light to medium discoloration to her outer left leg. RN A said she went over to Resident #1's room, assessed her. She described the discoloration as being yellowish in color. She said Resident #1 was wearing a heel protector on her left ankle. She said when she touched Resident #1's lower leg she was very sensitive. She said she thought her sensitivity was due to Resident #1 being Covid positive. RN A said Resident # 1 was crying and had facial grimacing so she decided to give her pain medication and monitor her as that was all I could do. RN A said she was not sure why she did not remove Resident #1's heel protector to assess her ankle. RN A said she documented her finding on PCC under MAR or progress notes. She said she did not inform the incoming nurse because she took it for granted the incoming nurse would read her notes. RN A said that was the first and only day she worked in the covid unit and had contact with Resident #1. In an interview on 12/18/2023 at 2:18 p.m., the DON said since Resident #1 was always in pain due to her stage IV coccyx pressure ulcer the nursing staff might have confused Resident #1's fractured ankle pain to her stage IV coccyx pressure ulcer pain. The DON said there were no negative outcome on Resident #1's delay to assess, notify the NP, and document on progress notes of discoloration which was first noticed on 11/29/2023 and later identified as an acute distal tibial and fibular fractures to the left ankle on 12/09/2023 because she was being assessed for pain and given pain medication when needed. She said that was all they could do since Resident #1 did not require surgery. In an interview on 12/18/2023 at 4:00 p.m., the Administrator said the information he collected during his investigation was conflicting in regards to Resident #1's discoloration to her lower left leg. He said RN A told him LVN B advised her that while she was doing wound care, she noticed the discoloration, but LVN B denied ever telling RN A. The Administrator said RN A told him she failed to document her findings, notify NP, and notify in-coming nurse. He said he was not able to say if Resident #1 suffered any negative effects because that was a clinical question. Record review of facility's policy on Change in a Resident's Condition or Status revised on February 2021 reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition This was determined to be an Immediate Jeopardy (IJ) on 12/19/2023 at 3:40 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/19/2023 at 3:40 p.m. The following Plan of Removal submitted by the facility was accepted on 12/21/2023 at 4:00 p.m. Immediate action taken On 12/19/2023 the Charge Nurse who failed to notify the physician of the discoloration was terminated. By 12/19/2023 all residents have updated pain assessments completed by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all residents have updated skin observations documents by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all direct care staff have been in-serviced by the DON, the ADON, the MDS, and Treatment Nurse on immediate notification of any skin observation, new onset of pain, and/or change of condition. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. As of 12/19/2023 the DON, the ADON, the MDS, and the Treatment Nurse educated CNA's on notifying the Charge Nurse regarding any new skin issue identified. The CNA will verbally inform Charge Nurse, and Nurses will document skin issue in Point Click Care and CNA's will document new skin issues or injuries in Point Click Care. Monitoring/Supervision As of 12/19/2023 the DON and the ADON review 24-hour report for documentation and pain/skin assessment daily during the morning clinical meetings. DON and ADON will review Point Click Care documentation during morning clinical meeting. As of 12/19/2023 the DON, the ADON, or the MDS will assess all nonverbal bedridden patients twice a week for a month to verify compliance and then monthly x 3 months. Any new direct care employee will be educated on immediate notification of any new skin observation, new onset of pain, and/or change of condition prior to working with residents. All the above-mentioned education/in-services should serve to resolve questions regarding steps taken during a change of condition. In addition to procedures for monitoring and initiating interventions to ensure residents safety. Verification: started on 12/20/2023 at 2:30 p.m. and included: The following observations, record reviews and interviews were conducted to ensure CNA's and licensed staff's understanding of in-service training received by 12/19/2023. Observations on 12/20/2023 and 12/21/2023 of 3 skin assessment conducted by RN I and LVN J. Record review of all direct care staff In-Serviced Sign In Sheet for the topic of: Notification of changes in condition and new skin issues conducted by the DON/ADON reflected 1of 2 RN's (1 is the DON), 19 of 20 LVN's (1 was out of the country), 23 of 23 CNA's and 6 of 6 Med Aides were in-serviced from all shifts. Interviews on 12/20/2023 and12/21/2023 with the following CNA's C, D, E, G, H, K, L, M, N, O, and P. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood they were to notify their charge nurse in case they observed any new skin condition and document their findings in PCC. Interviews on 12/20/2023 and 12/21/2023 with the following LVN's/RN F, I, J, Q, R, S, T, U, V, W, X, Y and Z. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood if a CNA informed them a resident has a new skin observation, new onset of pain and/or change of condition they are to do a head-to-toe assessment, notify their physician, document in PCC, and carry out any new orders. They were to also do a 24-hour report and verbally notify the in-coming nurse to any new discoveries. They also needed to complete an SBAR assessment. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2023 at 4:00 p.m. The facility remained out of compliance at the severity of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for five Residents (R#14, R#25, R#7, R#8, and R#18) of 24 residents reviewed for skin issues, in that: 1) The facility did not assess or consult with the physician to initiate treatment for [REDACTED].#14's scrotum, inguinal area, and buttocks area, resulting in pain and the resident's inability to tolerate being up in a wheelchair or participating in activities. 2) The facility did not assess and communicate findings of redness to R#25's perineal area. 3) The facility did not assess and communicate findings of redness to R#7's perineal area. 4) The facility did not assess and communicate findings of redness to R#8's perineal area. 5) The facility did not assess and communicate findings of redness to R#18's perineal area. This failure could place all 26 residents who were receiving wound care at risk for not receiving adequate treatment or pain relief. Findings included: 1) Record review of R#14's Face Sheet, dated 01/31/17, revealed R#14 was an [AGE] year-old male who was admitted to the facility on [DATE]. R#14's [DIAGNOSES REDACTED]. Record review of R#14's Care Plan, dated 11/16/16, revealed R#14 had a rash to the inner medial buttocks. Approaches were: -weekly skin checks with documentation, -evaluate current treatment for [REDACTED].>-keep area clean and dry, -provide prompt incontinent care, and -notify family and doctor of any changes. Record review of R#14's Weekly Head to Toe Skin Assessment, dated 01/29/17, indicated R#14 had no skin problems or [MEDICAL CONDITION] present for the past seven days and that currently there were no skin issues. The Assessment was documented as completed on 01/29/17 at 6:34 p.m. Assessments completed prior to and after the skin assessment on 01/29/17 indicated that R#14 was not in any pain. Record review of R#14's Nurse's Notes, dated 01/29/17, indicated R#14 did not have any skin problems within the past seven days. Record review of 24 hour Nursing Report Sheets for R#14's hall, for 01/25/17, 01/26/17, 01/27/17, 01/28/17, 01/29/17, and 01/30/17 revealed no notation or indication of a redness, discoloration, rash, or change in condition for R#14. On 01/31/17 at 2:40 p.m., surveyor observed Certified Nurse Aide (CNA) R and CNA S provide incontinent care to R#14. Surveyor noted R#14's scrotum and inguinal areas were bright red, with blistering, all the way to R#14's buttocks and between his buttocks. While incontinent care was performed, surveyor observed R#14 was wincing as the CNAs wiped his scrotum, inguinal area, and between his buttocks. The CNAs then applied barrier cream on R#14's buttocks and between his buttocks, but not on his scrotum or inguinal area. In an interview on 01/31/17 at 2:50 p.m., CNA R said she was not told of any redness, rash, discoloration, or skin changes for R#14 when she received report from the previous shift. CNA R said she and her coworker had not applied barrier cream to R#14's scrotum and inguinal areas because the areas, looked bad and they needed to report the areas to the nurse, so the nurse could look at the areas and determine if R#14 needed some other treatment. CNA R said she had been trained that when she found a new area of concern for a resident's skin, she was supposed to report the area to the nurse for follow up. In an interview on 01/31/17 at 3:00 p.m., CNA S said she had not been given any information in report about any redness, rash, discoloration, or skin changes for R#14. In an interview on 01/31/17 at 3:15 p.m., Licensed Vocational Nurse (LVN) T said that, when he received report for R#14, he was not told anything about redness, rash, discoloration, or skin changes to R#14's scrotum, inguinal area, or between his buttocks. At this time, LVN T observed R#14's areas of concern with surveyor. LVN T said he needed to contact R#14's Physician and obtain further orders. LVN T said that was the protocol when new areas of concern were discovered. In an interview on 02/01/17 at 10:15 a.m., CNA F said she had worked on the 100 hall on 01/31/17 during the 6:00 a.m. to 2:00 p.m. shift. CNA F said had performed incontinent care for R#14 more than once during her shift. CNA F said R#14 sometimes pushed CNAs' hands away while they were attempting to do incontinent care. CNA F said when she did R#14's incontinent care at the beginning of today's shift, she did not notice any changes to his inguinal, scrotal, or buttock areas. CNA F said that, towards the end of the shift, she changed R#14's his brief and still did not notice any redness, rash, or discoloration. CNA F said that, during report at the beginning of her shift on 01/31/17, they were not told of any concerns or any change in skin status for R#14. CNA F said it was the protocol that she has been taught by the facility to report any changes to residents' skin to the nurse immediately, and also to let the oncoming shift know of the changes that were observed. In an interview on 01/31/17 at 3:20 p.m., LVN H said she did not know of any reddened areas or breakdown to R#14's skin. LVN H said no concerns about R#14 had been reported to her by any of the aides and she did not get any concerns about R#14's skin passed on to her in report this morning. Record review of Nurses Notes dated 01/31/17 indicated that R#14 had a rash to scrotum and groin area and that his physician was contacted. At that time nurse's notes indicated that physician ordered Keflex 250 mg PO three times a day for seven days (antibiotic) as well as Lotrisome cream two times a day. In an interview on 02/01/17 at 11:30 a.m., LVN U said she worked on Sunday 01/29/17, during the 2:00 p.m. to 10:00 p.m. shift, and that she had been the nurse for R#14's hall. LVN U said that, during her shift, the head to toe skin assessment for R#14 was due on the Medication Administration Record [REDACTED]. LVN U said that, when she performed the head to toe assessment, she noted that R#14 had a rash on the scrotum and coccyx area, and that she requested that the aides apply skin barrier to the area. LVN U said she did not document in her notes or on the skin assessment about the rash findings because she knew the aides knew to apply skin barrier to any areas of redness or breakdown. LVN U said she did not relay her findings in her verbal report or document them in the 24 hour report because she had instructed both aides on the shift to apply barrier cream to R#14. LVN U said it was facility protocol to document the findings and to pass them on in report and that she was aware of the policy, but she did not carry it out. LVN U did not have a reason or response for not doing this, but said that she had been trained to. In an interview on 02/01/17 at 3:15 p.m., CNA Z said he normally worked the 2:00 p.m. to 10:00 p.m. shift and that he worked on Sunday 01/29/17 on the 100 hall. CNA Z said he was familiar with R#14 and that he had provided care for R#14 often. CNA Z said that, on 01/29/17, he was not told anything by the nurse about applying barrier cream to R#14. CNA Z said R#14 had recently been diagnosed with [REDACTED]. CNA Z said that, before the cream ran out completely, the area with the rash had improved, but when he saw it on 01/31/17, it looked the worse than he had ever seen it. CNA Z said R#14 had complained to him that he was in severe pain and that he wanted to go back to his room from activities and lay down in bed because it hurt too much to try to sit in the wheelchair. CNA Z said R#14 was crying when they got R#14 to his room and that he just wanted to lie down due to the pain. CNA Z said he made the nurse aware of R#14's complaints of pain. CNA Z said that when he made his first round today (02/01/17), R#14 complained to him that his scrotal area was very painful and burning. CNA Z said when they received report today on R#14, nobody relayed anything about R#14 having a rash, reddened area, or skin break-down. In an interview on 02/02/17 at 3:35 p.m., R#14 said he was in pain and pointed to his groin. In an interview on 02/01/17 at 12:30 p.m., the Director of Nurses (DON) said it was facility policy/protocol that, when a staff member did an assessment on a resident and noted skin changes or problems: -the changes or problems were to be documented on the skin assessment sheet, -the resident's physician should be contacted and orders obtained, -the residents family should be updated on the new findings and orders, -the orders should be carried out, -the findings should be added to 24 hour report sheet, and -the findings should be verbally given to the oncoming shift in order to ensure monitoring could continue. The DON said that any other way was not right and it was just not how they do it. Record review of the facility's, Skin Assessment Policy and Procedure, dated February 2015, revealed it was the facility's policy to document skin problems, including new areas of concern and/or progression of ongoing skin problems. Policy further indicated that each resident would have a computerized skin condition profile for each site of concern. 2) Record review of R#25's Face Sheet, dated 02/12/13, revealed R#25 was admitted to the facility on [DATE] and readmitted on [DATE]. R#25's [DIAGNOSES REDACTED]. Record review of R#25's Quarterly MDS assessment, dated 11/14/16, indicated R#25: -was rarely/never understood by others, -rarely/never understood others, and -was totally dependent on staff assistance for locomotion and for eating. Record review of R#25's skin assessment, dated 02/01/17 at 1:38 a.m., revealed R#25 had no skin problems or [MEDICAL CONDITION] present in the past 7 days. In an interview on 02/01/17 at 4:50 p.m. LVN Y said there were no skin concerns with R#25. LVN Y said the previous shift did not report any skin concerns to her. On 02/01/17 at 4:55 p.m., surveyor accompanied CNACC, entered R#25's room to make an observation of R#25's perineal area. CNACC donned gloves and unfastened R#25's disposable brief. Surveyor did not observe any skin barrier on R#25's perineal area. Surveyor observed redness to R#25's scrotum. Surveyor then asked for CNA CC to spread R#25's legs. Surveyor noticed a moderate amount of redness to R#25's right inguinal area. No barrier cream was noted. In an interview on 02/01/17 at 5:01 p.m., CNA CC said that she had not been aware of the redness to R#25's right inguinal area. In an interview on 02/02/17 at 2:20 p.m., CNA DD said that she worked on 02/01/17, but left at 11:00 a.m. CNA DD said that she had not seen any redness to R#25's perineal area yesterday. CNA DD said she bathed R#25 yesterday and did not see a reddened area. In an interview on 02/02/17 at 2:22 p.m., CNA CC said that, during observation yesterday with the surveyor, she did not see any skin issues. Surveyor asked about the redness to R#25's inguinal area. CNA CC said, oh yes and that she had reported it to LVN Y at the end of the shift and she reported it to the night shift. In an interview on 02/02/17 at 2:50 p.m., LVN FF said the only thing reported to her regarding R#25 was that his feeding had been decreased due to gagging and drooling. On 02/02/17 at 2:53 p.m., surveyor observed LVN FF conduct a head to toe assessment of R#25. LVN FF washed his hands, donned gloves, and proceeded to check R#25's head, upper body, lower extremities, and perineal area. Surveyor observed skin barrier cream on R#25's right inguinal area. Surveyor asked LVN FF to remove the skin barrier cream to get a better look of the area. LVN FF removed the skin barrier cream and surveyor observed a small amount of redness to the right inguinal area. The area had improved compared to surveyor's observation from 02/01/17. In an interview on 02/02/17 at 3:02 p.m., LVN FF said that R#25 was pretty much ok, he just needed barrier cream, nothing too alarming. Record review of R#25's skin assessment, dated 02/02/17 at 4:12 p.m., revealed: Skin Problems: Has no skin problems or [MEDICAL CONDITION] present in past 7 days. Noted dependent redness/pink discoloration to scrotum and peri area. No rash drainage or foul smell noted. No open areas of discomfort noted to area. Rest of body is clean and intact no redness or skin alterations noted. Record review of R#25's, Progress Notes, dated 02/03/17 revealed, Patient seen and examined. No skin condition noted on exam. 3) Record review of R#7's Face Sheet, dated 01/30/17, revealed R#7 was admitted to the facility on [DATE]. R#7's [DIAGNOSES REDACTED]. Record review of R#7's Quarterly MDS assessment, dated 10/28/16, indicated R#7: -had moderately impaired cognition, -was usually understood by others, -understood others, -required extensive assistance from two staff for bed mobility, transfers, and toilet use, -required extensive assistance from one staff for locomotion, dressing, and personal hygiene, -was always incontinent of urine, -was frequently incontinent of bowel, and -was not at risk of developing pressure ulcers. Record review of R#7's skin assessment, dated 01/28/17, indicated, skin color: pink, clean, head/neck/scalp: intact, normal for resident, skin problems: has no skin problems or [MEDICAL CONDITION] present in past 7 days. On 01/31/17 at 3:20 p.m., surveyor observed CNA V and CNA W provide incontinent care for R#7. During the incontinent care, surveyor observed some redness to the middle of R#7's labia majora. CNA W got a disposable wipe and wiped down the middle of the labia and, at this point, surveyor observed R#7 say, aye (translation: ouch). The CNAs finished with the incontinent care. The CNAs did not apply any skin barrier and were fastening R#7's disposable brief when surveyor intervened and asked staff to unfasten R#7's brief to take a look to R#7's peri area. Surveyor asked CNA W if she saw any concerns with R#7's peri area. The CNAs did not stop care and inform the nurse about the redness to R#7's labia. Surveyor observed CNA V open a small packet of Periguard ointment and apply some to R#7's labia. In an interview on 01/31/17 at 3:20 p.m., CNA W said that it was difficult to know if there was any redness to R#7's peri area because the area had a darker pigmented area. CNA W said that, after taking a second look, she saw that the area looked slightly pink and irritated. CNA W and CNA X said they would notify the nurse. In an interview on 01/31/17 at 3:28 p.m., R#7 said that she felt some burning to her peri area. Record review of R#7's nurses notes, dated 01/31/17, did not indicate any concerns with R#7's peri area. R#7's nurses notes did not indicate if the physician or RP (Responsible Party) were notified of any skin issues. In an interview on 02/01/17 at 12:05 p.m., CNA AA said she worked on the hall where R#7 resided yesterday morning. CNA AA said she got R#7 up from bed and changed her, but did not notice any irritation or redness to R#7's peri area. CNA AA said she knew to report any redness to the nurse. In an interview on 02/01/17 at 12:23 p.m., CNA BB said that she worked on hall where R#7 resided yesterday morning. CNA BB said that she assisted to get R#7 up from bed yesterday, but did not provide incontinent care. CNA BB said R#7 did not complain of pain, itching, or burning to the peri area. CNA BB said she bathed R#7 today in the morning and did not see any redness to the peri area. 4) Record review of R#8's Face Sheet, dated 01/30/17, revealed R#8 was admitted to the facility on [DATE] and readmitted on [DATE]. R#8's [DIAGNOSES REDACTED]. Record review of R#8's Quarterly MDS assessment revealed R#8: -was understood by others, -was able to understand others, -required extensive assistance from two staff for bed mobility, transfers, and toilet use, -required extensive assistance from one staff for locomotion, dressing, and personal hygiene, -was frequently incontinent of bladder and bowel, and -was at risk of developing pressure ulcers. Record review of R#8's skin assessment, dated 01/30/17, revealed, skin color was pink and clean. The head/neck/scalp was intact and dry. Skin problems: dry scab to left forearm, dry scab to right shin. Skin treatment: no skin problems. On 01/31/17 at 4:00 p.m., surveyor, accompanied by LVN X, observed CNA V and CNA W provide incontinent care for R#8. During the incontinent care, surveyor noted a small area of redness to R#8's left labia and a small reddened area to R#8's right buttock. Surveyor noted CNA V apply skin barrier cream on R#8's labia. In an interview on 01/31/17 at 4:00 p.m., LVN X said that she had not been aware of a rash or redness to R#8's vaginal area. LVN X said the morning shift nurse did not report anything regarding redness. LVN X said that the reddened area to R#8's left labia was something new. LVN X said that she was going to call the doctor. LVN X said some redness to the right buttock was noted, but they were going to have R#8 on her side and monitor it. In an interview on 01/31/17 at 4:04 p.m., CNA V and CNA W said the morning shift nurse aides did not report any skin concerns or redness for R#8. In an interview on 01/31/17 at 4:05 p.m., R#8 said that she did not have pain to her private area, only felt some itching all over, especially on her upper back and spinal area. Record review of R#8's nurses notes dated 01/31/17 did not reveal any concerns with R#8's peri area. R#8's nurses notes did not indicate if the physician or RP (Responsible Party) were notified of any skin issues. In an interview on 02/01/17 at 8:50 a.m., R#8 said that yesterday she was gotten up from bed by the nurse aides at about 6:00 a.m. and put back to bed at about 2:00 p.m. R#8 said she did not think she was checked to see if she needed to be changed from the time she was gotten up and believed she was changed when she was placed in bed at approximately 2:00 p.m. In an interview on 02/01/17 at 12:05 p.m., CNA AA said she worked on the hall where R#8 resided yesterday morning. CNA AA said R#8 had a history of [REDACTED].#8 yesterday, but did not notice any redness to the peri area. CNA AA said she knew to report any redness to the nurse. In an interview on 02/01/17 at 12:23 p.m., CNA BB said she got R#8 up from bed and changed her yesterday and only saw some redness to bilateral inguinal areas. Record review of R#8's, Progress Notes, dated 02/02/17, revealed, Patient seen and evaluated with nursing staff. Area of [DIAGNOSES REDACTED] at labia was observed. I believe at this point this is an area of inflammation that is resolving from recent treatment of [REDACTED]. 5) Record review of R#18's Face Sheet, dated 02/01/17, revealed R#18 was admitted to the facility on [DATE]. R#18's [DIAGNOSES REDACTED]. Record review of R#18's Quarterly MDS assessment, dated 01/09/17, revealed R#18: -was understood by others, -was able to understand others, -required extensive assistance from two staff for bed mobility, -was totally dependent on two staff for dressing and toilet use, -was totally dependent one staff for personal hygiene, -was always incontinent of bowel, -had an indwelling catheter, and -was at risk for pressure ulcers. Record review of R#18's skin assessment, dated 02/01/16 at 2:47 a.m., revealed, Skin Problems: has abrasions receives application of ointment/medications (other than to feet). Receives nutrition and hydration intervention to manage skin problems. Receives surgical wound care. On 02/03/17 at 11:00 a.m., surveyor observed LVN I and CNA GG conduct a head to toe assessment and provide wound care to a surgical wound to R#18's right hip area. LVN I washed her hands, donned gloves and proceeded to assess R#18's head, upper body, lower extremities and perineal area. When LVN I unfastened R#18's disposable brief, surveyor noted skin barrier applied to the inguinal areas, redness to the left groin area, and redness to the scrotum. In an interview on 02/03/17 at 11:18 a.m., LVN I said R#18 had a peri rash to the left groin area/anterior medial leg and a red peri rash to the scrotum. LVN I said she was not aware of the redness to R#18's perineal area. LVN I said the previous shift did not report any skin issues with R#18. In an interview on 02/03/17 at 11:1., CNA GG said that the previous shift nurse aides did not report any skin concerns. CNA GG said that R#18 was under hospice services and that a hospice aide had bathed him earlier and did not report any redness. In an interview on 02/06/17 at 4:30 p.m., R#18 said that he did not have any pain or discomfort to his private area. In an interview on 02/01/17 at 3:50 p.m., the DON said that if any skin concern was noted on a resident, staff was to report it to the nurse, the nurse was to document it on the nurses notes or the 24 hour report and notify the RP (Responsible Party) and the physician. Facility list provided on 02/06/17 by the facility's Infection Control Nurse indicated there were currently 26 residents receiving wound care.

Based on interview and record review, the facility failed to implement their written policies that prohibit mistreatement, neglect, and abuse of residents, for two Residents (R#14 and R#23) of 23 residents reviewed for abuse/neglect. 1) The facility did not assess or consult with the physician to initiate treatment for [REDACTED].#14's scrotum, inguinal area, and buttocks area, resulting in pain and the resident's inability to tolerate being up in a wheelchair or participating in activities. This failure could place all 26 residents who were receiving wound care at risk for not receiving adequate treatment or pain relief. 2) The facility failed to report allegations of neglect and mistreatment, made by R#23, to the Department of Aging and Disability Services (DADS). The facility did not thoroughly investigate R#23's allegations of neglect and mistreatment. This failure could place all 52 residents in Hall 100 at risk for abuse and neglect. The findings were: 1) Record review of the facility's undated Abuse and Neglect Policy and Procedures revealed: -Any form of resident abuse, mistreatment, neglect, or misappropriation of property will no be tolerated. It is the responsibility of all employees to report resident abuse, mistreatment, neglect, or misappropriation of property directly to the Director of Nursing and/or Administrator. -Neglect - failure to provide services, treatments, or care necessary to avoid physical harm, mental anguish, or mental illness. -Neglect: This facility and its individuals shall provide treatments and services which are necessary to maintain the residents' health and safety and which prevent noticeable deterioration of physical, mental, or emotional conditions of the resident. Record review of R#14's Face Sheet, dated [DATE], revealed R#14 was an [AGE] year-old male who was admitted to the facility on [DATE]. R#14's [DIAGNOSES REDACTED]. Record review of R#14's Care Plan, dated [DATE], revealed R#14 had a rash to the inner medial buttocks. Approaches were: -weekly skin checks with documentation, -evaluate current treatment for [REDACTED].>-keep area clean and dry, -provide prompt incontinent care, and -notify family and doctor of any changes. Record review of R#14's Weekly Head to Toe Skin Assessment, dated [DATE], indicated R#14 had no skin problems or [MEDICAL CONDITION] present for the past seven days and that currently there were no skin issues. The Assessment was documented as completed on [DATE] at 6:34 p.m. Assessments completed prior to and after the skin assessment on [DATE] indicated that R#14 was not in any pain. Record review of R#14's Nurse's Notes, dated [DATE], indicated R#14 did not have any skin problems within the past seven days. Record review of 24 hour Nursing Report Sheets for R#14's hall, for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed no notation or indication of a redness, discoloration, rash, or change in condition for R#14. On [DATE] at 2:40 p.m., surveyor observed Certified Nurse Aide (CNA) R and CNA S provide incontinent care to R#14. Surveyor noted R#14's scrotum and inguinal areas were bright red, with blistering, all the way to R#14's buttocks and between his buttocks. While incontinent care was performed, surveyor observed R#14 was wincing as the CNAs wiped his scrotum, inguinal area, and between his buttocks. The CNAs then applied barrier cream on R#14's buttocks and between his buttocks, but not on his scrotum or inguinal area. In an interview on [DATE] at 2:50 p.m., CNA R said she was not told of any redness, rash, discoloration, or skin changes for R#14 when she received report from the previous shift. CNA R said she and her coworker had not applied barrier cream to R#14's scrotum and inguinal areas because the areas, looked bad and they needed to report the areas to the nurse, so the nurse could look at the areas and determine if R#14 needed some other treatment. CNA R said she had been trained that when she found a new area of concern for a resident's skin, she was supposed to report the area to the nurse for follow up. In an interview on [DATE] at 3:00 p.m., CNA S said she had not been given any information in report about any redness, rash, discoloration, or skin changes for R#14. In an interview on [DATE] at 3:15 p.m., Licensed Vocational Nurse (LVN) T said that, when he received report for R#14, he was not told anything about redness, rash, discoloration, or skin changes to R#14's scrotum, inguinal area, or between his buttocks. At this time, LVN T observed R#14's areas of concern with surveyor. LVN T said he needed to contact R#14's Physician and obtain further orders. LVN T said that was the protocol when new areas of concern were discovered. In an interview on [DATE] at 10:15 a.m., CNA F said she had worked on the 100 hall on [DATE] during the 6:00 a.m. to 2:00 p.m. shift. CNA F said had performed incontinent care for R#14 more than once during her shift. CNA F said R#14 sometimes pushed CNAs' hands away while they were attempting to do incontinent care. CNA F said when she did R#14's incontinent care at the beginning of today's shift, she did not notice any changes to his inguinal, scrotal, or buttock areas. CNA F said that, towards the end of the shift, she changed R#14's his brief and still did not notice any redness, rash, or discoloration. CNA F said that, during report at the beginning of her shift on [DATE], they were not told of any concerns or any change in skin status for R#14. CNA F said it was the protocol that she has been taught by the facility to report any changes to residents' skin to the nurse immediately, and also to let the oncoming shift know of the changes that were observed. In an interview on [DATE] at 3:20 p.m., LVN H said she did not know of any reddened areas or breakdown to R#14's skin. LVN H said no concerns about R#14 had been reported to her by any of the aides and she did not get any concerns about R#14's skin passed on to her in report this morning. Record review of Nurses Notes dated [DATE] indicated that R#14 had a rash to scrotum and groin area and that his physician was contacted. At that time nurse's notes indicated that physician ordered Keflex 250 mg PO three times a day for seven days (antibiotic) as well as Lotrisome cream two times a day. In an interview on [DATE] at 11:30 a.m., LVN U said she worked on Sunday [DATE], during the 2:00 p.m. to 10:00 p.m. shift, and that she had been the nurse for R#14's hall. LVN U said that, during her shift, the head to toe skin assessment for R#14 was due on the Medication Administration Record [REDACTED]. LVN U said that, when she performed the head to toe assessment, she noted that R#14 had a rash on the scrotum and coccyx area, and that she requested that the aides apply skin barrier to the area. LVN U said she did not document in her notes or on the skin assessment about the rash findings because she knew the aides knew to apply skin barrier to any areas of redness or breakdown. LVN U said she did not relay her findings in her verbal report or document them in the 24 hour report because she had instructed both aides on the shift to apply barrier cream to R#14. LVN U said it was facility protocol to document the findings and to pass them on in report and that she was aware of the policy, but she did not carry it out. LVN U did not have a reason or response for not doing this, but said that she had been trained to. In an interview on [DATE] at 3:15 p.m., CNA Z said he normally worked the 2:00 p.m. to 10:00 p.m. shift and that he worked on Sunday [DATE] on the 100 hall. CNA Z said he was familiar with R#14 and that he had provided care for R#14 often. CNA Z said that, on [DATE], he was not told anything by the nurse about applying barrier cream to R#14. CNA Z said R#14 had recently been diagnosed with [REDACTED]. CNA Z said that, before the cream ran out completely, the area with the rash had improved, but when he saw it on [DATE], it looked the worse than he had ever seen it. CNA Z said R#14 had complained to him that he was in severe pain and that he wanted to go back to his room from activities and lay down in bed because it hurt too much to try to sit in the wheelchair. CNA Z said R#14 was crying when they got R#14 to his room and that he just wanted to lie down due to the pain. CNA Z said he made the nurse aware of R#14's complaints of pain. CNA Z said that when he made his first round today ([DATE]), R#14 complained to him that his scrotal area was very painful and burning. CNA Z said when they received report today on R#14, nobody relayed anything about R#14 having a rash, reddened area, or skin break-down. In an interview on [DATE] at 3:35 p.m., R#14 said he was in pain and pointed to his groin. In an interview on [DATE] at 12:30 p.m., the Director of Nurses (DON) said it was facility policy/protocol that, when a staff member did an assessment on a resident and noted skin changes or problems: -the changes or problems were to be documented on the skin assessment sheet, -the resident's physician should be contacted and orders obtained, -the residents family should be updated on the new findings and orders, -the orders should be carried out, -the findings should be added to 24 hour report sheet, and -the findings should be verbally given to the oncoming shift in order to ensure monitoring could continue. The DON said that any other way was not right and it was just not how they do it. Record review of the facility's, Skin Assessment Policy and Procedure, dated February 2015, revealed it was the facility's policy to document skin problems, including new areas of concern and/or progression of ongoing skin problems. Policy further indicated that each resident would have a computerized skin condition profile for each site of concern. Facility list provided on [DATE] by the facility's Infection Control Nurse indicated there were currently 26 residents receiving wound care. 2) Record review of the facility's undated Abuse and Neglect Policy and Procedure, under section Investigation, Protection, and Reporting revealed: When an incident of suspected resident abuse, mistreatment, or neglect is reported, the following will occur: 1. A thorough investigation of the allegation will be conducted by the facility. Included in the investigation will be results of a physical examination of the resident, review of the incident report, review of nursing notes, review of the 24-hour condition report, and written and signed witness interviews. 2. The facility will ensure that the victim receives necessary treatment to relieve their distress, fear, or need for medical attention. If sexual abuse is alleged, do no have the resident shower. Have resident taken to the hospital. 3. A case of suspected physical and/or sexual abuse would be immediately reported to the Texas state Survey Agency, and local law enforcement agency. 4. Complete an incident report for any abuse observed or alleged. 5. In the progress notes, record: -a detailed account of the episode, -all calls to family, doctor, and other professional or referrals. 6. The Administrator and Director of Nursing will document the incident on the state required form available from the Department of Human Services. Record review of DADS Provider Letter ,[DATE] - Abuse, Neglect, Exploitation and Other Incidents that Must be Reported, dated [DATE], revealed: Health and Safety Code §260A.002 and Texas Administrative Code, Title 40, Part 1, Chapter 19, §19.602(a) require any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Facilities are required at 40 TAC §19.601(c)(2) to ensure that all alleged violations involving mistreatment, neglect or abuse, including suspicious injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. Record review of R#23's Face Sheet revealed R#23 was admitted to the facility on [DATE] and discharged on [DATE]. Record review of R#23's February 2017 Physician order [REDACTED]., [MEDICAL CONDITIONS] Pectoris, [MEDICAL CONDITION] Disease of Native Coronary Artery, Gastroparesis, Constipation, Primary Generalized (Osteo) Arthritis, [MEDICAL CONDITION] Stage 3 (Moderate), Urinary Tract Infection, Hypoxemia, Fever, Pain, [MEDICAL CONDITION], Dependence on Supplemental Oxygen, Hemorrhage of Anus and Rectum, Gastrointestinal Hemorrhage, [DIAGNOSES REDACTED] Pneumonia, Diverticulitis of Intestine, Cognitive Communication Deficit, and Speech Disturbances. Record review of R#23's Quarterly MDS assessment, dated [DATE], revealed R#23: -had impaired vision, -had moderate difficulty hearing, -had clear speech, -was able to make herself understood, -was able to understand others, -required extensive assistance from staff for bed mobility, transfers, toileting, and personal hygiene, -required total assistance from staff for bathing, and -had range of motion impairment to the lower extremities on both sides. Record review of R#23's Progress Note dated [DATE] at 6:56 p.m., documented by LVN H, revealed: Incident Type: Bruise Date of Incident: [DATE] Time of Incident: 05:00 PM Location: Hallway Mental Status: Alert Activity at the Time: As per (R#23) she was being wheeled to shower room and her left elbow was hit against side rail in hallway. Record review of R#23's care plan, initiated on [DATE], revealed, (R#23) has a bruise to left elbow, she was being wheeled to shower room and her left elbow was hit against side rail in hallway. (R#23) is at risk to bruise easily due to has [MEDICAL CONDITION]. Record review of a facility, Complaint Resolution Record, dated [DATE], revealed: -Nature of Complaint: (R#23) complaint that the morning CNAs (Certified Nurse Aides) take a long time to answer call and then why they do go they turn off call light, tell (R#23) will be back and don't. As well in shower room, they are just talking among themselves and don't call for them, that one time CNA bumped her Rt (right) elbow against wall. -Referred to: Director of Nurses (DON) on [DATE]. -How complaint was investigated: DON and SW (Social Worker) met with CNAs and charge nurse (LVN H). CNAs - (CNA D, CNA E, CNA F, and CNA G). -Findings of Investigation: Bumped elbow on side rail in hallway before she got to shower room (was on w/c {wheelchair}). (LVN H), charge nurse had spoken to (R#23) during that incident. It wasn't in shower room -it was in hallway. It was at least 2 wks (weeks) ago. Resident stated doesn't remember who it was. Nurse called incident to (family member). Call lights are being responded too (sic). Often she isn't told we'll be back. One day (LVN H) remember incident when (R#23) did soil self due to not being helped in time. Was cleaned. Record review of an attached Word document from Assistant Director of Nurses (ADON) J to the DON, dated [DATE], revealed: Today (R#23) reported to me that the morning nurse aides are being rough with her. States that at times there's up to 3 nurse aides in the shower just talking to each other and don't tend to them properly they will ask her to get up on her own, and that one time 1 nurse aide hit her left elbow against the wall, that she had told her, 'you hit me .you see that's why you shouldn't be just talking to one another.' She actually showed me the bump/bruise where she had been hit. She states 3 times she has had incontinent episode because the nurse aides will just go in turn the light off and tell her, 'I'll be back but never do.' Also one nurse aide just pulled the call light from her hand and hurt it. She stated I have a rash on my buttocks from having BM for such long time one time it dried up on me. Record review of R#23's Progress Notes dated [DATE] revealed no documentation regarding R#23's complaints. In an interview on [DATE] at 2:37 p.m., LVN I said R#23 was transferred to the hospital on [DATE] due to respiratory distress and had expired. LVN I said R#23's family came by today to pick R#23's belongings. In an interview on [DATE] at 2:40 p.m., the facility's Social Worker said R#23's complaint was investigated, but was not reported to DADS. The Social Worker said R#23 told her that during her shower, one CNA was talking on the phone. The Social Worker said R#23 did not recall who showered her or the date/time it happened. The Social Worker said R#23 hit herself on the elbow while being wheeled down the hallway. The Social Worker said she and the DON spoke with CNA D, CNA E, CNA F, CNA G, and LVN H. The Social Worker said she felt R#23's complaint was investigated by the facility. In an interview on [DATE] at 4:39 p.m., LVN H said she was informed by a CNA that R#23 had a bruise on her elbow. LVN H said she went to assess and R#23 told her someone hit her elbow on the hallway rail while wheeling her down the hallway, in [DATE]. The Social Worker said R#23 did not mention anything less to her. LVN H said R#23 was showered every other day. LVN H said the DON and Social Worker spoke with her (LVN H) and the CNAs, however no issues were reported to her about CNAs talking during R#23's shower, issues regarding CNAs answering call lights, or R#23 having a rash (due to not being changed). In an interview on [DATE] at 8:30 a.m., CNA E said she was on vacation from the last week of [DATE] to the beginning week of [DATE]. CNA E said that, when she returned to work, the DON discussed with her and other CNAs regarding R#23's complaint about one CNA (unknown name) using a cell phone and not paying attention to R#23 during R#23's shower. CNA E denied hurting R#23 or removing R#23's call light. CNA E said she did not recall seeing R#23 with a bruise. CNA E denied leaving R#23 soiled for a long period of time. CNA E said the Charge Nurse assisted with call lights if the CNAs were busy. In an interview on [DATE] at 8:46 a.m., CNA G said R#23 was showered every other day. CNA G said that, before leaving for her days off, R#23 did not have a bruise. CNA G said that, when she returned to work, she noticed R#23 had a bruise on the elbow. CNA G denied ever handling R#23 in a rough manner, leaving R#23 soiled, or not answering R#23's call light. CNA G said if she was busy, the Charge Nurse would assist in answering the call lights. CNA G said the DON told her R#23 made a complaint about R#23's elbow being bumped. CNA G said the DON did not discuss with her other allegations. CNA G said CNAs were in-serviced about not using cell phone when taking residents to shower. In an interview on [DATE] at 9:02 a.m., CNA D said she did not recall the day of the incident because she did not know if she worked the day R#23 made the complaint. CNA D said she recalled the DON speaking with her about R#23 having a bruise on her elbow and told her to be careful when taking residents to the shower room. CNA D said she did not recall seeing a bruise. CNA D denied ever leaving R#23 soiled for a long period of time or hurting R#23 when answering the call light. CNA D said she did not know if CNAs were talking on a cell phone while providing care to R#23. In an interview on [DATE] at 9:08 a.m., ADON J said she had been making rounds in the dining room when R#23 made the complaint. ADON J said R#23 told her that CNAs were being rough when in the shower room and R#23 got a bruise/bump on the elbow. ADON J said she tried to see the elbow, but R#23 said it hurt. ADON J said R#23 was not able to give the name of the CNA, but said she would be able to recognize the CNA's face. ADON J said R#23 told her that CNAs were talking among themselves during the shower, but did not mention anything about a CNA using a cell phone. ADON J said she took the complaint and passed it on to the DON. ADON J said that, when R#23 mentioned CNAs were, rough, she knew the facility needed to investigate as a possible allegation of abuse or neglect. ADON J said she did not know what happened after that because the DON and Social Worker were to investigate and determine if the matter was to be reported to DADS. On [DATE] at 8:10 a.m., surveyor attempted to contact CNA K via telephone. Surveyor left a brief message and contact information. In an interview on [DATE] at 1:41 p.m., CNA F said there was an in-service meeting regarding R#23's complaint that someone had bumped R#23's elbow during a shower and that a CNA had removed R#23's call light from R#23's hand. CNA F denied ever being rough with R#23, removing the call light rom R#23's hand, or leaving R#23 soiled for a long period of time. In an interview on [DATE] at 9:27 a.m., the DON said R#23's complaint was made on [DATE], but the incident regarding the bruise to her elbow happened in [DATE]. The DON said R#23 complained to LVN J about other allegations. The DON said she spoke with the CNAs, and the CNAs told her the no incidents had happened. The DON said R#23 required assistance from two staff for ADL care. The DON said R#23 was transferred from D-Wing to C-Wing because the restroom was bigger and to help R#23 with better care. The DON said R#23 mentioned to her that CNA were using their cell phones in the shower room. The DON said the staff were in-serviced regarding the use of cell phones during ADL care. The DON said she felt the facility investigated the allegations by talking to the staff and the resident. The DON said she did not interview other residents, but had a conference with the CNAs. The DON said she assessed R#23, but there was no bruising on R#23's hand. The DON said she did not document her assessment of R#23. The DON said R#23's complaints were investigated and she had not thought about reporting them to DADS. The facility's Roster/Sample Matrix form 52 residents in Hall 100.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation, for one Resident (R#14) of 24 residents reviewed for abuse and neglect issues, in that: The facility did not assess or consult with the physician to initiate treatment for [REDACTED].#14's scrotum, inguinal area, and buttocks area, resulting in pain and the resident's inability to tolerate being up in a wheelchair or participating in activities. This failure could place all 26 residents who were receiving wound care at risk for not receiving adequate treatment or pain relief. Findings included: Record review of R#14's Face Sheet, dated 01/31/17, revealed R#14 was an [AGE] year-old male who was admitted to the facility on [DATE]. R#14's [DIAGNOSES REDACTED]. Record review of R#14's Care Plan, dated 11/16/16, revealed R#14 had a rash to the inner medial buttocks. Approaches were: -weekly skin checks with documentation, -evaluate current treatment for [REDACTED].>-keep area clean and dry, -provide prompt incontinent care, and -notify family and doctor of any changes. Record review of R#14's Weekly Head to Toe Skin Assessment, dated 01/29/17, indicated R#14 had no skin problems or [MEDICAL CONDITION] present for the past seven days and that currently there were no skin issues. The Assessment was documented as completed on 01/29/17 at 6:34 p.m. Assessments completed prior to and after the skin assessment on 01/29/17 indicated that R#14 was not in any pain. Record review of R#14's Nurse's Notes, dated 01/29/17, indicated R#14 did not have any skin problems within the past seven days. Record review of 24 hour Nursing Report Sheets for R#14's hall, for 01/25/17, 01/26/17, 01/27/17, 01/28/17, 01/29/17, and 01/30/17 revealed no notation or indication of a redness, discoloration, rash, or change in condition for R#14. On 01/31/17 at 2:40 p.m., surveyor observed Certified Nurse Aide (CNA) R and CNA S provide incontinent care to R#14. Surveyor noted R#14's scrotum and inguinal areas were bright red, with blistering, all the way to R#14's buttocks and between his buttocks. While incontinent care was performed, surveyor observed R#14 was wincing as the CNAs wiped his scrotum, inguinal area, and between his buttocks. The CNAs then applied barrier cream on R#14's buttocks and between his buttocks, but not on his scrotum or inguinal area. In an interview on 01/31/17 at 2:50 p.m., CNA R said she was not told of any redness, rash, discoloration, or skin changes for R#14 when she received report from the previous shift. CNA R said she and her coworker had not applied barrier cream to R#14's scrotum and inguinal areas because the areas, looked bad and they needed to report the areas to the nurse, so the nurse could look at the areas and determine if R#14 needed some other treatment. CNA R said she had been trained that when she found a new area of concern for a resident's skin, she was supposed to report the area to the nurse for follow up. In an interview on 01/31/17 at 3:00 p.m., CNA S said she had not been given any information in report about any redness, rash, discoloration, or skin changes for R#14. In an interview on 01/31/17 at 3:15 p.m., Licensed Vocational Nurse (LVN) T said that, when he received report for R#14, he was not told anything about redness, rash, discoloration, or skin changes to R#14's scrotum, inguinal area, or between his buttocks. At this time, LVN T observed R#14's areas of concern with surveyor. LVN T said he needed to contact R#14's Physician and obtain further orders. LVN T said that was the protocol when new areas of concern were discovered. In an interview on 02/01/17 at 10:15 a.m., CNA F said she had worked on the 100 hall on 01/31/17 during the 6:00 a.m. to 2:00 p.m. shift. CNA F said had performed incontinent care for R#14 more than once during her shift. CNA F said R#14 sometimes pushed CNAs' hands away while they were attempting to do incontinent care. CNA F said when she did R#14's incontinent care at the beginning of today's shift, she did not notice any changes to his inguinal, scrotal, or buttock areas. CNA F said that, towards the end of the shift, she changed R#14's his brief and still did not notice any redness, rash, or discoloration. CNA F said that, during report at the beginning of her shift on 01/31/17, they were not told of any concerns or any change in skin status for R#14. CNA F said it was the protocol that she has been taught by the facility to report any changes to residents' skin to the nurse immediately, and also to let the oncoming shift know of the changes that were observed. In an interview on 01/31/17 at 3:20 p.m., LVN H said she did not know of any reddened areas or breakdown to R#14's skin. LVN H said no concerns about R#14 had been reported to her by any of the aides and she did not get any concerns about R#14's skin passed on to her in report this morning. Record review of Nurses Notes dated 01/31/17 indicated that R#14 had a rash to scrotum and groin area and that his physician was contacted. At that time nurse's notes indicated that physician ordered Keflex 250 mg PO three times a day for seven days (antibiotic) as well as Lotrisome cream two times a day. In an interview on 02/01/17 at 11:30 a.m., LVN U said she worked on Sunday 01/29/17, during the 2:00 p.m. to 10:00 p.m. shift, and that she had been the nurse for R#14's hall. LVN U said that, during her shift, the head to toe skin assessment for R#14 was due on the Medication Administration Record [REDACTED]. LVN U said that, when she performed the head to toe assessment, she noted that R#14 had a rash on the scrotum and coccyx area, and that she requested that the aides apply skin barrier to the area. LVN U said she did not document in her notes or on the skin assessment about the rash findings because she knew the aides knew to apply skin barrier to any areas of redness or breakdown. LVN U said she did not relay her findings in her verbal report or document them in the 24 hour report because she had instructed both aides on the shift to apply barrier cream to R#14. LVN U said it was facility protocol to document the findings and to pass them on in report and that she was aware of the policy, but she did not carry it out. LVN U did not have a reason or response for not doing this, but said that she had been trained to. In an interview on 02/01/17 at 3:15 p.m., CNA Z said he normally worked the 2:00 p.m. to 10:00 p.m. shift and that he worked on Sunday 01/29/17 on the 100 hall. CNA Z said he was familiar with R#14 and that he had provided care for R#14 often. CNA Z said that, on 01/29/17, he was not told anything by the nurse about applying barrier cream to R#14. CNA Z said R#14 had recently been diagnosed with [REDACTED]. CNA Z said that, before the cream ran out completely, the area with the rash had improved, but when he saw it on 01/31/17, it looked the worse than he had ever seen it. CNA Z said R#14 had complained to him that he was in severe pain and that he wanted to go back to his room from activities and lay down in bed because it hurt too much to try to sit in the wheelchair. CNA Z said R#14 was crying when they got R#14 to his room and that he just wanted to lie down due to the pain. CNA Z said he made the nurse aware of R#14's complaints of pain. CNA Z said that when he made his first round today (02/01/17), R#14 complained to him that his scrotal area was very painful and burning. CNA Z said when they received report today on R#14, nobody relayed anything about R#14 having a rash, reddened area, or skin break-down. In an interview on 02/02/17 at 3:35 p.m., R#14 said he was in pain and pointed to his groin. In an interview on 02/01/17 at 12:30 p.m., the Director of Nurses (DON) said it was facility policy/protocol that, when a staff member did an assessment on a resident and noted skin changes or problems: -the changes or problems were to be documented on the skin assessment sheet, -the resident's physician should be contacted and orders obtained, -the residents family should be updated on the new findings and orders, -the orders should be carried out, -the findings should be added to 24 hour report sheet, and -the findings should be verbally given to the oncoming shift in order to ensure monitoring could continue. The DON said that any other way was not right and it was just not how they do it. Record review of the facility's undated Abuse and Neglect Policy and Procedures revealed: -Any form of resident abuse, mistreatment, neglect, or misappropriation of property will no be tolerated. It is the responsibility of all employees to report resident abuse, mistreatment, neglect, or misappropriation of property directly to the Director of Nursing and/or Administrator. -Neglect - failure to provide services, treatments, or care necessary to avoid physical harm, mental anguish, or mental illness. -Neglect: This facility and its individuals shall provide treatments and services which are necessary to maintain the residents' health and safety and which prevent noticeable deterioration of physical, mental, or emotional conditions of the resident. Record review of the facility's, Skin Assessment Policy and Procedure, dated February 2015, revealed it was the facility's policy to document skin problems, including new areas of concern and/or progression of ongoing skin problems. Policy further indicated that each resident would have a computerized skin condition profile for each site of concern. Facility list provided on 02/06/17 by the facility's Infection Control Nurse indicated there were currently 26 residents receiving wound care.

Based on observation, interview, and record review, the Administrator and the Director of Nurses (DON) failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being for two Residents (R#13 and R#16) of seven residents reviewed with weight loss and three Residents (R#19, R#11, and R#9) of seven residents reviewed with pressure ulcers, in that: The Administrator failed to supervise the Director of Nurses (DON) and ensure staff were trained and monitored to comply with their job responsibilities. The Administrator and DON failed to ensure systems were implemented for monitoring weight loss and changes in skin condition. The DON failed to supervise the facility's nurses to ensure: -CNAs were reporting any changes in skin condition, -Nurses were conducting and documenting the skin assessments, -CNAs were weighing residents and reporting weights to nurses, -Nurses were providing list of residents with changes in weight to Dietary Manager, -Dietary Manager was making referrals to the Dietary Consultant, and -Staff was following up on recommendations. These failures could place 118 residents at risk for developing pressure ulcers and/or insidious weight loss. Findings included: On 01/15/16 at 8:30 a.m. surveyor conducted an interview with the Administrator. The Administrator said he did not know where the breakdown to substandard quality of care occurred. The Administrator said he was not a nurse and he relied on the DON. The Administrator said it was the DON's responsibility to oversee the nurses and ensure they were conducting and documenting the skin assessments and providing a list of residents with weight changes to the Dietary Manager and following up on the Dietary Consultant recommendations. The Administrator said the facility conducted morning meetings with department heads to discuss concerns, issues or problems. The Administrator said the facility conducted a pre QA meeting once a month before the actual QA meeting. The Administrator said the facility had a weight loss and skin assessment committees. The Administrator said that there was no system in place, such as chart audits, to ensure nurses were doing their jobs. On 01/14/15 at 4:00 p.m. surveyor interviewed the DON. The DON said the facility had a weight committee. The committee was made up of the Assistant Director of Nurses, MDS nurses, and the Dietary Manager. The DON said the committee would identify which residents had weight loss and inform the Dietician Consultant. The DON said the Dietician Consultant would recommend Medpass. If the Medpass was not enough to stabilize resident, the Dietary Manager would inform the Dietician Consultant. In an interview on 01/14/16 at 4:00 p.m., the DON said skin assessments were to be done weekly. The DON said, if a resident was scheduled for a skin assessment, the 6:00 a.m. - 2:00 p.m. shift nurse had to conduct the skin assessment. The DON said the CNAs were trained on what to report regarding changes in skin conditions. The DON said the CNAs did not document information; all information was verbally given to the nurses. In an interview on 01/15/16 at 9:00 a.m., the DON said she had done one-to-one counseling with her nurses. The DON said the nurses had told DON that they had done the skin assessments, but had not documented the assessments. The DON said she told nurses if the assessments had not been documented, then they were not done. 1) R#13 had unplanned weight loss of 21 pounds in three months. R#13 routinely refused meals or ate less than 50%. The facility: -did not ensure staff gave R#13 cues or encouragement to continue to eat or to finish her meals, -did not offer R#13 a substitute when she did not finish her meal, -did not include a green meal ticket on R#13's meal tray to alert staff that R#13 had weight loss and required cues to continue to eat, and was to be offered substitutes, and -did not ensure the Dietary Consultant reviewed R#13's weights and made recommendations for R#13 to prevent further weight loss, for a period of five months. 2) R#16 had unplanned weight loss of 23 pounds in four months. The facility did not ensure the Dietary Consultant formulated interventions for R#13 to prevent further weight loss. 3) R#19 had a history of [REDACTED].#19 for four weeks. When staff performed a skin assessment on R#19 at surveyor's request, a previously unidentified and untreated avoidable Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) was discovered on R#19's left medial buttock. 4) R#11 had a history of [REDACTED].#11 for two weeks. When staff performed a skin assessment on R#11 at surveyor's request, a previously unidentified and untreated avoidable Stage 2 pressure ulcer was discovered on R#11's left inner buttock. A shear to R#11's right medial buttocks had deteriorated to a larger Stage 2 pressure ulcer. 5) R#9 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) to the left lateral foot. The facility did not perform weekly skin assessments on R#9 for three months. The facility did not provide heel lifters to bilateral feet as called for in R#9's care plan and physician's orders [REDACTED]. The facility's Roster/Sample Matrix 802 form identified 33 residents at high risk for pressure ulcers. The facility's Resident Census and Conditions of Residents form identified a census of 118 residents.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent the development of avoidable pressure ulcers for two Residents (R#19, R#11) and provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one Resident (R#9), of 24 residents reviewed for pressure ulcers. 1) R#19 had a history of [REDACTED].#19 for four weeks. When staff performed a skin assessment on R#19 at surveyor's request, a previously unidentified and untreated avoidable Stage II (2) pressure ulcer was discovered on R#19's left medial buttock. 2) R#11 had a history of [REDACTED].#11 for two weeks. When staff performed a skin assessment on R#11 at surveyor's request, a previously unidentified and untreated avoidable Stage 2 pressure ulcer was discovered on R#11's left inner buttock. A shear to R#11's right medial buttocks had deteriorated to a larger Stage 2 pressure ulcer. 3) R#9 had a Stage IV (4) pressure ulcer to the left lateral foot. The facility did not perform weekly skin assessments on R#9 for three months. The facility did not provide heel lifters to bilateral feet as called for in R#9's care plan and physician's orders [REDACTED]. These failures could place all 33 residents identified as at high risk for development of pressure ulcers at risk for worsening of current pressure ulcers or development of new pressure ulcers. The findings were: 1) Record review of R#19's Face Sheet dated 01/14/16 revealed R#19 was admitted to the facility on [DATE] and readmitted on [DATE]. R#19's [DIAGNOSES REDACTED]. Record review of R#19's Minimum Data Set (MDS) assessment dated [DATE] revealed R#19: -was able to make herself understood, -had OK long and short term memory, -weighed 120 pounds, -was at risk for developing pressure ulcers, and -did not have any Stage 1 or higher pressure ulcers. Record review of R#19's Admission assessment dated [DATE] revealed R#19 was readmitted to the facility with a community acquired pressure ulcer to the right heel. There was no skin breakdown or pressure ulcer noted to R#19's left medial buttocks on readmission. Record review of R#19's Care Plan dated 12/01/15 revealed R#19 was at risk for skin breakdown due to limited mobility and Diabetes. Goal and target date: Will be free from skin breakdown through next review on 03/15/16. Approaches: -Panacea pressure relieving mattress to alleviate pressure -Evaluate for need of pressure relieving devices as indicated -Braden scale skin assessment every 3 months or as indicated -May use positioning/pressure relieving devices as indicated (pillows/cushions/heel protectors/sheep skin etc). Record review of R#19's undated Skin Assessment Sheet revealed the last documented skin assessment for R#19 was 12/16/15. Record review of R#19's MDS assessment dated [DATE], after readmission on 12/01/15, revealed: -was able to make herself understood, -had OK long and short term memory, -weighed 106 pounds, -had weight-loss, but was not on a physician-prescribed weight loss regimen, -was continent of bowel and bladder, -required one person assistance with bed mobility, transfers, dressing, toilet use, -was not at risk of developing pressure ulcers, and -had a Stage 1 or higher pressure ulcer. On 01/14/16 at 11:35 a.m., surveyor requested to check R#19's skin condition. Surveyor, accompanied by Licensed Vocational Nurse (LVN) D, observed R#19 lying in bed awake. Surveyor observed as LVN D performed a skin assessment on R#19. During the skin assessment, surveyor noted that R#19 had an open area to the left medial buttock. In an interview on 01/14/16 at 11:45 a.m., LVN D said the open area found on R#19 had not been reported and was a new finding. At this time, LVN D asked Certified Nurse Aide (CNA) M if she had seen the open area on R#19's buttock. CNA M said she had not. LVN D said she had not assessed R#19's skin during her rounds, so she was not aware of the open area. Physician order [REDACTED]. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) to left medial buttocks with wound cleanser, pat dry, apply hydrogel, and cover with dry dressing daily. In an interview on 01/14/16 at 11:55 a.m., R#19 said she had informed someone already that she had burning to her bottom. She said she did not recall who she told, but stated that she did remember telling someone. R#19 said her wheelchair had a cushion, but that it was not enough. Observation on 01/14/16 at noon revealed a cushion on R#19's wheelchair and a panacea pressure relieving mattress on her bed. Record review of Wound Assessment sheet dated 01/14/16 for R#19 revealed the following: -Left Medial Buttocks Stage II Pressure Ulcer -Onset/Discovery: 01/14/16 - noted after admission -Wound Tissue: Granulated 100% -Drainage: light -Surrounding tissue: reddened -Healing Progress: (New Area) -Current Treatments: Hydrogel -Length: 2.4 cm -Width: 1.0 cm 2) Record review of R#11's Face Sheet dated 01/11/16 revealed R#11 was readmitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of R#11's January 2016 physician's orders [REDACTED]. Record review of R#11's Care Plans revealed: - Problem onset of 07/14/13: At risk for skin breakdown due to limited mobility related [MEDICAL CONDITION]([MEDICAL CONDITION] - stroke) with left sided weakness. Resident is very heavyset and unable to move without assistance. Resident is also frequently incontinent of bowel and bladder. Resident with potential friction/shear problem. - 09/09/15 - New order for Panacea foam seat cushion. Record review of R#11's Care Plans revealed: -Problem onset 11/26/15: Stage 2 ulcer to right upper medial buttock. Record review of physician's orders [REDACTED]. (every day) a.m. shift p.r.n. (as needed). Record review of R#11's quarterly MDS assessment dated [DATE] documented R#11: -was understood by others and able to understand others, -had adequate long and short term memory, -did not reject care, -required extensive assistance for transfers, dressing, toileting and personal hygiene, and -was frequently incontinent of bowel and bladder -was at risk of developing a pressure ulcer, and -had a Stage 2 pressure ulcer. Record review of R#11's skin assessments for December 2015 indicated: -12/19/15 at 1:05 p.m. - Decubitus: Yes (see wound/decubiti folder). -12/31/15 at 10:32 a.m. - Discontinued. There were no documented skin assessments for R#11 after 12/31/15. In an interview on 01/14/16 at 4:00 p.m., the DON said the entry of Discontinued on 12/31/15 at 10:32 a.m. meant R#11's Stage 2 to the right upper medial buttock had healed and the treatment had been discontinued. Record review of R#11's nurse's notes dated 01/12/16 at 1:45 p.m. revealed R#11 was found with a new onset shear to the right medial buttock, measuring 0.7 cm (centimeter) by 1.5 cm. Record review of R#11's Physician's Telephone Orders dated 01/13/16 (no time) revealed an order to apply [MEDICATION NAME] barrier to right medial buttock shear every shift and as needed. On 01/13/16 at 3:20 p.m., surveyor requested to observe the condition of R#11's skin. LVN F and surveyor observed R#11's skin in the shower room. Surveyor observed R#11 had open, reddish and non blanchable areas, Stage 2 pressure ulcers, one to the right inner buttocks and one to left inner buttocks. LVN F said they instructed R#11 on the importance of lying down in bed to help alleviate pressure, but R#11 was non-compliant and only wanted to be on the wheelchair. On 01/13/16 at 3:30 p.m., LVN E was called to the shower room. LVN E said R#11 had shearing to the buttocks that was reported on 01/12/16. LVN E said she had not been made aware of any other issues with R#11. LVN E examined R#11 at this time and stated that the shearing had worsened and she would have to call R#11's Primary Physician to let him know. LVN E said there was no one in-house who could stage the wound. LVN E said she would call the Physician and describe R#11's wound over the phone so that the Physician could stage it and then order the treatment he felt would be effective to help resolve the wound. Record review of nurse's notes date 01/13/16 at 6:44 p.m. documented R#11 had a Stage 2 ulcer to the left inner buttock measuring 3 cm by 3 cm and depth of 0.1 cm and a Stage 2 ulcer to right inner buttock measuring 2 cm by 2 cm with depth of 0.5 cm. Record review of telephone order dated 01/13/16 at 6:15 p.m. documented to cleanse stage II decubitis ulcer to left buttock with wound cleanser, pat dry and apply hydrogel and cover with dressing until resolved. Cleanse stage II ulcer to right inner buttock with wound cleanser, pat dry and apply hydrogel and cover with dry dressing daily until resolved. On 01/13/16 at 4:58 p.m., surveyor conducted an interview with CNA N. CNA N said she was, .supposed to report any change in skin condition. Need to report redness or change in condition to charge nurse. CNA N said she gives a verbal report to the nurse and the nurse will document and follow up on the report. In an interview on 01/14/16 at 4:00 p.m., the DON said skin assessments were to be done weekly. The DON said, if a resident was scheduled for a skin assessment, the 6:00 a.m. - 2:00 p.m. shift nurse had to conduct the skin assessment. The DON said the CNAs were trained on what to report regarding changes in skin conditions. The DON said the CNAs did not document information; all information was verbally given to the nurses. In an interview on 01/15/16 at 9:00 a.m., the DON said she had done one-to-one counseling with her nurses. The DON said the nurses had told DON that they had done the skin assessments, but had not documented the assessments. The DON said she told nurses if the assessments had not been documented, then they were not done. 3) Record review of R#9's Face Sheet dated 01/11/16 revealed R#9 was admitted to the facility on [DATE] and readmitted on [DATE]. R#9's [DIAGNOSES REDACTED]. Record review of R#9's Annual MDS assessment dated [DATE] revealed: -Hearing-adequate-no difficulty in normal conversation, social interaction, listening to TV, -Makes self understood-usually understood, -Ability to understand others-usually understands, -Transfer-total dependence with two persons physical assist, -Dressing-extensive assistance with two persons physical assist, -Eating-total dependence with one person physical assist, -Personal hygiene-total dependence with one person physical assist, and -Bathing-total dependence with one person physical assist. -Active Diagnoses: [REDACTED]. -Current number of unhealed pressure ulcers at each stage: 1 stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling). Record review of facility Skin Assessment Policy and Procedure documented the definition of unstageable as, Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green, or brown or black) and/or eschar (tan, brown, or black) in the wound bed. Stable (dry adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Record review of computer printout of R#9's physician's orders [REDACTED]. Record review of R#9's care plan dated 07/02/15 revealed that, on 05/28/15, R#9 had necrosis to the left lateral foot and was at risk for further deterioration. R#9 was on palliative care. The pressure ulcer became a Stage 4. Goal and Target date: Will not experience signs/symptoms of infection to site 04/04/16 Approaches: -Treatment as ordered with weekly skin checks with documentation. -Keep pressure off wound. -Off load heels. -Heel lifters at all times. Float heels while in bed. Record review of R#9's care plan dated 12/15/15 revealed that, on 12/04/15, the pressure ulcer to R#9's left lateral foot became unstageable. Approaches: -Treatment as ordered with weekly skin checks with documentation. -Keep pressure off wound, -Off load pressure to bilateral heels Record review on 01/14/16 of a computer printout dated 01/13/16 revealed there were no skin assessments completed on R#9 from 01/02/15 until 04/01/15. -R#9's skin assessment on 05/28/15 at 09:47 a.m. indicated, Decubitus: Yes (see wound/decubiti folder) site: left lateral foot (unstageable due to necrosis) and right medial ankle redness. -R#9's skin assessment on 07/21/5 indicated, Decubitus: Yes (see wound/decubiti folder) left foot. -R#9's skin assessment on 08/26/15 indicated, Decubitus: none. -There were no skin assessments completed for R#9 from 08/26/15 to 01/11/16. -R#9's next documented skin assessment was on 01/12/16 at 9:01 p.m., which indicated, Skin problems: stage IV to left lateral foot, scabbed skin tear to left arm, old scab to right heel. Record review of a computer printout of wound assessments dated 12/18/15 at 5:19 p.m. indicated: Wound type: stage 4, drainage: moderate serosanguinous, length: 1 cm (centimeter) and width: 1.5 cm. Record review of a computer printout of physician's orders [REDACTED].#9 indicated: 01/13/16 Bed cradle when in bed at all times to promote wound healing, alleviate pressure to wound (Stage IV to left lateral foot) am shift pm shift noc shift first date: 01/13/16. Observation on 01/11/16 at 3:35 p.m. revealed R#9 up to his wheelchair near the nurse's station. A heel lifter was noted on his left foot but no heel lifter was noted on his right foot. Observation on 01/12/16 at 8:45 a.m. revealed R#9 was lying in bed awake. A heel lifter was noted to his left foot but no heel lifter was noted on his right foot. Observation on 01/12/16 at 2:49 p.m. revealed R#9 was lying in bed awake. Prior to wound care surveyor noted only one heel lifter on his left foot. No heel lifter was noted on his right foot. Surveyor observed LVN M provide R#9 with wound care to his left foot. Surveyor noted an open area to be reddish/pinkish, with a small amount of serosanguinous (yellowish with small amounts of blood) drainage. Observation on 01/13/16 at 4:00 p.m. revealed R#9 was sitting on his wheelchair near the nurse's station. A heel lifter was noted on his left foot but no heel lifter was noted on his right foot. In an interview on 01/13/16 at 4:10 p.m., LVN E said R#9 should have bilateral heel lifters on. In an interview on 01/14/16 at 4:00 p.m., the Director of Nurses (DON) said R#9's skin assessments were scheduled to be done on the evening shift. The DON said she was aware that no skin assessments were done from January 2015 through April 2015 and from August 2015 until January 2016. Record review of the facility's Skin Assessment Policy and Procedure dated February 2013 revealed: Policy: It is the policy of the facility to document skin problems including new areas of concern and/or progression of the ongoing skin problem. Procedure: 01. The skin assessment profile form will be completed on residents when: a. New admission with skin problems. b. Weekly. c. New skin problems. Record review of the facility's Pressure Ulcer-Prevention Procedure, revised in 2013 revealed: Objective: To prevent and treat pressure sores. Care Prevention and Interventions: Repositioning and Support Surfaces: . 06. Keep residents off the reddened areas of skin . 09. Raise heels of bed bound residents off the bed using either pillows or heel protection device . 11. Use bed cradle to relieve pressure of clothing. The facility's Roster/Sample Matrix 802 form identified 33 residents at high risk for pressure ulcers.