BUENA VIDA NURSING AND REHAB-SAN ANTONIO

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the residents' right to be free from neglect for 1 of 8 residents (Resident #1) reviewed for neglect in that: 1. Resident #1 was not provided wound care daily to the left ankle or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. Resident #1 was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. 2. Resident #1 went for approximately one month without adequate treatment for wounds which led to infection and right BKA. 3. The facility failed to ensure Resident #1 was provided with wound care to a surgical wound on the resident's right leg. 4. The ADON failed to ensure wound care treatment orders were added to Resident #1's EMR. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect, worsening of existing wounds or the development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 1. Unstageable left lateral, (outer) ankle, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. 2. Unstageable right heel, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September WAR/TAR orders revealed orders, keep dressing clean, dry intact. Do not remove, do not get wet. Cover to shower, every shift for surgical wound and monitor right leg stump for signs and symptoms of infection every shift for surgical wound, with a start date of 08/19/2025. The WAR/TAR administration record for these orders was not initialed as completed on 09/07/2025 at 11 p.m. and 09/13/2025 on 3 p.m.- 11 p.m. Further review revealed there were no wound treatment orders for the left ankle. Record review of Resident #1's EMR revealed Resident #1 had a readmission initial skin assessment, dated 08/19/2025, that had yes checked for surgical incision. The assessment did not identify any other wounds and was not signed. Resident #1 had no additional weekly skin assessments or weekly pressure ulcer assessments through the end of August and during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Further review revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had a Stage IV pressure wound (a wound that has full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) of the left, lateral ankle and measured 3.5cm x 2.5 cm x 0.1 cm with a surface area of 8.75cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The goal of the treatment was healing evidenced by a 75% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Further review revealed Resident #1 had an (unstageable (due to necrosis) of the right heel (signing off-area has been amputated). The etiology revealed pressure and stage was unstageable necrosis. Record review of wound care physician assessment, dated 09/02/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3 cm x 2.5 cm x 0.5 cm with a surface area of 7.50 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 30 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 30 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 30 days. The goal of the treatment was healing evidenced by a 14.3% decrease in surface are within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/09/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.5 cm x 0.5 cm with a surface area of 8.75 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 23 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 23 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 23 days. The assessment revealed, Thorough review of history performed, including speaking with nursing staff for further information and Coordination of care and plan for this wound discussed with nursing staff for further information. Record review of Resident #1's Nurse Practitioner (NP) progress notes, dated 09/09/2025, revealed, surgical dressing orders reinforced; stump dressing remains clean/dry/intact without drainage. Record review of an outpatient clinic wound progress note, dated 09/15/2025, revealed, Veteran seen in clinic today with [physician name]. Veteran is at [facility name]. Wound dressings are soiled, and odor present to left foot dressing. The wound assessment revealed a stage IV pressure ulcer to the left lateral malleolus (bony prominence on the outer side of the ankle) measuring 4.0 cm x 4.5 cm x 0.5 cm. The assessment revealed a DTI pressure ulcer (deep tissue injury characterized by damage to tissue underneath intact skin) inferior (inside) to left lateral malleolus measuring 6.7 cm x 7.0 cm x 0.0 cm. The wound assessment identified the right BKA and revealed the wound bed sutures were in place and no drainage noted. Record review of wound care physician assessment, dated 09/16/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.9 cm x 0.5 cm with a surface area of 10.15 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 16 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 16 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 16 days. The goal of the treatment was healing evidenced by a 66.7% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. The assessment revealed, the patient's plan of care was discussed with patient assigned nurse. Record review of wound care physician assessment, dated 09/23/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 5.0 cm x 4.0 cm x 0.5 cm with a surface area of 20.00 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The assessment included an arterial wound (skin injury caused by poor blood circulation) of the left, distal (outer), lateral foot that was arterial and measured 1.5 cm x 1.7cm x 0 and described as a scab. Record review of Resident #1's podiatry progress note, dated 09/24/2025, revealed, patient presents to clinic in a stretcher for left lateral ankle decubitus ulcer (caused by prolonged pressure to an area). The note revealed the left lateral ankle pressure ulcer measured 2.5 cm x 3.0 cm on 09/04/2025 and measured 3.5 cm x 3.5 cm on 09/24/2025. The wound was described as necrotic (death of tissue) in the peri wound (tissue surrounding a wound), had purulent drainage (a skin of infection. Thick milky fluid that comes out of a wound) noted and revealed the fibula bone (long slender bone in the lower leg) was exposed. The assessment revealed a left lateral ankle pressure ulcer stage 4 and history of right BKA. The plan revealed purulent drainage, malodor (offensive odor), necrotic wound base (dead or dying cells and tissues within a wound that are no longer able to carry out their normal function), and exposed fibula notified to left lateral ankle wound. Due to this and high risk right BKA patient was advised to go to [hospital] ED for further workup. Patient was transported via [ambulance]. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, sutures in place from R BKA, central area with small area of chronic weeping wound (a type of wound that produces clear fluid, blood, or pus that seeps from the injured area), no cellulitis (bacterial infection of the skin and soft tissues causing swelling, redness and pain), no pain, or crepitus extending proximally (air inside body tissues that can cause popping or cracking sounds). Left ankle with 4 cm lateral wound with exposed lat al, appears to track to joint (tunneling of wounds underneath the skin). CT imaging of the LLE revealed, lateral malleolus soft tissue ulceration which extends to the bone. Osteomyelitis (infection in the bone) of the distal fibula. Septic tibiotalar joint (infection in the joint of the ankle) with associated osteomyelitis of the tibia and talus (small bone in the ankle). CT of RLE revealed, no evidence of active osteomyelitis at this time. No evidence of soft tissue gas. The disposition plan was to admit Resident #1 to the hospital for further management and stabilization with the diagnosis of osteomyelitis of the left ankle and stated a surgical intervention was scheduled for the following day. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility progress note, dated 09/25/2025 at 12:48 a.m. by RN G, revealed, received report that patient is out to a doctor's appointment. At this time, the patient still out. Reported to administrator. There were no other relevant progress notes related to Resident #1's wounds observed in the progress notes. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and also revealed for other skin findings, L ankle covered with dressing, L foot art. Wound. Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses were, osteomyelitis of left ankle status post (a patients condition after a specific procedure, treatment or event) left below knee amputation, completed 09/24/2025 and history of right below knee amputation status post right below knee amputation incision and drainage by orthopedic surgery. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to LBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Monitor surgical incision to RBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with the hospital case manager, 09/30/2025 at 3:08 p.m., the hospital case manager stated Resident #1 was sent to the hospital directly from a doctor's appointment on 09/24/2025 due to Resident #1 having an infection in his left leg wound and stated Resident #1 had to have a below the knee amputation. The hospital case manager stated an outpatient wound nurse would go to the facility to see Resident #1 approximately once a week. She stated the outpatient wound care nurse would have to perform wound care for Resident #1 because it was not getting done by the facility and observed Resident #1 with no treatment dressings to his left ankle. The hospital case manager stated the outpatient wound care nurse discussed her concerns with nurses providing care and with the ADON/LVN, but nothing was done about it. The hospital case manager expressed concern over Resident #1's lack of wound care that resulted in an amputation. During an interview with LVN T, 10/02/2025 at 9:50 a.m., LVN T stated Resident #1 had orders for wound care for his right amputated knee and stated she did not provide wound care to Resident #1's left foot in the month of September because he did not have any orders. LVN T stated she followed the physician orders for the right stump. LVN T was aware of the wound to the left foot because LVN T stated the wound had had black tissue (dead or dying tissue) but did not report it to anyone including the physician, because everyone already knew. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with LVN B, 10/02/2025 at 10:51 a.m., LVN B stated he was assigned to Resident #1 and had been assigned to work with Resident #1 on previous shifts. LVN B stated he was aware that Resident #1 had a right BKA and wounds to his left foot and did not recall Resident #1 having treatment orders for his left foot. LVN B stated the nurses were responsible for performing wound care and completing skin assessments if the wound care nurse was not available. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated he just returned from the hospital and said, they amputated my left foot so now I have no feet. Resident #1 stated his right foot was amputated about a month ago and stated the left foot was amputated because it was infected. Resident #1 stated the doctors at the hospital just told him his foot was infected, and he stated he was glad that the infection did not go up further into his body. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1 stated staff were checking his right stump when he returned from the hospital after the right BKA but stated he did not recall any staff members providing wound dressings to his left foot in the last month. During an interview with CNA F, 10/02/2025 at 1:13 p.m. CNA F stated she was aware that Resident #1 had wounds on his left foot and stated she was in his room a day or two before he went to the hospital on [DATE]. CNA F stated Resident #1's left foot had an odor, and she would have to open the window to let the stench out of the room. CNA F stated Resident #1 told her he could not feel his leg and Resident #1 told CNA F that he thought it was getting infected and stated, he could also smell it and asked me to open the window. CNA F stated she told LVN H that Resident #1's foot had an odor when CNA F would give him bed baths. CNA F stated she thought other CNAs reported the wound odor to the nurses as well but could not confirm. During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. ADON/LVN stated when she transitioned to ADON/LVN the charge nurses were responsible for wound treatments and the charges nurses would follow the physician orders for wound care. The ADON/LVN stated Resident #1 was being followed by a wound care physician and the wound care physician would write wound orders in the wound care physician's progress notes and the progress notes were uploaded into the resident EMR. The ADON/LVN stated that she was responsible for reviewing the wound care physician notes and entering new wound care orders into a resident's EMR. The ADON/LVN stated, it's me, I am responsible for all the systems, and we should have a DON, but we don't, so I missed it. The wound care physician comes on Tuesday, and I will look in the system the next day to see if she saw any patients. IF there are new orders I go in and update them, but she does not change the orders often, so I didn't verify them every single week. ADON/LVN stated Resident #1 did not have wound care orders in his administration record and charge nurses would not have known to do wound care if there were no wound care orders. The ADON/LVN stated she performed wound care for Resident #1's left ankle wound several days during the month of September but did not know what days and did not document the wound care. The ADON/LVN stated she followed the orders in the wound care physician progress notes to complete the treatments for Resident #1 and stated she should have reviewed Resident #1's treatment orders and added the wound orders into Resident #1's orders at that time. The ADON/LVN stated the nurses were responsible for completing weekly skin assessments. The ADON/LVN stated she was responsible for completing the pressure ulcer assessments and no pressure ulcer assessments were completed for Resident #1 during September. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated it was important for residents to have treatment orders for their wounds, so the wound did not worsen or get infected. The ADON/LVN stated Resident #1 did not have any weekly skin assessments or pressure ulcer assessments during the month of September and stated she was responsible for monitoring the UDAs to ensure they were completed weekly. During an interview with the RCN, 10/02/2025 at 4:05 p.m., the RCN stated she became aware of a concern regarding Resident #1's wound care the prior night, 10/01/2025, when the RCN was reviewing Resident #1's clinicals and found that Resident #1 did not have wound care orders for his left ankle prior to his hospitalization and amputation of the left BKA. The RCN stated the concern was identified as neglect and reported the incident to HHSC. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was aware that Resident #1 had an amputation of his right leg, a few weeks ago and LVN L stated she did not recall any wound care orders for him and there was really not anything documented in the computer for what to do about the stump. LVN L stated she observed the stump on several occasions and stated that every time she observed the stump it did not have a dressing on it. LVN L stated she was unaware of Resident #1 having any wounds on his left foot and did not recall any treatment orders for his left foot. LVN L stated LVN N told her last week that Resident #1's stump was red and warm and stated LVN N reported the stump concern to nursing management. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was notified by a CNA that Resident #1's stump did not have a dressing on it and LVN N reviewed Resident #1's orders and recalled an order for the stump to have a wound dressing and to be kept clean and dry and stated Resident #1 had no other treatment orders. LVN N stated she did not recall the wound being red or warm and did not recall reporting an issue with Resident #1's stump. During an interview with CNA Q, 10/03/2025 at 8:35 a.m., CNA Q stated she had worked at the facility for two months and CNA Q stated she would help get Resident #1 ready for doctor appointments and stated she did not observe any wound care bandages on Resident #1's left foot. During an interview with LVN H, 10/03/2025 at 8:49 a.m., LVN H stated she was not sure if Resident #1 had any wounds, did not perform any wound care for Resident #1 and stated she never observed any wound care orders for Resident #1. During an interview with the Nurse Practitioner, 10/03/2025 at 10:42 a.m., the Nurse Practitioner stated when a resident returns from the hospital with wounds and no wound care orders, the nursing staff should have reassessed and measured the wounds, and a nurse should have called to get wound care orders. The Nurse Practitioner stated Resident #1 should have had wound care treatments completed daily and stated the lack of wound care treatments daily could have led to a catastrophic event. With such a complicated medical history, yes, it is very possible for lack of wound care to have led to that and worse. The Nurse Practitioner stated the facility wound care had room for improvement. During an interview with the Wound Care Physician, 10/03/2025 at 12:11 p.m., the Wound Care Physician stated that any changes in treatment orders were documented in her progress notes and uploaded into a resident's EMR and stated she did not have access to view resident orders. The Wound Care Physician stated it was up to the facility as to who was responsible for adding the Wound Care Physician orders into a resident's administrative orders and stated in most facilities it was completed by the Wound Care Nurse or the ADON. The Wound Care Physician stated she had concerns about the wound care performed for Resident #1 because he would have wound dressings that were not dated and there was no way for the Wound Care Physician to know when the treatment was completed. The Wound Care Physician stated Resident #1 should have had daily wound care treatments and stated Resident #1's wound had declined prior to Resident #1 going to the hospital on [DATE]. The Wound Care Physician stated leaving a wound dressing in place too long for Resident #1 could lead to infection for someone like him who had multiple other comorbidities and is vascular compromised and that can lead to wound deterioration and risk of infection. The Wound Care Physician stated a lack of daily wound care could have contributed to Resident #1 being admitted to the hospital with sepsis, osteomyelitis, and an amputation. The Wound Care Physician stated she would do a wound dressing for Resident #1 when she assessed him but stated she would only see him weekly. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated resident skin assessment should be completed by the nursing staff on admission, readmission and weekly. The Administrator stated it was important to complete weekly skin assessments because, it tells us if there is skin breakdown, wounds, pressure, etc. and we can monitor to see if skin is changing and what the baseline of the patient is and what the integrity of the skin is and to make sure the skin is taken care of because if you don't, it can lead to infection, sepsis, etc. During an interview with the Administrator, 10/03/2025 at 4:31 p.m., the Administrator stated that the lack of wound care for Resident #1 was neglect because it was a failure of the facility to not inquire about Resident #1's wound care and treatments and stated, all around, the staff were not doing their due diligence to take care of the wound. During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. Record review of an undated facility policy titled, Documentation, revealed, Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). The procedure revealed, document completed assessments in a timely manner and per policy. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. Record review of facility wound treatment management policy, revised 05/05/2025, revealed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse and treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Record review of the facility's undated abuse and neglect policy revealed, neglect is 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. This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal F600 Problem: The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE OR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with surgical wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 8 residents (Resident 1) reviewed for surgical wounds in that: Resident #1 did not have weekly skin assessments during the month of September 2025, did not receive care to the right surgical wound as ordered by the physician and was admitted to the hospital on [DATE] with an infection to Resident #1's right below the knee amputation. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing surgical wounds or development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 2. Unstageable right heel, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September 2025 WAR/TAR revealed orders, start date 08/19/2025, keep dressing clean, dry intact. Do not remove, do not get wet. Cover to shower, every shift for surgical wound and monitor right leg stump for signs and symptoms of infection every shift for surgical wound. The WAR/TAR administration record for these orders was not initialed as completed on 09/07/2025 at 11 p.m. and 09/13/2025 on 3 p.m.- 11 p.m. Record review of Resident #1's EMR revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had an (unstageable (due to necrosis) of the right heel (signing off-area has been amputated). The etiology revealed pressure and stage was unstageable necrosis. Record review of Resident #1's Nurse Practitioner (NP) progress notes, dated 09/09/2025, revealed, surgical dressing orders reinforced; stump dressing remains clean/dry/intact without drainage. Record review of an outpatient clinic wound assessment progress note, dated 09/15/2025, revealed, Resident #1 had a right BKA and the wound bed sutures were in place and no drainage noted. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, sutures in place from R BKA, central area with small area of chronic weeping wound (a type of wound that produces clear fluid, blood, or pus that seeps from the injured area), no cellulitis (bacterial infection of the skin and soft tissues causing swelling, redness and pain), no pain, or crepitus extending proximally (air inside body tissues that can cause popping or cracking sounds). CT of RLE revealed, no evidence of active osteomyelitis at this time. No evidence of soft tissue gas. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and revealed, Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses revealed, history of right below knee amputation status post right below knee amputation incision and drainage by orthopedic surgery. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to RBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated his right foot was amputated about a month ago. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1 stated staff were checking his right stump when he returned from the hospital after the right BKA During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. The ADON/LVN stated the charge nurses were responsible for completing weekly skin assessments and the ADON/LVN was responsible for completing the pressure ulcer assessments. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated Resident #1 did not have any weekly skin assessments or pressure ulcer assessments during the month of September and stated she was responsible for monitoring the UDAs to ensure they were completed weekly. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was aware that Resident #1 had an amputation of his right leg, a few weeks ago and LVN L stated she did not recall any wound care orders for him and there was really not anything documented in the computer for what to do about the stump. LVN L stated she observed the stump on several occasions and stated that every time she observed the stump it did not have a dressing on it. LVN L stated she was unaware of Resident #1 having any wounds on his left foot and did not recall any treatment orders for his left foot. LVN L stated LVN N told her last week that Resident #1's stump was red and warm and stated LVN N reported the stump concern to nursing management. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was notified by a CNA that Resident #1's stump did not have a dressing on it and LVN N reviewed Resident #1's orders and recalled an order for the stump to have a wound dressing and to be kept clean and dry and stated Resident #1 had no other treatment orders. LVN N stated she did not recall the wound being red or warm and did not recall reporting an issue with Resident #1's stump. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated resident skin assessment should be completed by the nursing staff on admission, readmission and weekly. The Administrator stated it was important to complete weekly skin assessments because, it tells us if there is skin breakdown, wounds, pressure, etc. and we can monitor to see if skin is changing and what the baseline of the patient is and what the integrity of the skin is and to make sure the skin is taken care of because if you don't, it can lead to infection, sepsis, etc. During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. Record review of an undated facility policy titled, Documentation, revealed, Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). The procedure revealed, document completed assessments in a timely manner and per policy. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal Problem: The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE ORDERS MATCH. THIS MONITORING WILL BE INIATED [sic] ON 10/7/25 AND INDEFINATELY [sic]. CNAs INSERVICED ON REPORTING ALL NEW SKIN ISSUES TO NURSE ASAP AND DOCUMENTING THE FINDING/ALERT IN THE KIOSK ON 10/4/25 BY REGIONAL COMPLIANCE NURSE. CNAs INSERVICED ON S/SX OF SKIN BREAKDOWN, COMMON PRESSURE AREAS, AND PREVENTION ON 10/4/25 BY REGIONAL COMPLIANCE NURSE NURSES WERE INSERVICED ON COMPLETING SKIN ASSESSMENTS ON ADMISSION/readmission AND WEEKLY THEREAFTER, PER THE SCHEDULE PROVIDED. MANAGERS INSERVICED TO REVIEW CLINICAL ALERTS IN DAILY STAND UP TO MONTIOR FOR NEW WOUNDS, CHANGES IN WOUND, AND DECLINING WOUNDS. The medical director [physician] was notified of the immediate jeopardy situation on 10/4/2025 at 1:25 pm. MonitoringThe DON / designee will view each wound weekly AND ENDURE [sic] CORRECT ORDER IS IN PLACEThe DON / designee will audit all skin assessments and Weekly ulcer assessments weekly to ensure all assessment match the resident's current condition weekly.DON/Designee will audit all skin assessments and ulcer assessments weekly to ensure all residents received an assessment.DON/Designee will review all admissions/readmissions within 24 hours of admission to ensure orders are transcribed correctly and appointments are scheduled.DON/Designee will review WAR for completion of ordered wound treatments DAILY IN STAND UPDON/Designee will assess all dressings to ensure date reflects current date 5 x week X 4 WEEKSRegional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks.The QA committee will review findings and makes changes as needed monthly.The Administrator/Designee will review during stand up meetings if there was any evidence of any potential Neglect and initiate investigation / Self Report to HHSCADO/Regional Compliance Nurse will monitor by participating in facility's weekly SOC meeting x 6 weeks and at least 1 x per month x 3 months or until compliance is met. Monitoring of the POR included the following: During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head to toe skin assessment for Resident #3 and #5. The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings. Record review of EMR UDA log revealed 63 resident names. The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed. Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present. Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN). Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with the training for reporting and identifying skin concerns, abuse and neglect and reporting grievances or concerns from outside care teams. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text. Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issues to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention. The in-service had 16 signatures. Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns. Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD. All [wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match. The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN. Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks. The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. DON/Designee will assess all dressings to ensure date reflects the current date of 5 x week. DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The QA committee will review the findings and make changes as needed monthly. Wound care monitoring will be reviewing in stand up and stand down. Wound care monitoring will be reviewed for holes/omissions daily in stand up and stand down. Admin personnel must ensure systems will have adequate coverage when position is vacated. The in-service was signed by the ADON/LVN, Administrator and Interim DON. Record review of a facility in-service tracking spreadsheet revealed 12 licensed nurses received in person training and 6 licensed nurses had not worked the floor and received a text message with the training for identifying, assessing, notification, skin assessments and treatments. Record review of the daily staffing schedules for 10/02/2025 - 10/05/2025 and 10/06/2025 6a-6p revealed that all licensed nurses had signed the in-service for licensed nurses. Record review of an in-service dated 10/2/2025, for licensed nurses, read Pressure ulcer prevention and treatment including providing treatment as ordered and initialing/dating dressings-see attached policy. Documentation and accurate assessment of pressure ulcers- see policy. Initiating wound orders per MDs and upon admission/readmission. If a CNA reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MDs of changes immediately. Notification of physician with change of condition immediately. The in-service was signed by 12 LVNs. Record review of an employee roster revealed 73 total employees. Record review of an in-service dated 10/02/2025 revealed the topic was abuse and neglect and revealed 40 employee signatures. Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation. The in-service revealed 62 signatures. During an interview with CNA R, 10/04/2025 at 9:43 a.m. CNA R stated she had received training on identifying wounds and reporting wounds to the charge nurse. During an interview with LVN P, 10/04/2025 at 11:56 a.m., LVN P stated she received training on wound care, following physician orders and abuse and neglect on 10/02/2025 and stated the training was provided by the RCN. During an interview with CNA U, 10/04/2025 at 12:13 p.m. CNA U stated she had received training on identifying wounds and abuse and neglect on 10/02/2025 and stated she would report any skin concerns to the charge nurse and report allegations of abuse to the Administrator. During an interview with the Administrator, 10/4/2025 at 3:30pm, the Administrator stated Admin/Personnel were identified as the Administrator, Interim DON, and ADON. The Administrator revealed the Medical Director was notified of the immediate jeopardy regarding neglect and wound care on 10/4/2025. The Administrator revealed monitoring forms were created to monitor the wound care processes and stated the DON/Designee will review wounds weekly to ensure the correct orders are in place, will audit skin assessments and weekly pressure ulcer assessments, review admission and readmissions within 24 hours of admission, review resident WAR/TAR weekly to ensure treatments are being completed and will observe resident wound dressing for accurate dates and validate that resident wounds have treatment orders in place. These findings will be documented on the monitoring forms and the findings will be brought to QA. The Administrator stated she received the training and education on expectations from the RCN on 10/4/25. During an interview with the Administrator, 10/05/2025 at 3:30 p.m., the Administrator stated staff in-servicing on abuse and neglect was initiated on 10/02/2025 and all staff that have worked since 10/02/25 have been educated on abuse and neglect. The Administrator stated staff were educated on types of abuse and neglect, who to report to, how soon to report and the importance of reporting complaints or concerns from visitors, vendors, etc. directly to the administrator. During interviews conducted on 10/05/2025 and 10/06/2025, included a total of 10 CNAs [CNA E, R, F, Q, LL, KK, X, LL, MM, NN] ( 5 - 6a-6p and 1 6p-6a) (2 6a-6p and 1 6p-6a who confirmed receipt of a text message with training on abuse and neglect [CNA LL, MM, NN]), 4 LVNs [LVN P, O, B, H] (2 6a-6p, 1 6p-6a, 1 PRN both shifts), 1 PRN 6p-6a RN [ RN J] who confirmed receipt for a text in-service on abuse and neglect, 1 RN [RN G] ( 6p-6a), 1 MDS/LVN, 1 BOM, 4 Dietary [Dietary Y, DD, EE, FF], 5 Housekeeping [Housekeeping Z, AA, BB, CC, JJ], 1 Maintenance Director, 2 Therapists [Therapy GG, HH], 1 Social Worker, 1 Activity Director, 1 Medical Records/Central Supply and 1 HR. Staff interviews revealed staff had received education on abuse and neglect and were able to provide examples of neglect Staff demonstrated understanding of reporting allegations of abuse and neglect directly to the administrator immediately and reporting any concerns or complaints to the Administrator immediately. During an interview with the Administrator, 10/04/2025 at 4:03 p.m., revealed the Administrator was educated by the ADO on 10/04/2025 on ensuring the DON/ADON reviewed new wound orders and validated the orders that were transcribed into PCC accurately by auditing an order listing report and the Administrator was to investigate and report to corporate and HHSC any incidents that may be considered abuse or neglect. During an interview with the RCN, 10/05/2025 at 9:45 a.m., the RCN revealed 100% resident skin rounds were completed on 10/02/2025 that included head to toe assessments of each resident. Skin assessments were completed with detailed findings and new orders were transcribed into [EMR]. The RCN revealed multiple in-services were initiated for CNAs, licensed nurses and administration/personnel and all staff currently working had been in-serviced by discipline. The RCN stated any staff that had not been in-serviced would be in-serviced prior to the start of their shift and the in-servicing was completed by the RCN and Administrator. The RCN stated CNAs were in-serviced on 10/04/2025 and ongoing on identifying skin breakdown, reporting skin issues to the nurse immediately and where to document new findings on the kiosk. The RCN stated licensed nurses were in-serviced on 10/02/2025 regarding pressure ulcer prevention and initialing and dating dressing, documentation and completing accurate assessments, initiating wound orders upon admission/readmission, immediately assessing and notifying the physician, documenting and obtaining treatment orders when notified or observing a new skin issue and notifying the physician immediately of changes in condition. The RCN stated all facility staff were in-serviced on abuse and neglect and reporting complaints directly to the Administrator. The Administrator/DON and ADON were educated on 10/04/2025 that the DON/Designee will round with the wound care physician weekly and will ensure orders are immediately entered into the EMR when the order is verbally given by the wound care physician and the progress notes will be printed 24 hours after the wound care physician visit to ensure the orders match in the EMR. The RCN revealed the Administrator, DON and ADON were educated on expectations monitoring of the plan of removal. The RCN stated monitoring forms were created to track the monitoring, and the DON/Designee was responsible for completing and documenting on the monitoring tool. Monitoring included viewing each wound weekly and making sure the correct orders were in place and round with the wound care physician weekly. Audit all skin and ulcer assessments weekly to make sure they match the resident's current condition and audit to make sure all residents have weekly skin assessments and ulcer assessments. Review admission/readmissions to ensure the orders are transcribed correctly and appointments were scheduled as needed. Review the administration record for the completion of ordered wound treatments from the previous day and ensure all dressing have the current date and are initialed. The monitoring forms will be reviewed, signed, and dated by the RCN weekly to validate it was being completed. The RCN and ADO will attend standard of care meetings weekly. Findings from the monitoring will be brought to QAPI monthly and reviewed for compliance and changes to the plan initiated as needed. During an interview with the ADO, 10/05/2025 at 10:50 a.m., revealed the ADO educated the Administrator on 10/04/2025 regarding checking orders daily in the morning meeting and ensuring the nursing managers were reviewing wound orders and validating the orders were transcribed into the EMR. During an interview with DON, 10/05/2025 at 11:48 a.m., revealed the DON received education and training from the RCN on 10/2/2025 and 10/4/2025 regarding expectations for rounding with the wound care physician weekly and validating daily in clinical review that resident treatment orders reflect the wound care physician progress notes, wound assessments are completed weekly and on admission and readmission, each resident has appropriate wound care orders, wound dressings are accurately dated and monitoring wound administration to ensure wound treatments are completed daily. The DON stated she would track the monitoring on a monitoring log and document her findings, and the findings would be brought to the monthly QAPI to review for compliance. During an interview with Medical Director, 10/5/2025 at 2:09pm, revealed the Medical Director and [physician] were notified of the immediate jeopardy for neglect and wound care by the Administrator on 10/04/2025 and the Medical Director reviewed the plan of removal, the protocols and steps being taken to ensure compliance. Record review of a monitoring document revealed, The DON/designee will view each wound weekly to ensure the correct order is in place. The document had 5 blocks with blanks for a date, resident name, and staff name. Record review of a monitoring document revealed, The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly. The document had 5 blocks with blanks for the date, weekly skin assessments correct YES/No, staff name. Record review of a monitoring document revealed, DON/Designee will review all admissions/readmissions within 24 hours of admission. The document had 5 blocks with blanks for date, resident name, admission complete YES/NO if no describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. The document had 5 blocks for date, resident name, WAR/TAR completed YES/No If no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will assess all dressing to ensure date reflects current date. The document had 5 blocks for date, resident name, Dressing dated correctly YES/NO if no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The document had 5 blocks for date, resident name, treatment orders in place YES/NO If no, describe on back of form and staff name. Record review of an ADHOC QAPI meeting, dated 10/2/2025 revealed signatures including the Administrator, Interim DON, and ADON. The Administrator was informed that the Immediate Jeopardy was removed on 10/06/2025 at 2:24 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 8 residents (Resident 1) reviewed for pressure ulcers in that: Resident #1 had a Stage IV pressure ulcer on his left ankle and did not have wound treatment orders in the month of September 2025. Resident #1 was admitted to the hospital on [DATE] with osteomyelitis and had a left below the knee amputation on 09/25/2025. An Immediate Jeopardy (IJ) was identified on 10/03/2025. The IJ template was provided to the facility on [DATE] at 4:53 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 1. Unstageable left lateral, (outer) ankle, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September 2025 WAR/TAR revealed no wound care treatment orders for the left ankle. Record review of Resident #1's EMR revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had a Stage IV pressure wound (a wound that has full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) of the left, lateral ankle and measured 3.5cm x 2.5 cm x 0.1 cm with a surface area of 8.75cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The goal of the treatment was healing evidenced by a 75% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/02/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3 cm x 2.5 cm x 0.5 cm with a surface area of 7.50 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 30 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 30 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 30 days. The goal of the treatment was healing evidenced by a 14.3% decrease in surface are a within the wound bed in comparison to the previous wound care visit.Record review of wound care physician assessment, dated 09/09/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.5 cm x 0.5 cm with a surface area of 8.75 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 23 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 23 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 23 days. Record review of an outpatient clinic wound progress note, dated 09/15/2025, revealed, Veteran seen in clinic today with [physician name]. Veteran is at [facility name]. Wound dressings are soiled, and odor present to left foot dressing. The wound assessment revealed a stage IV pressure ulcer to the left lateral malleolus (bony prominence on the outer side of the ankle) measuring 4.0 cm x 4.5 cm x 0.5 cm. The assessment revealed a DTI pressure ulcer (deep tissue injury characterized by damage to tissue underneath intact skin) inferior (inside) to left lateral malleolus measuring 6.7 cm x 7.0 cm x 0.0 cm. Record review of wound care physician assessment, dated 09/16/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.9 cm x 0.5 cm with a surface area of 10.15 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 16 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 16 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 16 days. The goal of the treatment was healing evidenced by a 66.7% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/23/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 5.0 cm x 4.0 cm x 0.5 cm with a surface area of 20.00 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The assessment included an arterial wound (skin injury caused by poor blood circulation) of the left, distal (outer) lateral foot that was arterial and measured 1.5 cm x 1.7cm x 0 and described as a scab. Record review of Resident #1's podiatry progress note, dated 09/24/2025, revealed, patient presents to clinic in a stretcher for left lateral ankle decubitus ulcer (caused by prolonged pressure to an area). The note revealed the left lateral ankle pressure ulcer measured 2.5 cm x 3.0 cm on 09/04/2025 and measured 3.5 cm x 3.5 cm on 09/24/2025. The wound was described as necrotic (death of tissue) in the peri wound (tissue surrounding a wound), had purulent drainage (a skin of infection. Thick milky fluid that comes out of a wound) noted and revealed the fibula bone (long slender bone in the lower leg) was exposed. The assessment revealed a left lateral ankle pressure ulcer stage 4 and history of right BKA. The plan revealed purulent drainage, malodor (offensive odor), necrotic wound base (dead or dying cells and tissues within a wound that are no longer able to carry out their normal function), and exposed fibula notified to left lateral ankle wound. Due to this and high risk right BKA patient was advised to go to [hospital] ED for further workup. Patient was transported via [ambulance]. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, left ankle with 4 cm lateral wound with exposed lat al, appears to track to joint (tunneling of wounds underneath the skin). CT imaging of the LLE revealed, lateral malleolus soft tissue ulceration which extends to the bone. Osteomyelitis (infection in the bone) of the distal fibula. Septic tibiotalar joint (infection in the joint of the ankle) with associated osteomyelitis of the tibia and talus (small bone in the ankle). The disposition plan was to admit Resident #1 to the hospital for further management and stabilization with the diagnosis of osteomyelitis of the left ankle and stated a surgical intervention was scheduled for the following day. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility progress note, dated 09/25/2025 at 12:48 a.m. by RN G, revealed, received report that patient is out to a doctor's appointment. At this time, the patient still out. Reported to administrator. There were no other relevant progress notes related to Resident #1's wounds observed in the progress notes. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and also revealed for other skin findings, L ankle covered with dressing, L foot art. Wound. Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses were, osteomyelitis of left ankle status post (a patient's condition after a specific procedure, treatment or event) left below knee amputation, completed 09/24/2025. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to LBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025. Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with the hospital case manager, 09/30/2025 at 3:08 p.m., the hospital case manager stated Resident #1 was sent to the hospital directly from a doctor's appointment on 09/24/2025 due to Resident #1 having an infection in his left leg wound and stated Resident #1 had to have a below the knee amputation. The hospital case manager stated an outpatient wound nurse would go to the facility to see Resident #1 approximately once a week. She stated the outpatient wound care nurse would have to perform wound care for Resident #1 because it was not getting done by the facility and observed Resident #1 with no treatment dressings to his left ankle. During an interview with the Interim DON, 10/1/2025 at 12:51 p.m. The Interim DON stated she started at the facility 3 days prior, and the previous DON had not worked in the facility for approximately 3 weeks. The Interim DON stated ADON/LVN was the prior wound care nurse and moved into the ADON/LVN position several weeks ago. During an interview with LVN C, 10/01/2025 at 2:03 p.m., LVN C said she was assigned to Resident #1's hall and stated she had not received training on completing wound care and stated the wound care nurse was responsible for wound care treatments and she thought the facility had a wound care physician but did not know who reported findings to the physician. LVN C stated if the wound care nurse was not in the facility, the charge nurses were responsible for completing wound care and LVN C said she would review a resident's administration orders in the EMR to determine what wound treatments are ordered. LVN C stated wound orders are located in a resident's EMR under the TAR or WAR section of the orders and the orders would detail the interventions to follow to provide wound care. LVN C stated if she were aware of a resident wound that did not have an order for treatment, she would have notified the wound care nurse or the ADON. LVN C stated she was not aware of any residents having wounds without orders and stated it was important for resident wounds to be treated, to prevent further breakdown of the skin and they could become septic. We want to stop infection. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated she knew when a resident had wounds because she would review a resident's physician orders and see if the resident had wound care treatment orders. LVN D stated the wound treatment nurse was responsible for wound treatments and if that person was not available, the charge nurses were responsible for wound care. LVN D stated she thought the ADON, or wound care nurse communicated directly with the wound care physician regarding resident wound progress and orders. LVN D stated resident wound care orders and treatments were listed in the EMR under the TAR/WAR for the residents and stated the ADON or DON were responsible for adding wound care orders to the TAR/WAR. LVN D stated it was important for residents to have wound care treatment orders if they had a wound, because if not, they could get an infection and get septic, and the wound will never heal if it does not get treated. LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with LVN B, 10/02/2025 at 10:51 a.m., LVN B stated he would look at a resident's treatment orders in the EMR to see if a resident had a wound and what treatment orders were to be administered for the resident. LVN B stated nurses were responsible for completing weekly skin assessments and performing wound care if the wound care nurse was not available. LVN B stated he was assigned to Resident #1 and had been assigned to work with Resident #1 on previous shifts. LVN B stated Resident #1 had wounds on his left leg. LVN B stated he would complete wound treatments for Resident #1 based on the wound treatment orders in the EMR and stated he was unaware of what treatment orders were in place for Resident #1. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated he just returned from the hospital and said, they amputated my left foot so now I have no feet. Resident #1 stated his right foot was amputated about a month ago and stated the left foot was amputated because it was infected. Resident #1 stated the doctors at the hospital just told him his foot was infected, and he stated he was glad that the infection did not go up further into his body. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1stated he did not recall any staff members providing wound dressings to his left foot in the last month. During an interview with CNA F, 10/02/2025 at 1:13 p.m. CNA F stated she was aware that Resident #1 had wounds on his left foot and stated she was in his room a day or two before he went to the hospital on [DATE]. CNA F stated Resident #1's left foot had an odor, and she would have to open the window to let the stench out of the room. CNA F stated Resident #1 told her he could not feel his leg and Resident #1 told CNA F that he thought it was getting infected and stated, he could also smell it and asked me to open the window. CNA F stated she told LVN H that Resident #1's foot had an odor when CNA F would give him bed baths. CNA F stated she would see a bandage on his left ankle at times but unable to recall dates or times. CNA F stated she thought other CNAs reported the wound odor to the nurses as well but could not confirm. During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. ADON/LVN stated when she transitioned to ADON/LVN the charge nurses were responsible for wound treatments and the charges nurses would follow the physician orders for wound care. The ADON/LVN stated Resident #1 was being followed by a wound care physician and the wound care physician would write wound orders in the wound care physician's progress notes and the progress notes were uploaded into the resident EMR. The ADON/LVN stated that she was responsible for reviewing the wound care physician notes and entering new wound care orders into a resident's EMR. The ADON/LVN stated, it's me, I am responsible for all the systems, and we should have a DON, but we don't, so I missed it. The wound care physician comes on Tuesday, and I will look in the system the next day to see if she saw any patients. IF there are new orders I go in and update them, but she does not change the orders often, so I didn't verify them every single week. ADON/LVN stated Resident #1 did not have wound care orders in his administration record and charge nurses would not have known to do wound care if there were no wound care orders. The ADON/LVN stated the charge nurses were responsible for completing weekly skin assessments and the ADON/LVN was responsible for completing the pressure ulcer assessments. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated it was important for residents to have treatment orders for their wounds, so the wound did not worsen or get infected. During an interview with LVN H, 10/02/2025 at 3:51 p.m., LVN H stated no one had reported Resident #1 having an odor to his left foot wound. During an interview with the RCN, 10/02/2025 4:05 p.m., the RCN stated she became aware of a concern regarding Resident #1's wound care the prior night, 10/01/2025, when the RCN was reviewing Resident #1's clinicals and found that Resident #1 did not have wound care orders for his left ankle prior to his hospitalization and amputation of the left BKA. The RCN stated the concern was identified as neglect and reported the incident to HHSC. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was unaware of Resident #1 having any wounds on his left foot, did not perform any wound care for Resident #1's left foot, and did not recall any treatment orders for his left foot. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was not aware of Resident #1 having any wounds on his left foot. LVN N stated she did not provide wound care for Resident #1's left foot and never observed anyone doing wound care for Resident #1's left foot. During an interview with CNA Q, 10/03/2025 at 8:35 a.m., CNA Q stated she had worked at the facility for two months and CNA Q stated she would help get Resident #1 ready for doctor appointments and stated she did not observe any wound care bandages on Resident #1's left foot. During an interview with LVN H, 10/02/2025 at 8:49 a.m., LVN H stated she did not perform any wound care for Resident #1 and stated she never observed any wound care orders for Resident #1. During an interview with the Nurse Practitioner, 10/03/2025 at 10:42 a.m., the Nurse Practitioner stated when a resident returns from the hospital with wounds and no wound care orders, the nursing staff should have reassessed and measured the wounds, and a nurse should have called to get wound care orders. The Nurse Practitioner stated Resident #1 should have had wound care treatments completed daily and stated the lack of wound care treatments daily could have led to a catastrophic event. With such a complicated medical history, yes, it is very possible for lack of wound care to have led to that and worse. The Nurse Practitioner stated the facility wound care had room for improvement. During an interview with the Wound Care Physician, 10/03/2025 at 12:11 p.m., the Wound Care Physician stated that any changes in treatment orders were documented in her progress notes and uploaded into a resident's EMR and stated she did not have access to view resident orders. The Wound Care Physician stated it was up to the facility as to who was responsible for adding the Wound Care Physician orders into a resident's administrative orders and stated in most facilities it was completed by the Wound Care Nurse or the ADON. The Wound Care Physician stated she had concerns about the wound care performed for Resident #1 because he would have wound dressings that were not dated and there was no way for the Wound Care Physician to know when the treatment was completed. The Wound Care Physician stated Resident #1 should have had daily wound care treatments and stated Resident #1's wound had declined prior to Resident #1 going to the hospital on [DATE]. The Wound Care Physician stated leaving a wound dressing in place too long for Resident #1 could lead to infection for someone like him who had multiple other comorbidities and is vascular compromised and that can lead to wound deterioration and risk of infection. The Wound Care Physician stated a lack of daily wound care could have contributed to Resident #1 being admitted to the hospital with sepsis, osteomyelitis, and an amputation. The Wound Care Physician stated she would do a wound dressing for Resident #1 when she assessed him but stated she would only see him weekly. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated the ADON/LVN was still responsible for doing wound care treatments 3 days out of the week and overseeing the wound care responsibilities after she transitioned to the ADON/LVN position. The Administrator stated it should have been communicated to the Wound Care Physician that Resident #1 did not have wound care orders to provide wound care and stated a resident who had a wound and no wound care orders could lead to an amputation of an extremity and cause infections and sepsis. Record review of facility wound treatment management policy, revised 05/05/2025, revealed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse and treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. 2. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. This was determined to be an Immediate Jeopardy (IJ) on 10/03/2025 at 4:20 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/03/2025 at 4:53 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 12:26 p.m.: Problem: The facility failed to ensure that a resident with pressure ulcers (Resident #1) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from development. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR] AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE ORDERS MATCH. THIS MONITORING WILL BE INIATED [sic] ON 10/7/25 AND INDEFINATELY [sic]. CNAs INSERVICED ON REPORTING ALL NEW SKIN ISSUED [sic] TO NURSE ASAP AND DOCUMENTING THE FINDING/ALERT IN THE KIOSK ON 10/4/25 BY REGIONAL COMPLIANCE NURSE. CNAs INSERVICED ON S/SX OF SKIN BREAKDOWN, COMMON PRESSURE AREAS, AND PREVENTION ON 10/4/25 BY REGIONAL COMPLIANCE NURSE NURSES WERE INSERVICED ON COMPLETING SKIN ASSESSMENTS ON ADMISSION/readmission AND WEEKLY THEREAFTER, PER THE SCHEDULE PROVIDED. MANAGERS INSERVICED TO REVIEW CLINICAL ALERTS DAILY STAND UP TO MONTIOR FOR NEW WOUNDS, CHANGES IN WOUND, AND DECLINING WOUNDS. The medical director [name] was notified of the immediate jeopardy situation on 10/3/2025 at 5:26 pm. MonitoringThe DON / designee will view each wound weekly AND ENDURE [sic] CORRECT ORDER IS IN PLACEThe DON / designee will audit all skin assessments and Weekly ulcer assessments weekly to ensure all assessment match the resident's current condition weekly.DON/Designee will audit all skin assessments and ulcer assessments weekly to ensure all residents received an assessment.DON/Designee will review all admissions/readmissions within 24 hours of admission to ensure orders are transcribed correctly and appointments are scheduled.DON/Designee will review WAR for completion of ordered wound treatments DAILY IN STAND UPDON/Designee will assess all dressings to ensure date reflects current date 5 x week X 4 WEEKSRegional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks.The QA committee will review findings and make changes as needed monthly. Monitoring of the POR included the following: During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head-to-toe skin assessment for Resident #3 and #5. The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings. Record review of EMR UDA log revealed 63 resident names. The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed. Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present. Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN). Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with training for reporting and identifying skin concerns. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text. Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issued to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention. The in-service had 16 signatures. Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns. Record review of an employee roster revealed 73 total employees. Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation. The in-service revealed 62 signatures. Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD. All [Wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match. The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN. Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks. The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 8 residents (Resident #3 and Resident #34) reviewed for infection control: 1. The facility failed to ensure staff wore proper PPE while performing wound care for Resident #3. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene between glove changes while performing incontinent care for Resident #34. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #3's admission record, dated 8/29/25, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included liver cell carcinoma (liver cancer), mid protein calorie malnutrition, malignant neoplasm (cancerous tumors) of bone and articular cartilage, and alcoholic cirrhosis of liver without ascites (condition resulting from long term heavy alcohol use, characterized by the scarring of liver tissue. Unlike other forms is does not usually cause fluid retention in the abdomen). Record review of Resident #3's quarterly MDS assessment, dated 8/4/25, revealed the resident cognition was severely impaired for daily decision-making skills, and section M revealed he had 1 stage 1 pressure injury, 1 stage 4 pressure injury, 4 unstageable pressure ulcers, and 2 deep tissue injuries. Record review of Resident #3's care plan, initiated 2/7/25 revealed the resident was on enhanced barrier precautions, with interventions to gloves and gown should be donned if any of the following activities occur . wound care. Record review of Resident #3's Physician Order, dated 8/29/25, revealed the following:- Stage IV (L) Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Stage IV Sacrum Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Unstageable R Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25.-Unstageable DTI left heel, Cleanse with wound cleanser/Normal saline pat dry WITH 4X4 gauze. Apply skin prep/betadine to area left open to air as, one time a day for Skin fragility or hair/nail weakness for 30 Days with a start date of 8/11/25 and end date of 9/10/25. -Unstageable DTI left lateral foot, cleanse with wound cleanser/normal saline, pat dry with 4X4 gauze apply skin prep/betadine daily/as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. -Unstageable DTI to right ankle cleanse with wound cleanser/normal saline, pat dry with 4x4 gauze apply skin prep/betadine daily or as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. - Unstageable left hip Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. During an observation on 8/29/25 at 11:19 a.m. the ADON prepare to provide wound care to Resident #3's wounds. The ADON cleansed the residents right foot wound with skin prep, removed her gloves, and stated she forgot a PPE gown and went outside the room to put one on. During an interview on 8/29/25 at 12:34 p.m. the ADON stated she needed a gown to provide wound care to resident #3 because he was on EBP and also to prevent her from getting any wound drainage on her. During an interview on 8/29/25 at 1:15 p.m., the DON stated staff should be wearing a gown while providing wound care to Resident #3 because he was on EBP. The DON stated the gown helped protect staff and resident from infection. 2. Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes(high blood sugar levels, insulin resistance, and a relative last of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 had bowel incontinence with an intervention to check resident every 2 hours and assist with toileting as needed. During an observation on 8/29/25 at 10:54 a.m. CNA F and CNA G provided incontinent care to Resident #34. Both aides removed their gloves during the care and put on new gloves. They did not perform hand hygiene after removing soiled/used gloves, and putting on new gloves. During a joint interview on 8/29/25 at 11:11 a.m. CNA F and CNA G stated they did not have any hand sanitizer on them when they started. They stated the resident was in pain so they wanted to be quick with the incontinent care. They stated they should have preformed hand hygiene between glove changes to prevent infection to the resident. During an interview on 8/29/25 at 1:07 p.m. the DON stated staff was expected to perform hand hygiene between glove changes to provide infection control. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 3/2024, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care.After removing gloves or aprons. Record review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, stated Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following. Wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an alleged romantic relationship between Resident #1 and LVN A, as reported by Resident #1 to the DON, and LVN A to the ADON. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission record, undated, reflected a [AGE] year-old resident with an initial admission of 02/03/2025 and diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood) and quadriplegia (paralysis of all four limbs). Record review of Resident #1's BIMS Assessment reflected that Resident #1 had a BIMS score of 9, reflecting moderate cognitive impairment. Record review of Resident #1's Care Plan, undated, did not indicate that Resident #1 had a history of sexually inappropriate behavior toward residents or staff. Record review of Resident #1's Progress note, dated 05/13/2025, reflected that Resident #1 requested to be sent to the emergency room for evaluation that day due to started to cough while asleep and had difficulty catching his breath. Record review of the Intake Investigation Worksheet #1009602 dated 0514/2025 revealed facility reported residents' allegations of abuse and neglect and not wanting to return to the facility. Neither self-report nor addendums revealed concern for possible sexual abuse or exploitation. Record review of the Provider Investigation Report (PIR), dated 05/19/2025, reflected that Resident #1 complained about the facility at the hospital, but when the DON went to speak with him at the hospital, Resident #1 declined the complaints, saying he was angry and just wanted to go to where LVN A worked. The PIR did not reflect possible sexual abuse or exploitation.Interview on 07/10/2025 at 3:55 PM, the facility's previous DON (DON C), who was the DON at the facility at the time of the incident, stated that she initially she went to the hospital to check on Resident #1 because of the complaints he had at the hospital of the facility, including pest control issues and being left soiled for a long time. Resident #1 recanted the complaints to DON C, stating he was just upset due to them firing LVN A, and wanted to live where she was because they were in a relationship. DON C stated that she had heard from Resident #1's Stepsister, LVN B, that she had a suspicion Resident #1 and LVN A were having a relationship. DON C stated she had reported LVN A to the Texas Board of Nursing on 05/22/2025 out of an abundance of caution due to the allegations of LVN A having a physical relationship with Resident #1. DON C stated LVN A had not been fired, but had changed her employment to PRN status. Interview on 07/10/2025 at 4:22 PM, LVN B stated she had informed the DON, at the time, DON C, that she felt Resident #1 was having a relationship with LVN A. LVN B stated that everything seemed normal at first for a working relationship between a nurse and a patient, but toward the end of LVN A working at the facility, she became hostile toward LVN B. LVN B stated that she did not know the extent of their relationship and whether it was sexual or not, because shortly after going to the hospital, Resident #1 ceased communication with LVN B and she had not heard from him since. LVN B stated she was aware Resident #1 had similar behaviors at a previous facility, but had not told any facility staff or administration of these behaviors. Interview on 07/10/2025 at 4:42 PM, ADON D stated she never had a concern of a sexual relationship between Resident #1 and LVN A. She stated she observed that Resident #1 and LVN A were friendly and LVN A would hang out in his room frequently. ADON D stated she did complete a verbal conversation with LVN A, and reprimanded her for spending too much time with Resident #1 and that she should focus on all residents equally. ADON D stated that DON C returned from the hospital after visiting Resident #1 and identified concerns of a possible inappropriate relationship. ADON D stated that staff members were questioned and interviewed regarding potential sexual abuse and/or inappropriate relationships between residents and staff. ADON D stated that during investigations she informs the ADM and the ADM reports to the state as necessary. Interview on 07/11/25 at 10:30 AM, Resident #1 stated that he did not have a relationship with LVN A. Resident #1 stated that they were friends and stated, she was my age, and we were able to click together. Resident #1 denied any sexual encounters and inappropriate interactions with LVN A. Interview on 07/11/2025 at 2:40 PM, the ADM stated that, during the course of the investigation of Resident Neglect for Resident #1, she should have identified that an allegation of inappropriate relationship between Resident #1 and LVN A should have been recognized as possible abuse, and HHSC should have been notified. The ADM stated Resident #1 was not in the facility at the time of the investigation. The ADM stated that the incident should have been reported to the state. The ADM stated after DON C visited with Resident #1, the investigation was expanded to include sexual abuse and exploitation. Record review reflected LVN A's most recent shift worked at the facility was 04/29/2025, at which time her employment status changed to PRN . Further review reflected LVN A was suspended pending the facilities investigation and terminated when the investigation was concluded. An interview with LVN A was attempted on 07/10/2025 at 2:00 PM, LVN A did not answer the attempt for a phone interview. Record Review of Complaint Form to TBON, date submitted 05/22/2025, reflected Resident #1 as the patient involved in the complaint, and LVN A as the nurse being reported to the TBON. The description of incident is as follows: Resident and LVN had multiple situations where they were physically involved per resident and LVN. LVN stated to resident she had been fired due to this discovery. This promoted [sic] resident to ask to be transferred to hospital. Resident then reported to hospital social worker that he did not want to return to facility due to wanting to go where Nurse [LVN A] is now working. This caused social worker to report situation to be reported to state. This facility has also self-reported this situation.Review of the facility's Nursing Policy and Procedure Manual, Version 03-1.0 F.7. revealed, The facility will report .any and all investigations concerning reports of abuse, neglect, exploitation .to the state survey and certification agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that:<BR/>1. Resident #1's care plan did not indicate that Resident #1 was noncompliant with the facility smoking policy and did not indicate effective interventions for the noncompliance.<BR/>2. Resident #1's care plan did not indicate that Resident #1 had verbally disruptive and aggressive behaviors toward staff and others and did not indicate effective interventions for the behaviors.<BR/>This deficient practice could affect residents with behaviors and/or residents who smoke due to these conditions not being identified in the care plan and not indicating effective interventions to the behaviors in the care plan.<BR/>The findings were:<BR/>Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Bipolar Disorder (a mental illness characterized by alternating periods of elation and depression), Chronic Viral Hepatitis C (a virus that causes liver swelling and can lead to serious liver damage), Depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (a feeling of worry, nervousness or unease, typically about an imminent event or something with an uncertain outcome). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 01/19/2025, revealed Resident #1 had a BIMS score of 13, indicating no cognitive impairment. <BR/>1. Record review of Resident #1 comprehensive care plan, date initiated 01/09/2024 and revised on 02/05/2025 revealed a care plan Resident smokes and is aware of designated smoking area. The goal of the care plan stated resident will be able to smoke without causing injury. Resident aware of smoke policy and will not violate smoking rules. The comprehensive care plan did not reveal a care plan that addressed Resident #1's noncompliance with the smoking policy or interventions to address the noncompliance.<BR/>Record review of Resident #1's progress note, dated 10/08/2024 at 5:49 a.m. by LVN G, revealed Resident pushed front door open, setting off alarm to let himself out. Resident is currently sitting out front smoking.<BR/>Record review of Resident #1's late entry progress note, dated 11/09/2024 at 6:16 p.m. by the DON, revealed This nurse arrived to facility from lunch break and noted resident sitting at the edge of the front entrance area with a lit cigarette. Resident was reminded he is only to smoke in designated smoking areas as he was recently reeducated on in October 2024. Resident threw lit cigarette on ground and started to curse at this nurse and then stated, 'I am not a fu**ing child you can't tell me what to do.' Resident then proceeded to enter facility and continued cursing. Resident was asked not to curse in facility due to other residents being in close proximity, and several female residents stated they did not like it when he yells. Resident continued to curse as he got in the elevator and went to his room.<BR/>Record review of Resident #1's progress note, dated 11/13/2024 at 3:51 p.m. by the Social Worker, revealed Social Worker engaged resident due to reports of smoking cigarettes during non-smoke break times and, outside of designated smoking area on 11/13/24. Resident stated, 'that is a lie, I did not smoke a cigarette when and where they say I did'. Social Worker requested a smoking policy be reviewed, updated, signed. Resident responded, 'I am not signing anything'. Social worker asked about smoking materials including lighters in which the resident stated, 'I do not have anything'.<BR/>Record review of Resident #1's progress note, dated 11/20/2024 at 1:56 p.m. by the Social Worker, revealed Social worker engaged resident regarding reports of the resident keeping a cigarette lighter on his person. Resident stated, 'I gave it to staff'.<BR/>Record review of Resident #1's progress note, dated 01/09/2025 at 11:37 a.m. by the Social Worker, revealed Facility informed resident of an immediate discharge due to continually violating smoking policies which endanger resident safety. <BR/>Record review of Resident #1's late entry progress note, dated 01/09/2025 at 6:15 p.m. by the DON, revealed Resident noted by front door with lit cigarette in area that resident has been informed before of not being an appropriate smoking are. Resident had just had a conversation with DON, and another administrative staff regarding smoke break being a few min. late due to the inclement weather and having to ensure all residents are properly dressed. Resident went out front door and started smoking. When resident was asked to stop smoking in this area, resident stated yelling and curing at staff. Resident was informed that this was cause or immediate discharge. Resident stated he did not know where to go. Resident was informed that a 30-day discharge will be issued starting today 1/09/2025. 30-day notice is to be completed on 02/09/2025. Resident stated being aware and thanked both social worker and this DON for changing immediate discharge to a 30-day discharge. <BR/>Record review of a facility document titled, [Facility Name] Health Care Center Policies, Information and Required Notices: Acknowledgement of Receipt of Policies, Information and Required Notices, listed Statement of Resident Rights and Smoking Policy. An acknowledgement at the bottom of the form stated, My signature below acknowledges that I have received copies of the above listed items as of the date of the signing of this form. The form is signed by Resident #1 on 07/01/2024. <BR/>2. Record review of Resident #1 comprehensive care plan, date initiated 07/09/2024 and revised 08/14/2024 revealed a care plan The resident has a mood problem r/t Bipolar Disorder, Current episode depressed, mild or moderate severity, unspecified. The goal, date initiated 07/09/2024 and revised 08/14/2024, stated the resident will have improved mood state through the review date. The care plan did not address Resident #1's verbal and physical aggression toward staff and interventions to address the aggression. <BR/>Record review of Resident #1's progress note, dated 09/23/2024 at 12:00 a.m. by RN F, revealed At approximately 12:15 a.m. patient received his 12:00 a.m. scheduled dose of norco. After taking his medication resident threw his glass of water at this writer. Resident then states 'I will take my antibiotic now. The writer reminded resident that it was scheduled for 10 p.m. and he refused the medication. Resident then yelled and stated, 'you are a fucking liar'. This writer left room to obtain mediation. Resident then came out of his room in his wheelchair stood up and lunged forward swinging his closed fist at this writer. It was at this time CNA approached bother writer and resident attempting to de-escalate resident. The resident then redirected their aggression towards CNA, attempting to strike her as well. During this episode, the resident was shouting and making verbally abusive threats towards both myself and other staff members. Resident continue to yell at staff calling them 'stupid bitches'. <BR/>Record review of Resident #1's progress note, dated 09/23/2024 at 12:30 a.m. by RN F, revealed 911 called to seek assistance with resident as resident was now a threat to staff and other residents' safety. Resident's behaviors were witnessed by several other residents who were sitting by nursing station and sitting on couch.<BR/>Record review of Resident #1's progress note, dated 09/23/2024 at 1:15 a.m. by RN F, revealed EMS arrived and left as resident refused to go to the hospital for evaluation. Stated 'she is a fucking bitch, I have my rights'. 2:00 a.m. EMS did reach out to police and explained the need for an ED d/t threats, aggression and attempting to physically harm staff. 3:20 a.m. No police presence at this time. Resident can be heard laughing and saying, you are nothing but a fucking bitch' while in his room.<BR/>Record review of Resident #1's progress note, dated 10/08/2024 at 6:19 a.m. by RN F, revealed Resident out of his room at nurses station being verbally aggressive, shouting 'fuck you. I don't know who the fuck you think you are. You are nothing but a stupid bitch. And what the fuck are you going to do about it? Huh what are you going to do? Exactly you are not going to do shit. Stupid bitch, you are not even a nurse. Go back to school'. As he was entering the elevator, he said 'once again I will be calling state to report you stupid bitch, fuck you'. ADON made aware.<BR/>Record review of Resident #1's progress note, dated 10/19/2024 at 6:30 p.m. by LVN E, revealed Resident verbally aggressive towards staff and another resident. Redirected, refused to be redirected. Had to move another resident to 2300 hall.<BR/>Record review of Resident #1's progress note, dated 11/13/2024 at 3:50 p.m. by the DON, revealed Resident came to DON office with Transition Specialist [name], for [insurance company name]. Resident was yelling profanities at DON asking 'Hey [DON name] why are you lying to this lady'. DON asked resident what he was talking about, resident responded 'why are you saying I schedule my own transportation and appointments?' DON attempted to explain to resident that he has and continues to do this. Resident continued to yell profanities. [Transition specialist name] asked resident to please not yell and warned that he could possibly be asked to leave the facility due to his continued behaviors that are starting to be noticed by other residents.<BR/>Record review of Resident #1's progress note, dated 02/03/2025 at 4:13 p.m. by LVN E, revealed resident refused pain medication stated only wants hydrocodone, resident refused vital signs. Resident started recording with phone and yelling and stating he is calling state to get me fired that he has fired everyone and will continue firing nurses, Resident pulling finger and making gestures. <BR/>Record review of Resident #1's late entry progress note, effective date of 02/09/2025 at 9:32 p.m. by the DON, revealed Resident was reminded today at 12:30pm of discharge scheduled for today (2/9/2025). Resident stated he was never told about this. Resident reminded that he was reminded of his discharge on Wednesday 2/5/25 during his care plan meeting and resident was informed on 2/5/25 that [facility name] was contacted again about admitting resident. [Facility name] informed this DON that they would admit resident. When resident came out of his room he was packed up and stated 'call the cops cause I am just leaving. If they don't come I am going to F*** S***up. When police arrived resident was argumentative and stated 'they have to send me to [facility name]. At this point [police department name] officers asked resident again if he didn't want to call family. Resident stated no I want you to take me to jail. Officers issued an emergency for resident. When EMS arrived to transport resident to hospital for eval, resident started cursing at EMS and refused to be assessed. At this point a third officer arrived and Resident was informed that he will be transported by police instead of EMS. Officers loaded all resident belongings into their vehicles and resident was placed in the backs seat of the police car and transported for eval. Resident was given all paperwork to support his discharge. Resident was not allowed to take medication with him per [police department name].<BR/>Record review of a document titled, Notification of Emergency Detention, dated 02/09/2025, listed Resident #1 as name of person being detained. The document stated No comes [officer name], a peace officer with [police department name] of the State of Texas states as follows: 1. I have reason to believe and do believe [Resident #1 name] evidence mental illness. 2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based upon the following: Consumer is diagnosed with schizophrenia, currently taking medications. Consumer is very combative with staff. 3. I have reason to believe and do believe that the above risk of harm is imminent unless the above-named person is immediately restrained. 4. My beliefs are based upon the following recent behavior, overacts, attempts, statements, or threats observed by me or reliably reported to me: consumer is constantly harassing staff and being verbally aggressive toward them. Harassing has gone to the point where staff are switching schedules due to the fear of caring for consumer. Consumer has been discharged from the facility. <BR/>During an interview with LVN B, 02/12/2025 at 1:18 p.m., LVN B stated Resident #1 was verbally aggressive toward the nurses and CNA's and stated Resident #1 curses at the staff when he gets agitated and was very short tempered. LVN B stated staff would be walking on eggshells, we didn't want to upset him because he would start yelling and cursing at us.<BR/>During an interview with LVN C, 02/12/2025 at 1:36 p.m., LVN C stated she was Resident #1's Charge Nurse and witnessed him yelling and cursing at staff. LVN C stated Resident #1 would sign out and go across the street, buy cigarettes and then try to smoke the cigarettes on the front patio and refuse to turn in his cigarettes and lighter when he got back inside the facility. LVN C stated Resident #1 told LVN C about 4 weeks ago that Resident #1 got in trouble for not following the smoking policy and was getting evicted and Resident #1 said he was refusing to turn in his lighter and cigarettes and was refusing to follow the rules. LVN C stated Resident #1 was very noncompliant and would go right outside the front door and try to smoke and refused to go to the right smoking area. LVN C also stated Resident #1 called staff racial slurs and yell and curse at staff if he got upset.<BR/>During an interview with the admission Coordinator, 02/12/2025 at 2:00 p.m., The Admissions Coordinator stated new admissions were provided copies of resident rights and the facility smoking policy. The Admissions Coordinator stated Resident #1 was very aggressive. You could hear him yelling and cursing at the staff in front of other residents. He would cuss in the foyer in front of people. He has cussed me out before and would follow me down the hall and curse at me and then stand outside of other resident rooms that I was in and scream and cuss at me. The Admissions Coordinator stated Resident #1 was noncompliant with the smoking policy as far as the times and the designated smoking areas. The Admissions Coordinator stated staff would try to redirect and would provide education on safe smoking and the danger of not smoking in the correct areas.<BR/>During an interview with LVN D, 02/12/2025 at 1:43 p.m., LVN D stated Resident #1 was his own responsible party and regardless of him knowing the smoking policy, he would go out and smoke where he was not supposed to try and push the limit of what he was able to do. LVN D stated on 02/09/2025 Resident #1 stated he was going to discharge home with his family member. LVN D stated LVN D heard Resident on the phone with his family member later in the day and Resident #1 said he was not leaving and was yelling and cursing at the staff. LVN D stated the police department was notified, and Resident #1 became very argumentative with the officers and EMS. LVN D stated the police ended up taking him away and detaining him because he was ugly and cursing at them and EMS as well. LVN D stated she had received training on dealing with residents with difficult behaviors and noncompliant behaviors. <BR/>During an interview with Resident #1, 02/12/2025 at 2:25 p.m., Resident #1 stated he was at [City name] Medical Behavioral Hospital and said, at least I am getting to see a psychiatrist. Resident #1 stated he was aware of the smoking policy and stated he was notified of his discharge notice due to not being compliant with the smoking policy. Resident stated he did not know why the police detained him and stated the police told him they were putting him on a three day hold for threatening people and took him to a hospital and then transferred him to the behavioral hospital. Resident #1 said hospital case manager was working with him to find alternate placement after he is discharged from the behavioral hospital. <BR/>During an interview with the DON, 02/13/2025 at 10:00 a.m., the DON stated Resident #1 was noncompliant with the smoking policy and stated Resident #1 also displayed aggressive behaviors toward staff. The DON stated Resident #1's care plan should have been updated to reflect the smoking noncompliance and the aggressive behaviors. The DON stated resident care plans should be updated at the time of a change in condition or behavior and stated the DON, ADON or MDS Nurse were responsible for updating and tweaking the care plan when there were changes in resident care or interventions. The DON stated staff would know what interventions were effective when addressing resident behaviors by reviewing the resident [NAME] that would tell the person about certain behaviors to watch for and stated that information was pulled from the resident care plan. The DON stated the accuracy of a resident care plan was important because it is our guide for caring for our residents. It tells us what has and hasn't not been done for them and all of our care revolves are the care plan. The DON also stated the care plan was important so we can properly care for the resident do that hopefully the behavior does not get repeated and helps us look back to see what worked and it is our guideline to how to treat the resident.<BR/>During an interview with the Social Worker, 02/13/2025 at 12:28 p.m., the Social Worker stated a resident care plan was comprehensive and should have been updated when there is a change of the intervention, a decline or physical or mental health or if the responsible party is verbalizing a revision that is needed. The Social Worker stated the MDS Nurse was usually responsible for updating the care plan and stated Resident #1's aggressive behaviors and smoking noncompliance should have been reflected in Resident #1's care plan. <BR/>During an interview with the MDS Nurse, 02/13/2025 at 2:03 p.m., the MDS Nurse stated all disciplines were responsible for updating resident care plans and stated resident care plans should have been updated every time there was a change in the resident. The MDS Nurse stated the importance of the care plan was to give a picture of the residents that we take care of and shows the interventions that work and did not work.<BR/>Record review of a facility document titled, Comprehensive Care Plan (Nursing Policy and Procedure Manual 03-18.0), stated Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drivees the type of care and services that a resident received. In situations where a resident's choice to decline care of treatment (e.g. due to preferences, maintain autonomy, etc.) poses a risk to the residents health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempt to find alternative means to address the identified risk/need should be documented in the care plan. The policy also stated, The comprehensive care plan will be- The resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to be informed of and participate in their treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option they prefer for 1 of 6 residents (Resident #35) whose records were reviewed for informed consent. The facility failed to obtain signed consent prior to administering the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability) for Resident #35. This failure could place residents at risk of receiving medications without consent and without the option choose alternative treatment or decline treatment based on awareness of the risks and benefits of the medications.The findings included: Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Record review of Resident #35's order summary included active orders for Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar. Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as ordered. Record review of Resident #35's medication consents included a Texas Health and Human Services Form 3713 Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment for the medication Risperdal with no resident or resident representative signature in Section II of the form. During an interview with the DON on 8/29/25 at 1:23 PM, the DON stated for new psychotropic medication orders, her expectation is for consents to be complete with doctor and resident signatures on the appropriate forms and be obtained within 24 to 48 hours for inclusion in the resident's medical record. The DON stated all consents should be signed by either the resident if they are their own responsible party, or by their designated representative if they are unable to sign themselves. The DON stated Resident #35's consent for Risperdal should have been signed by the resident or the responsible party so they would be informed of the medication's potential side effects, understand why they have been prescribed the medication, and decide if they want to take the medication. Record review of the facility policy titled Unnecessary Medications, with a revision date of 2/12/2025, documented Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a mediation. To demonstrate compliance, the resident's medical record must include documentation that the resident or resident representative was informed in advance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 4 of 6 residents (Resident #7, Resident #8, Resident #10, and Resident #35) who were reviewed for resident assessments. 1.The facility failed to document Resident #7's use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to accurately code Resident #8's hypoglycemic medication on the quarterly MDS assessment.3. The facility failed to document Resident #10's use of antiplatelet medication on the quarterly MDS assessment.4. The facility failed to accurately code Resident #35's diagnosis of bipolar disorder on the quarterly MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #7's admission sheet dated 10/16/2023 with an original date of 4/08/2020 documented a [AGE] year-old female resident with diagnoses including dementia, schizophrenia, diabetes mellitus, anxiety, hypertension (high blood pressure), bipolar disorder, depression, and hyperlipidemia (high cholesterol). Record review of Resident #7's MDS dated [DATE] documented a BIMS of 6 indicating severe cognitive impairment and recorded the use of antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications. Further review of Resident #7's MDS revealed the assessment did not include the use of anticonvulsants, despite the resident receiving Lamotrigine and Depakote. Record review of Resident #7's order summary documented active orders for the psychotropic medications: -Lamotrigine 100 mg give by mouth one time a day for anxiety, with a start date of 04/22/2024.-Depakote 500 mg give one tablet by mouth two times per day related to biploar disorder, with a start date of 04/21/2024.-Sertraline 100 mg give on e tablet by mouth one time a day related to major depressive disorder, with a start date of 08/26/2024. -Zyprexa 20 mg give one by mouth one time a day related to schizophrenia, with a start date of 04/21/2024. Record review of Resident #7's July 2025 MAR documented the resident had been receiving Lamotrigine, Sertraline, Zyprexa, and Depakote as prescribed. Further review of the July MAR documented that Lamotrigine was ordered as Lamotrigine 100mg, give 1 tablet by mouth one time a day for anxiety. Sertraline was ordered as Sertraline 100mg give 1 tablet by mouth one time a day.give with 25mg tab to equal 125mg daily. Zyprexa was ordered as Zyprexa 20mg give 1 tablet by mouth one time a day. Depakote was ordered as Depakote 500mg give 1 tablet by mouth two times a day. Record review of Resident # 7's care plan, revision dated on 04/07/2025, documented ANTIPSYCHOTIC MEDICATIONS: The resident requires the use of antipsychotic medications r/t long-standing mental illness, dx Schizophrenia -depakote -lamotrigine. The care plan listed Depakote and Lamotrigine in the antipsychotic medication section. The care plan did not include monitoring for anticonvulsant medications. 2. Record review of Resident #8's admission sheet dated 3/28/2023 with an original date of 9/13/2017 documented a [AGE] year-old male resident with diagnoses including schizoaffective disorder, diabetes mellitus, dementia, depression, anxiety, insomnia, hypertension, and cerebral infarction (stroke). Record review of Resident #8's MDS assessment dated [DATE] documented a BIMS score of 14 indicating intact cognition and recorded the use antipsychotic, diuretic, and hypoglycemic medications. Further review of Resident #8's MDS revealed the assessment inaccurately recorded a total of one day for the number of days that insulin injections were received during the last 7 days. Record review of Resident #8's order summary documented an active order for the hypoglycemic medication Trulicity (a glucagon-like peptide 1 [GLP-1] receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus). Further review of the order summary did not include an order for insulin. Record review of Resident #8's June 2025 MAR documented the resident had been receiving Trulicity as prescribed. Further review of the June MAR recorded Trulicity was ordered as Trulicity 3mg/0.5mL, Inject 3mg subcutaneously one time a day every 7 day(s) related to type 2 diabetes mellitus without complications. Record review of Resident #8's care plan documented a diagnosis of diabetes mellitus with interventions including Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. 3. Record review of Resident #10's admission sheet dated 8/13/2024 with an original date of 7/30/2024 documented a [AGE] year-old female resident with diagnoses including schizophrenia, diabetes mellitus, hyperlipidemia, depression, hypertension, and chronic obstructive pulmonary disease (a lung condition caused by damaged to the airways that limits air flow). Record review of Resident #10's MDS dated [DATE] documented a BIMS score of 13 indicating intact cognition and recorded the use of antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, opioid, and hypoglycemic medications. Further review of Resident #10's MDS revealed the assessment did not include the use of antiplatelet medications and inaccurately recorded the resident as receiving anticoagulant therapy. Record review of Resident #10's August 2025 MAR documented the resident had been receiving Aspirin as prescribed. Further review of the August MAR recorded Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day for heart health. Further review of the August MAR revealed Resident #10 did not have an order for an anticoagulant medication. Record review of Resident #10's care plan, dated 08/03/2024, documented The resident is on anticoagulant therapy. Further review of the care plan showed the assessment did not include monitoring for antiplatelet therapy. 4. Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's order summary documented active orders for the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability). Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as prescribed. Further review of the July 2025 MAR documented Risperdal was ordered as Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar, with a start date of 07/01/2025. Record review of Resident #35's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Further review of Resident #35's MDS revealed the assessment did not include a diagnosis of bipolar disorder. Record review of Resident #35's care plan, revised dated on 07/18/2025, documented Adverse medication effect and behavior monitoring but did not specify the type of medication class to monitor. Further review of the care plan revealed the diagnosis of bipolar disorder was not included on the diagnosis list. In an interview with the MDS Coordinator on 8/29/25 at 10:01 AM, the MDS Coordinator stated if the MDS was not coded correctly or has missing information, they could miss a side effect of a medication. The MDS Coordinator went on to state they would not know if behaviors were mania or altered mental status, and a resident could have issues if someone did not know specific side effects of a medication to look for if something was wrong. The MDS Coordinator stated it was important for the MDS to be accurate so the facility could know what was going on with the whole resident. In an interview with the DON on 8/29/25 at 1:23 PM, the DON stated her expectation for the MDS was that it be accurate, complete, and detail-oriented. The DON went on to state the MDS is the whole picture of a resident, it encompasses everything, and if medications and diagnoses were coded incorrectly, they needed to do some education with the staff. In an interview with the Regional Compliance Nurse on 8/26/25 at 12:58 PM, the Regional Compliance Nurse stated they did not have an MDS or assessment policy, and they followed the RAI manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 noted Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. and Code all high-risk drug class medications according to their pharmacological classification. and Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 8 residents reviewed for PASRR (Resident #34). The facility failed to ensure Resident #34 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included: Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and had anxiety, seizure disorder, and schizophrenia. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 required anti-psychotic medications, to administer as ordered, and monitor/document for side effects and effectiveness. Record review of Resident #34's physician's order, dated 8/26/25, indicated Resident #34 took Risperdal for schizophrenia daily. Record review of Resident #34's PASRR Level 1 Screening completed on 5/19/25 indicated in section C0100 there was no evidence of this individual having mental illness or dementia. During an interview on 8/28/25 at 11:48 a.m. the MDS Coordinator stated Resident #34 did not have a qualifying mental disorder for PASRR services. The MDS Coordinator stated the resident came with the PASRR already completed prior to her admission and she did not think there were any errors on Resident #34's PASRR Level 1 Screening. During a follow up interview on 8/28/25 at 5:00 p.m. the MDS Coordinator stated they had corrected the PASRR for Resident #34 to answer yes to the mental illness question so the resident could be evaluated by the local authority to see if the resident could qualify for services. Record review of the facility's policy titled PASRR Nursing Facility Specialized Policy and Procedure, dated 3/6/19, stated Policy: It is the policy of [corporate name] facilities to ensure NFSS Forms are submitted timely and accurately. Procedure: 1. PL1 is completed. 2. If PL1 is coded as suspicion of MI, ID or DD, then a PE is required. 3. The LA completes the PE and if Positive, a PCSP Initial Meeting is scheduled. 4. NF PCSP meetings scheduled within 14days of admission and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan after each assessment for 5 of 6 residents (Residents #1, #4, #7, #10, and #35) reviewed for care planning. 1. The facility failed to ensure Resident #1's care plan was accurate to reflect that he was not a smoker.2. The Facility failed to ensure Resident #4's care plan reflected he was on dialysis. 3. The facility failed to ensure Resident #7's care plan was accurate and updated to reflect the type of psychoactive medications prescribed for Resident #7 and the specific side effect monitoring of those medications. 4. The facility failed to ensure Resident #10's care plan was accurate and updated to reflect the type of blood thinning medication Resident #10 was prescribed.5. The facility failed to ensure Resident #35's care plan was accurate and updated to reflect Resident #35's psychiatric diagnoses and psychoactive specific medication monitoring. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #1's admission Record dated 08/28/2025, reflected a [AGE] year-old male admitted to the facility 07/09/2025. His diagnoses included other frontotemporal neurocognitive disorder (a group of neurodegenerative disorders associated with changes in the brain's frontal and temporal lobes which control functions related to personality, behavior, and language), pneumonia due to methicillin susceptible staphylococcus aureus (a bacterial infection of the lungs that can be treated with antibiotics), and schizophrenia (a mental health condition where people can experience a disconnection from reality, presenting with symptoms such as false beliefs and disorganized thinking). Record review of Resident #1's Smoking Assessment with an effective date of 07/28/2025 revealed he was unable to find the smoking areas, was unable to extinguish smoking materials or know how to dispose of ashes and was unable to smoke unattended. The assessment had a box checked indicating the evaluation has been explained to the family responsible party. There was no indication on the form, however, if the resident was a current smoker or had ever smoked. Record review of Resident #1's Care Plan, with date initiated 07/27/2025, indicated Resident Smokes with a goal of resident will be able to smoke without causing injury. Another entry on the same Care Plan with date initiated 08/13/2025 indicated Resident is a smoker with a goal of will smoke in designated areas without occurrence of injury over next 90 days. Record review of Progress Notes dated 07/09/2025 contained an admission Note that documented Resident Smokes: No. Observations of Resident #1 during the survey from 08/26/2025 through 08/29/2025, revealed resident sleeping or wandering in the secure unit with his arms crossed in front of him. Resident #1 was never observed in the smoking area with other residents. During an interview with LVN E on 08/29/2025 at 9:45 am, LVN E stated that Resident #1 was not a smoker and did not participate in many activities. During an interview with MDS Coordinator on 08/29/2025 at 10:01 am, MDS Coordinator stated she had only been employed in this facility for 2 months. The MDS stated, I review Care Plans and make sure the whole IDT team is in agreement with the needs of the residents. I am also part of the care conference team. In the first set of care plans, I go through the triggers and I do an assessment. I look at the resident as well as look at notes from the Treatment Nurse, weekly nurse assessment, etc. The MDS Coordinator stated that Resident #1 was not a smoker and this should not have been placed in the Care Plan. 2. Record review of Resident #4's admission record, dated 8/29/25 with an initial admission date of 12/13/2017 and readmission of 7/31/25 revealed an [AGE] year-old male resident with diagnoses that included end stage renal disease (the final stage of kidney failure), and type 2 diabetes mellitus (high blood sugar levels and insulin resistance) without complications. Record Review of Resident #4's quarterly MDS assessment, dated 7/31/25, reflected Resident #34 had severely impaired cognition for daily decision making and section O revealed he received dialysis while a resident. Record review of Resident #4's physician's order, dated 8/29/25, revealed Resident #4 received dialysis every Monday, Wednesday, and Friday, with a start date of 8/1/25, and no end date. Record review of Resident #4's care plan, dated 8/28/25, revealed he was at risk for malnutrition and to monitor and document meal intake and resident weights. There were no care areas for dialysis. During an interview on 8/28/25 at 11:39 a.m. the DON stated dialysis should be care planned for continuity of care and to ensure staff was monitoring the resident and dialysis site. During an interview on 8/28/25 at 11:51 a.m. the MDS Coordinator stated the resident was started on dialysis about 2 weeks prior. The MDS Coordinator stated she was responsible for updating the care plans and should have updated the residents care plan to include he was on dialysis. The MDS Coordinator stated the care plan needed to be updated for nursing staff and CNAs to see necessary interventions on their point of care system. 3. Record review of Resident #7's admission sheet dated 10/16/2023 with an original date of 4/08/2020 documented a [AGE] year-old female resident with diagnoses including dementia, schizophrenia, diabetes mellitus, anxiety, hypertension (high blood pressure), bipolar disorder, depression, and hyperlipidemia (high cholesterol). Record review of Resident #7's MDS dated [DATE] documented a BIMS score of 6 indicating severe cognitive impairment and documented the use of antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications. Record review of Resident #7's order summary documented active orders for the psychotropic medications Lamotrigine (an anticonvulsant indicated for the treatment of epilepsy and bipolar disorder), Sertraline (an antidepressant indicated for the treatment of depression, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder), Zyprexa (an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar disorder), and Depakote (an anticonvulsant indicated for the treatment of manic episodes associated with bipolar disorder, seizures, and migraine prophylaxis). Record review of Resident #7's July 2025 MAR documented the resident had been receiving Lamotrigine, Sertraline, Zyprexa, and Depakote as prescribed. Further review of the July MAR documented that Lamotrigine was ordered as Lamotrigine 100mg, give 1 tablet by mouth one time a day for anxiety. Sertraline was ordered as Sertraline 100mg give 1 tablet by mouth one time a day.give with 25mg tab to equal 125mg daily. Zyprexa was ordered as Zyprexa 20mg give 1 tablet by mouth one time a day. Depakote was ordered as Depakote 500mg give 1 tablet by mouth two times a day. Record review of Resident #7's care plan, revision dated on 04/07/2025, documented ANTIPSYCHOTIC MEDICATIONS: The resident requires the use of antipsychotic medications r/t long-standing mental illness, dx Schizophrenia -Depakote -lamotrigine. The care plan listed Depakote and Lamotrigine in the antipsychotic medication section, however both medications are in the anticonvulsant medication class. The care plan did not include the use of Zyprexa in the antipsychotic medication class. 4. Record review of Resident #10's admission sheet dated 8/13/2024 with an original date of 7/30/2024 documented a [AGE] year-old female resident with diagnoses including schizophrenia, diabetes mellitus, hyperlipidemia, depression, hypertension, and chronic obstructive pulmonary disease (a lung condition caused by damaged to the airways that limits air flow). Record review of Resident #10's MDS dated [DATE] documented a BIMS score of 13 indicating intact cognition and documented the use of antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, opioid, and hypoglycemic medications. Record review of Resident #10's August 2025 MAR documented the resident had been receiving Aspirin (an antiplatelet medication) as prescribed. Further review of the August MAR documented Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day for heart health. Record review of Resident #10's care plan, dated 08/03/2024, documented The resident is on anticoagulant therapy. Resident #10's active orders did not include any anticoagulant medications. Further review of the care plan showed the assessment did not include monitoring for antiplatelet therapy. 5. Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Record review of Resident #35's order summary documented active orders for the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability). Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as prescribed. Further review of the July 2025 MAR documented Risperdal was ordered as Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar, with a start date of 07/01/2025. Record review of Resident #35's care plan, revised dated on 07/18/2025, documented Adverse medication effect and behavior monitoring but did not specify the type of medication class to monitor. Further review of the care plan revealed the diagnosis of bipolar disorder was not included on the diagnosis list. During an interview with the DON on 8/29/25 at 1:23 PM, the DON stated it was important for the care plan to be accurate, because the care plan is the communication between staff regarding a resident's care and includes information necessary for the Kardex (a patient care summary tool often found in digital format). The DON stated her expectation is for care plans to be part of the morning meetings so they can be done quickly, and important things needed on the plan can be covered in the meetings. Review of the facility's policy titled Comprehensive Care Planning, undated, noted Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs and The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #34) reviewed for incontinent care: The facility failed to ensure CNA F did not wipe between Resident #34's gluteal folds from back to front in the wrong direction during incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (high blood sugar levels, insulin resistance, and a relative loss of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 had bowel incontinence with an intervention to check resident every 2 hours and assist with toileting as needed. During an observation on 8/29/25 at 10:54 a.m. CNA F provided incontinent care to Resident #34. After cleansing the resident's urethral area, CNA F moved to her rectal area and wiped between the gluteal folds and towards to urethra and vaginal area. During an interview on 8/29/25 at 11:11 a.m. CNA F stated she should wipe from front to back or away from the front area of the resident to prevent from getting bacteria from her rectal area in her urethral or vaginal area. CNA F stated the resident was at risk of a UTI. CNA F stated she did not realize she was wiping the wrong direction while cleaning between the gluteal folds. During an interview on 8/29/25 at 1:07 p.m. the DON stated staff needed to wipe the resident from front to back direction while providing incontinent care to prevent infection. Record review of the facility's policy titled Perineal Care, effective date 5/11/22, stated Purpose, This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.Front. 17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY. Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh.Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #4) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #4. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included:Record review of Resident #4's admission record, dated 8/29/25 with an initial admission date of 12/13/2017 and readmission of 7/31/25 revealed a resident [AGE] year-old male resident with diagnoses that included end stage renal disease (the final stage of and type 2 diabetes mellitus (high blood sugar levels, insulin resistance, and a relative last of insulin) without complications. Record Review of Resident #4's quarterly MDS assessment, dated 7/31/25, reflected Resident #4 had severely impaired cognition for daily decision making and section O revealed he received dialysis while a resident. Record review of Resident #4's care plan, dated 8/28/25, revealed he was at risk for malnutrition and to monitor and document meal intake and resident weights. There were no care areas for dialysis. Record review of Resident #4's physician's order, dated 8/29/25, revealed Resident #4 received dialysis every Monday, Wednesday, and Friday, with a start date of 8/1/25, and no end date. Record review of Resident #4's dialysis communication forms revealed: -8/1/25 the dialysis communication form was complete. -8/4/25 the dialysis communication form had the prior to dialysis assessment completed but was missing the dialysis center assessment, and the facility post assessment portion of the form.-8/6/25 the form was not in the resident's dialysis binder. -8/8/25 the form was not in the resident's dialysis binder.-8/11/25 the form was not in the resident's dialysis binder.-8/13/25 the dialysis communication form had the prior to dialysis assessment completed and the dialysis center assessment completed but was missing the facility post assessment portion of the form.-8/15/25 the dialysis communication form had the prior to dialysis assessment completed but was missing the dialysis center assessment, and the facility post assessment portion of the form.-8/18/25 the dialysis communication form had the prior to dialysis assessment completed but was missing the dialysis center assessment, and the facility post assessment portion of the form.-8/20/25 the dialysis communication form had the prior to dialysis assessment completed but was missing the dialysis center assessment, and the facility post assessment portion of the form.-8/22/25 the dialysis communication form had the prior to dialysis assessment completed but was missing the dialysis center assessment, and the facility post assessment portion of the form. During an interview on 8/26/25 at 3:18 p.m. Resident #4 stated he went to dialysis a few days a week. He stated staff assessed his port and he had no concerns or issues. During an interview on 8/28/25 at 11:39 a.m. the DON stated the dialysis communication forms should be completed in entirety for continuity of care, to ensure the resident was stable pre and post dialysis, and to monitor the resident's port site. Record review of the facility's policy titled Dialysis, no date, stated Dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so because of impaired function or when toxins or poisons must be removed immediately to prevent permanent or life-threatening damage. The purposes of dialysis are to maintain the life and wellbeing of the patient until kidney function is restored and to remove unwanted substances from the blood if renal function does not return .Procedure. 7. The site will be assessed for bleeding, bruising, lack of pulsations, and aneurysm, as ordered by the physician. The nurse will palpate the access from the from the distal anastomosis to the proximal anastomosis.the procedure should be conducted once a shift.record the results of the examination.18. The resident's clinical record will be documented with this information. The date and time that the resident leaves the facility will be recorded by the nurse. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 8 residents (Resident #3 and Resident #34) reviewed for infection control: 1. The facility failed to ensure staff wore proper PPE while performing wound care for Resident #3. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene between glove changes while performing incontinent care for Resident #34. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #3's admission record, dated 8/29/25, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included liver cell carcinoma (liver cancer), mid protein calorie malnutrition, malignant neoplasm (cancerous tumors) of bone and articular cartilage, and alcoholic cirrhosis of liver without ascites (condition resulting from long term heavy alcohol use, characterized by the scarring of liver tissue. Unlike other forms is does not usually cause fluid retention in the abdomen). Record review of Resident #3's quarterly MDS assessment, dated 8/4/25, revealed the resident cognition was severely impaired for daily decision-making skills, and section M revealed he had 1 stage 1 pressure injury, 1 stage 4 pressure injury, 4 unstageable pressure ulcers, and 2 deep tissue injuries. Record review of Resident #3's care plan, initiated 2/7/25 revealed the resident was on enhanced barrier precautions, with interventions to gloves and gown should be donned if any of the following activities occur . wound care. Record review of Resident #3's Physician Order, dated 8/29/25, revealed the following:- Stage IV (L) Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Stage IV Sacrum Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Unstageable R Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25.-Unstageable DTI left heel, Cleanse with wound cleanser/Normal saline pat dry WITH 4X4 gauze. Apply skin prep/betadine to area left open to air as, one time a day for Skin fragility or hair/nail weakness for 30 Days with a start date of 8/11/25 and end date of 9/10/25. -Unstageable DTI left lateral foot, cleanse with wound cleanser/normal saline, pat dry with 4X4 gauze apply skin prep/betadine daily/as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. -Unstageable DTI to right ankle cleanse with wound cleanser/normal saline, pat dry with 4x4 gauze apply skin prep/betadine daily or as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. - Unstageable left hip Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. During an observation on 8/29/25 at 11:19 a.m. the ADON prepare to provide wound care to Resident #3's wounds. The ADON cleansed the residents right foot wound with skin prep, removed her gloves, and stated she forgot a PPE gown and went outside the room to put one on. During an interview on 8/29/25 at 12:34 p.m. the ADON stated she needed a gown to provide wound care to resident #3 because he was on EBP and also to prevent her from getting any wound drainage on her. During an interview on 8/29/25 at 1:15 p.m., the DON stated staff should be wearing a gown while providing wound care to Resident #3 because he was on EBP. The DON stated the gown helped protect staff and resident from infection. 2. Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes(high blood sugar levels, insulin resistance, and a relative last of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 had bowel incontinence with an intervention to check resident every 2 hours and assist with toileting as needed. During an observation on 8/29/25 at 10:54 a.m. CNA F and CNA G provided incontinent care to Resident #34. Both aides removed their gloves during the care and put on new gloves. They did not perform hand hygiene after removing soiled/used gloves, and putting on new gloves. During a joint interview on 8/29/25 at 11:11 a.m. CNA F and CNA G stated they did not have any hand sanitizer on them when they started. They stated the resident was in pain so they wanted to be quick with the incontinent care. They stated they should have preformed hand hygiene between glove changes to prevent infection to the resident. During an interview on 8/29/25 at 1:07 p.m. the DON stated staff was expected to perform hand hygiene between glove changes to provide infection control. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 3/2024, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care.After removing gloves or aprons. Record review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, stated Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following. Wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with surgical wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 8 residents (Resident 1) reviewed for surgical wounds in that: Resident #1 did not have weekly skin assessments during the month of September 2025, did not receive care to the right surgical wound as ordered by the physician and was admitted to the hospital on [DATE] with an infection to Resident #1's right below the knee amputation. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing surgical wounds or development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 2. Unstageable right heel, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September 2025 WAR/TAR revealed orders, start date 08/19/2025, keep dressing clean, dry intact. Do not remove, do not get wet. Cover to shower, every shift for surgical wound and monitor right leg stump for signs and symptoms of infection every shift for surgical wound. The WAR/TAR administration record for these orders was not initialed as completed on 09/07/2025 at 11 p.m. and 09/13/2025 on 3 p.m.- 11 p.m. Record review of Resident #1's EMR revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had an (unstageable (due to necrosis) of the right heel (signing off-area has been amputated). The etiology revealed pressure and stage was unstageable necrosis. Record review of Resident #1's Nurse Practitioner (NP) progress notes, dated 09/09/2025, revealed, surgical dressing orders reinforced; stump dressing remains clean/dry/intact without drainage. Record review of an outpatient clinic wound assessment progress note, dated 09/15/2025, revealed, Resident #1 had a right BKA and the wound bed sutures were in place and no drainage noted. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, sutures in place from R BKA, central area with small area of chronic weeping wound (a type of wound that produces clear fluid, blood, or pus that seeps from the injured area), no cellulitis (bacterial infection of the skin and soft tissues causing swelling, redness and pain), no pain, or crepitus extending proximally (air inside body tissues that can cause popping or cracking sounds). CT of RLE revealed, no evidence of active osteomyelitis at this time. No evidence of soft tissue gas. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and revealed, Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses revealed, history of right below knee amputation status post right below knee amputation incision and drainage by orthopedic surgery. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to RBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated his right foot was amputated about a month ago. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1 stated staff were checking his right stump when he returned from the hospital after the right BKA During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. The ADON/LVN stated the charge nurses were responsible for completing weekly skin assessments and the ADON/LVN was responsible for completing the pressure ulcer assessments. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated Resident #1 did not have any weekly skin assessments or pressure ulcer assessments during the month of September and stated she was responsible for monitoring the UDAs to ensure they were completed weekly. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was aware that Resident #1 had an amputation of his right leg, a few weeks ago and LVN L stated she did not recall any wound care orders for him and there was really not anything documented in the computer for what to do about the stump. LVN L stated she observed the stump on several occasions and stated that every time she observed the stump it did not have a dressing on it. LVN L stated she was unaware of Resident #1 having any wounds on his left foot and did not recall any treatment orders for his left foot. LVN L stated LVN N told her last week that Resident #1's stump was red and warm and stated LVN N reported the stump concern to nursing management. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was notified by a CNA that Resident #1's stump did not have a dressing on it and LVN N reviewed Resident #1's orders and recalled an order for the stump to have a wound dressing and to be kept clean and dry and stated Resident #1 had no other treatment orders. LVN N stated she did not recall the wound being red or warm and did not recall reporting an issue with Resident #1's stump. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated resident skin assessment should be completed by the nursing staff on admission, readmission and weekly. The Administrator stated it was important to complete weekly skin assessments because, it tells us if there is skin breakdown, wounds, pressure, etc. and we can monitor to see if skin is changing and what the baseline of the patient is and what the integrity of the skin is and to make sure the skin is taken care of because if you don't, it can lead to infection, sepsis, etc. During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. Record review of an undated facility policy titled, Documentation, revealed, Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). The procedure revealed, document completed assessments in a timely manner and per policy. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal Problem: The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE ORDERS MATCH. THIS MONITORING WILL BE INIATED [sic] ON 10/7/25 AND INDEFINATELY [sic]. CNAs INSERVICED ON REPORTING ALL NEW SKIN ISSUES TO NURSE ASAP AND DOCUMENTING THE FINDING/ALERT IN THE KIOSK ON 10/4/25 BY REGIONAL COMPLIANCE NURSE. CNAs INSERVICED ON S/SX OF SKIN BREAKDOWN, COMMON PRESSURE AREAS, AND PREVENTION ON 10/4/25 BY REGIONAL COMPLIANCE NURSE NURSES WERE INSERVICED ON COMPLETING SKIN ASSESSMENTS ON ADMISSION/readmission AND WEEKLY THEREAFTER, PER THE SCHEDULE PROVIDED. MANAGERS INSERVICED TO REVIEW CLINICAL ALERTS IN DAILY STAND UP TO MONTIOR FOR NEW WOUNDS, CHANGES IN WOUND, AND DECLINING WOUNDS. The medical director [physician] was notified of the immediate jeopardy situation on 10/4/2025 at 1:25 pm. MonitoringThe DON / designee will view each wound weekly AND ENDURE [sic] CORRECT ORDER IS IN PLACEThe DON / designee will audit all skin assessments and Weekly ulcer assessments weekly to ensure all assessment match the resident's current condition weekly.DON/Designee will audit all skin assessments and ulcer assessments weekly to ensure all residents received an assessment.DON/Designee will review all admissions/readmissions within 24 hours of admission to ensure orders are transcribed correctly and appointments are scheduled.DON/Designee will review WAR for completion of ordered wound treatments DAILY IN STAND UPDON/Designee will assess all dressings to ensure date reflects current date 5 x week X 4 WEEKSRegional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks.The QA committee will review findings and makes changes as needed monthly.The Administrator/Designee will review during stand up meetings if there was any evidence of any potential Neglect and initiate investigation / Self Report to HHSCADO/Regional Compliance Nurse will monitor by participating in facility's weekly SOC meeting x 6 weeks and at least 1 x per month x 3 months or until compliance is met. Monitoring of the POR included the following: During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head to toe skin assessment for Resident #3 and #5. The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings. Record review of EMR UDA log revealed 63 resident names. The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed. Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present. Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN). Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with the training for reporting and identifying skin concerns, abuse and neglect and reporting grievances or concerns from outside care teams. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text. Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issues to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention. The in-service had 16 signatures. Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns. Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD. All [wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match. The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN. Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks. The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. DON/Designee will assess all dressings to ensure date reflects the current date of 5 x week. DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The QA committee will review the findings and make changes as needed monthly. Wound care monitoring will be reviewing in stand up and stand down. Wound care monitoring will be reviewed for holes/omissions daily in stand up and stand down. Admin personnel must ensure systems will have adequate coverage when position is vacated. The in-service was signed by the ADON/LVN, Administrator and Interim DON. Record review of a facility in-service tracking spreadsheet revealed 12 licensed nurses received in person training and 6 licensed nurses had not worked the floor and received a text message with the training for identifying, assessing, notification, skin assessments and treatments. Record review of the daily staffing schedules for 10/02/2025 - 10/05/2025 and 10/06/2025 6a-6p revealed that all licensed nurses had signed the in-service for licensed nurses. Record review of an in-service dated 10/2/2025, for licensed nurses, read Pressure ulcer prevention and treatment including providing treatment as ordered and initialing/dating dressings-see attached policy. Documentation and accurate assessment of pressure ulcers- see policy. Initiating wound orders per MDs and upon admission/readmission. If a CNA reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MDs of changes immediately. Notification of physician with change of condition immediately. The in-service was signed by 12 LVNs. Record review of an employee roster revealed 73 total employees. Record review of an in-service dated 10/02/2025 revealed the topic was abuse and neglect and revealed 40 employee signatures. Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation. The in-service revealed 62 signatures. During an interview with CNA R, 10/04/2025 at 9:43 a.m. CNA R stated she had received training on identifying wounds and reporting wounds to the charge nurse. During an interview with LVN P, 10/04/2025 at 11:56 a.m., LVN P stated she received training on wound care, following physician orders and abuse and neglect on 10/02/2025 and stated the training was provided by the RCN. During an interview with CNA U, 10/04/2025 at 12:13 p.m. CNA U stated she had received training on identifying wounds and abuse and neglect on 10/02/2025 and stated she would report any skin concerns to the charge nurse and report allegations of abuse to the Administrator. During an interview with the Administrator, 10/4/2025 at 3:30pm, the Administrator stated Admin/Personnel were identified as the Administrator, Interim DON, and ADON. The Administrator revealed the Medical Director was notified of the immediate jeopardy regarding neglect and wound care on 10/4/2025. The Administrator revealed monitoring forms were created to monitor the wound care processes and stated the DON/Designee will review wounds weekly to ensure the correct orders are in place, will audit skin assessments and weekly pressure ulcer assessments, review admission and readmissions within 24 hours of admission, review resident WAR/TAR weekly to ensure treatments are being completed and will observe resident wound dressing for accurate dates and validate that resident wounds have treatment orders in place. These findings will be documented on the monitoring forms and the findings will be brought to QA. The Administrator stated she received the training and education on expectations from the RCN on 10/4/25. During an interview with the Administrator, 10/05/2025 at 3:30 p.m., the Administrator stated staff in-servicing on abuse and neglect was initiated on 10/02/2025 and all staff that have worked since 10/02/25 have been educated on abuse and neglect. The Administrator stated staff were educated on types of abuse and neglect, who to report to, how soon to report and the importance of reporting complaints or concerns from visitors, vendors, etc. directly to the administrator. During interviews conducted on 10/05/2025 and 10/06/2025, included a total of 10 CNAs [CNA E, R, F, Q, LL, KK, X, LL, MM, NN] ( 5 - 6a-6p and 1 6p-6a) (2 6a-6p and 1 6p-6a who confirmed receipt of a text message with training on abuse and neglect [CNA LL, MM, NN]), 4 LVNs [LVN P, O, B, H] (2 6a-6p, 1 6p-6a, 1 PRN both shifts), 1 PRN 6p-6a RN [ RN J] who confirmed receipt for a text in-service on abuse and neglect, 1 RN [RN G] ( 6p-6a), 1 MDS/LVN, 1 BOM, 4 Dietary [Dietary Y, DD, EE, FF], 5 Housekeeping [Housekeeping Z, AA, BB, CC, JJ], 1 Maintenance Director, 2 Therapists [Therapy GG, HH], 1 Social Worker, 1 Activity Director, 1 Medical Records/Central Supply and 1 HR. Staff interviews revealed staff had received education on abuse and neglect and were able to provide examples of neglect Staff demonstrated understanding of reporting allegations of abuse and neglect directly to the administrator immediately and reporting any concerns or complaints to the Administrator immediately. During an interview with the Administrator, 10/04/2025 at 4:03 p.m., revealed the Administrator was educated by the ADO on 10/04/2025 on ensuring the DON/ADON reviewed new wound orders and validated the orders that were transcribed into PCC accurately by auditing an order listing report and the Administrator was to investigate and report to corporate and HHSC any incidents that may be considered abuse or neglect. During an interview with the RCN, 10/05/2025 at 9:45 a.m., the RCN revealed 100% resident skin rounds were completed on 10/02/2025 that included head to toe assessments of each resident. Skin assessments were completed with detailed findings and new orders were transcribed into [EMR]. The RCN revealed multiple in-services were initiated for CNAs, licensed nurses and administration/personnel and all staff currently working had been in-serviced by discipline. The RCN stated any staff that had not been in-serviced would be in-serviced prior to the start of their shift and the in-servicing was completed by the RCN and Administrator. The RCN stated CNAs were in-serviced on 10/04/2025 and ongoing on identifying skin breakdown, reporting skin issues to the nurse immediately and where to document new findings on the kiosk. The RCN stated licensed nurses were in-serviced on 10/02/2025 regarding pressure ulcer prevention and initialing and dating dressing, documentation and completing accurate assessments, initiating wound orders upon admission/readmission, immediately assessing and notifying the physician, documenting and obtaining treatment orders when notified or observing a new skin issue and notifying the physician immediately of changes in condition. The RCN stated all facility staff were in-serviced on abuse and neglect and reporting complaints directly to the Administrator. The Administrator/DON and ADON were educated on 10/04/2025 that the DON/Designee will round with the wound care physician weekly and will ensure orders are immediately entered into the EMR when the order is verbally given by the wound care physician and the progress notes will be printed 24 hours after the wound care physician visit to ensure the orders match in the EMR. The RCN revealed the Administrator, DON and ADON were educated on expectations monitoring of the plan of removal. The RCN stated monitoring forms were created to track the monitoring, and the DON/Designee was responsible for completing and documenting on the monitoring tool. Monitoring included viewing each wound weekly and making sure the correct orders were in place and round with the wound care physician weekly. Audit all skin and ulcer assessments weekly to make sure they match the resident's current condition and audit to make sure all residents have weekly skin assessments and ulcer assessments. Review admission/readmissions to ensure the orders are transcribed correctly and appointments were scheduled as needed. Review the administration record for the completion of ordered wound treatments from the previous day and ensure all dressing have the current date and are initialed. The monitoring forms will be reviewed, signed, and dated by the RCN weekly to validate it was being completed. The RCN and ADO will attend standard of care meetings weekly. Findings from the monitoring will be brought to QAPI monthly and reviewed for compliance and changes to the plan initiated as needed. During an interview with the ADO, 10/05/2025 at 10:50 a.m., revealed the ADO educated the Administrator on 10/04/2025 regarding checking orders daily in the morning meeting and ensuring the nursing managers were reviewing wound orders and validating the orders were transcribed into the EMR. During an interview with DON, 10/05/2025 at 11:48 a.m., revealed the DON received education and training from the RCN on 10/2/2025 and 10/4/2025 regarding expectations for rounding with the wound care physician weekly and validating daily in clinical review that resident treatment orders reflect the wound care physician progress notes, wound assessments are completed weekly and on admission and readmission, each resident has appropriate wound care orders, wound dressings are accurately dated and monitoring wound administration to ensure wound treatments are completed daily. The DON stated she would track the monitoring on a monitoring log and document her findings, and the findings would be brought to the monthly QAPI to review for compliance. During an interview with Medical Director, 10/5/2025 at 2:09pm, revealed the Medical Director and [physician] were notified of the immediate jeopardy for neglect and wound care by the Administrator on 10/04/2025 and the Medical Director reviewed the plan of removal, the protocols and steps being taken to ensure compliance. Record review of a monitoring document revealed, The DON/designee will view each wound weekly to ensure the correct order is in place. The document had 5 blocks with blanks for a date, resident name, and staff name. Record review of a monitoring document revealed, The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly. The document had 5 blocks with blanks for the date, weekly skin assessments correct YES/No, staff name. Record review of a monitoring document revealed, DON/Designee will review all admissions/readmissions within 24 hours of admission. The document had 5 blocks with blanks for date, resident name, admission complete YES/NO if no describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. The document had 5 blocks for date, resident name, WAR/TAR completed YES/No If no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will assess all dressing to ensure date reflects current date. The document had 5 blocks for date, resident name, Dressing dated correctly YES/NO if no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The document had 5 blocks for date, resident name, treatment orders in place YES/NO If no, describe on back of form and staff name. Record review of an ADHOC QAPI meeting, dated 10/2/2025 revealed signatures including the Administrator, Interim DON, and ADON. The Administrator was informed that the Immediate Jeopardy was removed on 10/06/2025 at 2:24 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 8 residents (Resident #3 and Resident #34) reviewed for infection control: 1. The facility failed to ensure staff wore proper PPE while performing wound care for Resident #3. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene between glove changes while performing incontinent care for Resident #34. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #3's admission record, dated 8/29/25, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included liver cell carcinoma (liver cancer), mid protein calorie malnutrition, malignant neoplasm (cancerous tumors) of bone and articular cartilage, and alcoholic cirrhosis of liver without ascites (condition resulting from long term heavy alcohol use, characterized by the scarring of liver tissue. Unlike other forms is does not usually cause fluid retention in the abdomen). Record review of Resident #3's quarterly MDS assessment, dated 8/4/25, revealed the resident cognition was severely impaired for daily decision-making skills, and section M revealed he had 1 stage 1 pressure injury, 1 stage 4 pressure injury, 4 unstageable pressure ulcers, and 2 deep tissue injuries. Record review of Resident #3's care plan, initiated 2/7/25 revealed the resident was on enhanced barrier precautions, with interventions to gloves and gown should be donned if any of the following activities occur . wound care. Record review of Resident #3's Physician Order, dated 8/29/25, revealed the following:- Stage IV (L) Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Stage IV Sacrum Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Unstageable R Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25.-Unstageable DTI left heel, Cleanse with wound cleanser/Normal saline pat dry WITH 4X4 gauze. Apply skin prep/betadine to area left open to air as, one time a day for Skin fragility or hair/nail weakness for 30 Days with a start date of 8/11/25 and end date of 9/10/25. -Unstageable DTI left lateral foot, cleanse with wound cleanser/normal saline, pat dry with 4X4 gauze apply skin prep/betadine daily/as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. -Unstageable DTI to right ankle cleanse with wound cleanser/normal saline, pat dry with 4x4 gauze apply skin prep/betadine daily or as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. - Unstageable left hip Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. During an observation on 8/29/25 at 11:19 a.m. the ADON prepare to provide wound care to Resident #3's wounds. The ADON cleansed the residents right foot wound with skin prep, removed her gloves, and stated she forgot a PPE gown and went outside the room to put one on. During an interview on 8/29/25 at 12:34 p.m. the ADON stated she needed a gown to provide wound care to resident #3 because he was on EBP and also to prevent her from getting any wound drainage on her. During an interview on 8/29/25 at 1:15 p.m., the DON stated staff should be wearing a gown while providing wound care to Resident #3 because he was on EBP. The DON stated the gown helped protect staff and resident from infection. 2. Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes(high blood sugar levels, insulin resistance, and a relative last of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 had bowel incontinence with an intervention to check resident every 2 hours and assist with toileting as needed. During an observation on 8/29/25 at 10:54 a.m. CNA F and CNA G provided incontinent care to Resident #34. Both aides removed their gloves during the care and put on new gloves. They did not perform hand hygiene after removing soiled/used gloves, and putting on new gloves. During a joint interview on 8/29/25 at 11:11 a.m. CNA F and CNA G stated they did not have any hand sanitizer on them when they started. They stated the resident was in pain so they wanted to be quick with the incontinent care. They stated they should have preformed hand hygiene between glove changes to prevent infection to the resident. During an interview on 8/29/25 at 1:07 p.m. the DON stated staff was expected to perform hand hygiene between glove changes to provide infection control. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 3/2024, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care.After removing gloves or aprons. Record review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, stated Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following. Wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 facility reviewed for safe, clean, comfortable environment, in that: <BR/>1. In room [ROOM NUMBER], there were loose tiles around the toilet, the bolt securing the toilet to the flood was rusted, there was an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser, and the vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening.<BR/>2. A light above the sink in the Secured Unit shower room was not functioning. <BR/>3. In the bathroom of room [ROOM NUMBER], the toilet seat had a broken hinge. <BR/>4. In room [ROOM NUMBER], there were broken window blinds, there were large water marks on the ceiling panels of the bathroom, and the ceiling exhaust fan in the bathroom was separated from the ceiling. <BR/>5. In room [ROOM NUMBER], 2 of the 3 lights in the bathroom above the sink were not functioning, and the toilet was not properly secured to the floor allowing the toilet to move in place. <BR/>These failures could place residents who reside at the facility at risk of decreased quality of life due to living spaces in need to repairs. <BR/>The findings were:<BR/>1. Observation on 07/09/2024 at 11:10 AM in room [ROOM NUMBER] revealed four loose tiles around the toilet, and the bolt securing the toilet to the floor was rusted and not covered with a plastic cap. Further observation revealed an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser. The vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening.<BR/>During an interview on 07/09/2024 at 11:11 AM, the resident in room [ROOM NUMBER] stated, dirty, dirty over and over and stated the dirt made her upset. The resident appeared visibly anxious as she pointed to several areas on the floor and walls inside the bathroom with visible dirt and dust.<BR/>During an interview on 07/12/2024 at 11:20 AM , the Corporate RN stated the tiles on the floor required replacing and there was excessive dust in the bathroom that should not be there. The Corporate RN stated she heard the resident in room [ROOM NUMBER] complain about the dirt and it was apparent the resident was bothered by it. The Corporate RN also noted the vent outside the bathroom had an accumulation of debris indicating it had not been cleaned. <BR/>During an interview on 07/12/2024 at 11:45 AM, the Maintenance Director stated he was waiting on tiles to replace the ones in the bathroom of room [ROOM NUMBER]. He also stated the entire area around the toilet needed to be re-caulked and he would take care of that as well.<BR/>During an interview on 07/12/2024 at 11:50 AM, the Housekeeping Supervisor, stated room [ROOM NUMBER] needed additional cleaning service and it would be addressed.<BR/>2. During an observation tour on the 500 Hall on 07/10/24 from 9:55 AM. to 10:25 AM with the Maintenance Director revealed the following:<BR/>a. The Secured Unit shower room had a 1 of 3 lights above the sink that were not working.<BR/>b. Resident room [ROOM NUMBER] had a bathroom toilet with a broken seat hinge.<BR/>3. During an observation tour on the 2300 Hall on 07/10/24 from 9:55 AM to 10:25 AM revealed the following:<BR/>a. room [ROOM NUMBER] had 11 broken window blind slats.<BR/>b. room [ROOM NUMBER] had a bathroom ceiling panel measuring approximately 25 x 46 inches that had water markings on the panel.<BR/>c. room [ROOM NUMBER] had a bathroom ceiling exhaust fan that was separated from the ceiling.<BR/>d. room [ROOM NUMBER] had 2 of 3 lights above the sink that were not working.<BR/>e. room [ROOM NUMBER] had a bathroom toilet that was not properly seated allowing the toilet to move in place.<BR/>During an interview with the Maintenance Director on 7/10/24 at 10:15 AM, the Maintenance Director stated that he would repair all of the maintenance concerns revealed during the observation tour. The Maintenance Director stated that the repairs would improve resident safety and homelike environment.<BR/>During an interview with the Administrator on 7/10/24 at 10:30 AM, the Administrator stated that completing the maintenance repairs would improve the resident's quality of life.<BR/>Record review of the facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, revealed, The facility will repair or replace damaged/broken equipment or building amenities as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: <BR/>1. The facility failed to ensure medications prescribed to Resident #1 were documented on the MAR for multiple dates in August 2024.<BR/>2. The facility failed to ensure medications prescribed to Resident #2 were documented on the MAR for multiple dates in August 2024. <BR/>These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.<BR/>The findings included: <BR/>1. Record review of Resident #1's face sheet, dated 8/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, lack of coordination, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), conversion disorder with seizures or convulsions (a mental health disorder that can cause physical symptoms, including seizures, that a person can't control), and pain.<BR/>Record review of Resident #1's comprehensive care plan, with revision date 8/14/24 revealed the resident had a potential for uncontrolled pain with interventions that included to monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, monitor/document for side effects of pain medication and, the resident prefers to have pain controlled by medication, treatment.<BR/>Record review of Resident #1's Order Summary Report, dated 8/16/24 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG Give 1 capsule by mouth three times a day for pain, with order date 7/22/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain NTE (not to exceed) 3 GM of APAP (acetaminophen) in 24 HOURS FROM ALL SOURCES, end date 8/14/24<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain, WHILE AWAKE NTE 3 GM of APAP IN 24 HOURS FROM ALL SOURCES, with order date 8/14/24 and no end date<BR/>Record review of Resident #1's MAR (medication administration record) for August 2024 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG capsule was coded 7 on 8/8/24 and scheduled at 1:00 p.m. was not administered because the resident was sleeping<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, with end date 8/14/24 was missing documentation for a nursing assessment of Pain Level and administration of the medication on 8/2/24, 8/9/24, 8/10/24, and 8/13/24 all scheduled at 6:00 a.m.<BR/>During an interview on 8/14/24 at 1:50 p.m., Resident #1 stated nursing had refused to administer gabapentin two days ago because the dosage was too high. Resident #1 stated he was prescribed the hydrocodone-acetaminophen and the gabapentin to deal with knee pain. <BR/>2. Record review of Resident #2's face sheet, dated 8/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included psychotic disorder with delusions and hallucinations, Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), lack of coordination, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (elevated blood pressure), localized edema (swelling), pain in left hand, and hyperlipidemia (elevated cholesterol).<BR/>Record review of Resident #2's most recent quarterly MDS assessment, dated 4/30/24 revealed the resident was cognitively intact for daily decision-making skills and was treated with diuretics, antipsychotics, antianxiety and antidepressant medications and had pain.<BR/>Record review of Resident #2's comprehensive care plan, with revision date 5/22/24 revealed the following:<BR/>- resident required antidepressant medication with interventions to give antidepressant medications ordered by physician and monitor/document side effects and effectiveness<BR/>- resident has Parkinson's with interventions that included to give medications as ordered by the physician and monitor/document side effects and effectiveness<BR/>- resident has hypertension with interventions that included to give anti-hypertensive medications as ordered and monitor/document side effects and effectiveness<BR/>- resident required anti-psychotic medications with interventions that included to administer medications as orders and monitor/document for side effects and effectiveness<BR/>- resident on diuretic therapy with interventions that included to administer medication as orders and to monitor vital signs as ordered and report to the physician if abnormal for this resident<BR/>- resident has a potential for uncontrolled pain with interventions that included to administer analgesia as per orders<BR/>Record review of Resident #2's Order Summary Report dated 8/19/24 revealed the following:<BR/> - Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day for edema to low extremities edema to low extremities with start date 6/20/22 and no end date<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 with start date 4/22/24 and no end date<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain with order date 6/27/24 and no end date<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 5/4/24 and no end date <BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day for Sexual Inappropriate Disorder with order date 7/2/24 and no end date<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day related to PARKINSON'S DISEASE: PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION with order date 8/10/23 and no end date<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day related to OVERACTIVE BLADDER with order date 7/12/23 and no end date<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Give along with the 300 mg to equal 500 mg with order date 6/10/24 and no end date<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 2/17/23 and no end date<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day for parkinson's disease with order date 9/11/23 and no end date<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day for dementia give 2 caps to equal 6 mg BID (twice a day) with order date 10/17/23 and no end date<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION give with 600 mg tab to equal 900 mg total BID with order date 2/12/24 and no end date<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED with order date 1/17/24 and no end date<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain with order date 1/25/22 and no end date<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a day for pain NTE (not to exceed) 3gm in 24 hours from all sources with order date 6/27/24 and no end date<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day for restless leg syndrome with order date 4/11/24 and no end date<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours for pain APPLY IN AM AND REMOVE AT BEDTIME and remove per schedule with order date 4/7/24 and no end date<BR/>Record review of Resident #2's MAR for August 2024 revealed the following:<BR/>- Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 was missing documentation on 8/4/24 and 8/13/24<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain was missing documentation on 8/4/24<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime was missing documentation on 8/16/24 and 8/17/24<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day was missing documentation on 8/4/24<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m. and 8:00 p.m.<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m., and 1:00 p.m., 8/10/24 at 1:00 p.m., 8/13/24 at 1:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 1:00 p.m. and 8:00 p.m.<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 9:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m., and 9:00 p.m.<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day was missing documentation on 8/2/24 at 12:00 a.m., and 6:00 a.m., 8/3/24 at 12:00 a.m., and 6:00 a.m., 8/4/24 at 6:00 a.m., and 12:00 p.m., 8/5/24 at 6:00 a.m., 8/8/24 at 6:00 a.m., 8/9/24 at 6:00 a.m., 8/10/24 at 12:00 p.m., 8/11/24 at 6:00 a.m., 8/13/24 at 6:00 a.m., and 12:00 p.m., 8/14/24 at 6:00 a.m., 8/14/24 at 6:00 a.m., and 8/17/24 at 12:00 p.m.<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours was missing documentation on 8/4/24, 8/13/24 and 8/17/24<BR/>During an interview on 8/16/24 at 10:45 a.m., Resident #2 stated she had lived in the facility for about 3 &frac12; years and did not take medication for pain very often, but if in pain and wanted medication, they would give it to me.<BR/>During an interview on 8/16/24 at 12:59 p.m., LVN A revealed, the facility policy was to administer scheduled medications within a two-hour window. LVN A stated, if a resident missed a scheduled medication because the resident was not in the facility or the resident refused the medication, then a reason why the medication was not given had to be documented in the clinical record. LVN A revealed there should not be any empty spaces in the MAR because it looked like the dosage was skipped. LVN A stated, you still have to give a reason why it was not given.<BR/>During an interview on 8/16/24 at 1:26 p.m., RN B revealed there was an opportunity to administer a scheduled medication an hour before or an hour after the medication was scheduled. RN B stated, a pain medication required a pain assessment by the nurse and documentation when the medication was given. RN B stated, we notify the resident if the medication is given late and we should notify the doctor if the medication was late or missed. RN B stated, there should not be any holes in the MAR. There should be some kind of documentation because it not it will look like the medication was not given and the nurse ignored it.<BR/>During an interview on 8/16/24 at 2:09 p.m., LVN C stated, there should not be any holes in the MAR and if there is no explanation why there was no documentation, you might assume the medication was not given. If it's not documented, it was not given. LVN C further stated, the missing documentation made it appear as if the medication was not administered and that was not acceptable. LVN C stated, I know some of the nurses don't know how to document in the electronic record.<BR/>During an interview and record review on 8/16/24 at 3:33 p.m., the DON revealed, Resident #1 had scheduled hydrocodone-acetaminophen and had it prn (as needed). The DON stated she believed nursing staff were not administering the scheduled hydrocodone-acetaminophen medication because the resident would be sleeping and nursing staff were waiting to administer the prn dose. The DON, after reviewing Resident #1's MAR and the narcotic log stated Resident #1 was given the medication according to the narcotic log, but it was incorrect because it was not documented in the computer that it was given and there was no pain assessment for the actual time the medication was given, so it's a clinical record issue. The DON revealed there should not be any holes in the MAR because there was a doctor's order to assess for pain and no documentation looks like the medication was not given. The DON stated, she and the ADON were responsible for doing routine audits on documentation on the MAR but admitted they had not kept up with it.<BR/>During an interview and record review on 8/16/24 at 4:20 p.m., LVN D stated, missing documentation on the MAR looks like the medication was not given. LVN D, after reviewing Resident #1's MAR stated, there should be documentation in the resident's record that explained why the medication was not given. If there's no documentation it wasn't done. LVN D, referring to the blanks on the MAR then stated, on the 9th (of August) I probably got sidetracked, maybe working with another resident and I guess when I counted with the nurse the narcotic log at the end of the shift, the count was correct, I just left. LVN D stated Resident #1 had not complained to her about not getting pain medication and had never seen the resident in pain.<BR/>Record review of the facility policy and procedure titled, Medication Administration Procedures 2003, revealed in part, .All medications are administered by licensed medical or nursing personnel .administer the medication and immediately chart doses administered on the medication administration record .If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record .An explanation as to symptoms prior to administration and results are to be documented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident for 1 of 17 (Resident #29) in that:<BR/>The facility failed to honor Resident #29's right to present when Administrator A entered the resident's room and misappropriated personal items and threw them away in the trash. <BR/>This failure could result in residents experiencing a decline in self-worth and quality of life. <BR/>The findings were: <BR/>Record review of Resident #29's face sheet, dated 06/26/24, revealed a [AGE] year-old female resident who was re-admitted on [DATE] with diagnoses that included: end stage renal disease, anxiety, major depressive disorder, HTN (hypertension). Resident was her own RP. <BR/>Record review of Resident #29's quarterly MDS dated [DATE] revealed BIMS score was 15 (cognitively intact).<BR/>Record review of Resident# 29's Care Plan, undated, revealed the resident had major depression and interventions included: monitor feelings of worthlessness.<BR/>Record review of facility's self report dated 5/31/24 revealed that on 5/31/24 at 3:12 PM Resident #29 complained that Administrator B threw out some of her personal belongings while she (the resident) was away at a dialysis appointment. Resident #29 reacted when she returned to the facility by crying and expressing feelings of being nothing. There were three witnesses to the incident on 5/31/24 (LVN B, LVN C and Hospitality Aide D). <BR/>Record review of Resident #29's General Note noted dated 5/31/24 at 1:28 PM authored by Administrator A revealed: the administrator and housekeeping entered Resident #29's room to throw away trash and expired foods. The Administrator had informed Resident #29 about one month ago that the room needed to be cleaned. The administrator stated that clothing on the floor was sent to the laundry. [The General Note did not address the resident's right to be present and to consent]<BR/>Record review of Resident #29's Dialysis Center Communication Form revealed on 5/3/124, Resident went to dialysis and returned; vital signs were normal and assessment completed on access port.<BR/>Record review of facility's internal investigation file revealed:<BR/>Employee [Administrator A] disciplinary Report revealing suspension on 5/31/24 for alleged abuse of a resident. <BR/>Written Statements revealed: <BR/>o 6/3/24: Housekeeper F wrote that the Administrator [A] was cleaned Resident #29's room and threw out trash.<BR/>o 6/2/24: ADON, wrote: Resident #29 was in emotional distress . The resident was upset and traumatized because items were thrown away from her room. <BR/>o 6/1/24: The Admissions Coordinator wrote: she follow-up with Resident #29 and the resident was still upset over items from her room thrown in trash bags. The admission Coordinator in the written statement that the resident [#29] had sentimental value to some of the items thrown away.<BR/>o 5/31/24:Hospitality Aide D wrote: Resident #1 was upset over items thrown away from her room. The resident estimated the value of the items thrown away at $300. The Administrator [A] told Resident #29 that items were thrown away and put in a trash bag. Resident #29 yelled at the administrator and the administrator left the scene.<BR/>o 5/31/24: LVN C wrote: Resident #29 was yelling at the Nurse Station and alleged that $300 worth of items were thrown away from her room. The Resident and the administrator had a brief argument which resulted in the administrator going to her office and the resident to the dining hall. <BR/>o 5/31/24: Admissions Coordinator wrote: Resident #29 yelled at the administrator over items taken from her room. The resident was upset. <BR/>o 5/31/24: SW wrote: she witnessed resident [#29] and the administrator arguing over items thrown away from the resident's room. The resident was very upset.<BR/>o 5/31/24: Resident# 29 wrote: the items thrown away were valued at $300 which included clothing and figurines and foodies. The resident stated, She made me feel like I was noting and that she could do whatever she want with my things.<BR/>o 5/31/:24: LVN B wrote: the resident [#29] was upset at the nurse station alleging that the administrator threw away items from her room. The administrator and the resident had a brief argument where the administrator stated she only threw away trash. The resident was visibly upset. <BR/> o6/3/24: Activity Director wrote: she purchased for the resident [#29] some of the missing items at a local store. Receipt 5/3/23 from resident purchase of figurines worth $69. Receipt 4/21/23 from resident purchase of figurines worth $105. <BR/>During an interview on 6/26/24 at 1:45 PM, Corporate RN stated: the incident reported to HHS read resident complain[ed] that Administrator [A] threw out some of her personal belongings, making her feel like she was nothing and could just do whatever she wanted to do with her stuff. Corporate RN stated that an investigation revealed the Administrator [A] was cleaning trash and food and a bag with trash and clothing were removed from the room. The Corporate RN stated that initially the resident did not approve of the trash removal. The former administrator [A] showed the bag to the resident and the resident was able to remove some of her belongings. The Corporate RN added, the trash bag was thrown out and the resident claimed trinkets were missing. The facility purchased for the resident the missing trinkets [valued at $172] and the resident was satisfied. The Corporate RN stated that she does not know why the former administrator[A] did not stop taking the trash out of the room because of resident rights and the resident was not present. The Corporate RN stated that if a resident said stop regarding a trash bag that may contained clothing the former administrator should have stopped and assess what other options were available. The Corporate RN stated the former administrator [A] was not terminated because of the incident; but rather other events at the time of the incident contributed to the administrator's suspension pending an investigation. The Corporate RN stated that she could not confirm the General Note dated 5/31/24 that Resident 29's clothing on the floor was sent to the laundry. Corporate RN stated at the time of the incident the resident was not present in the room when the Administrator[A]entered the room and threw out personal items from the room belonging to the resident. The Corporate RN stated that the actions of Administrator A on 5/3/24 could be considered a violation of resident rights. <BR/>Observation and interview on 6/26/24 at 2:15 PM, Resident #29 was in her room, in bed, watching TV; alert and oriented to time, person, and place. The room was cluttered with many items to include: clothing, trinkets, trash, and bottle of apple juice on the floor; and other items on the window sill. The resident stated she had dialysis that morning (6/26/24. The resident stated, I was in dialysis on 5/31/24 in the morning and returned around 10:30 am-11:00 am .when I returned I went to the dining room and returned to my room in the afternoon .I saw that my red bag on the floor was missing and saw it near a trash bag near the kitchen .in the bag I had foodies .and Activity Director purchased about $300 of staff [after the grievance was filed on 5/3/124]. Resident added, the Administrator [A] threw away my crayons and color pencils and anything she felt was trash .this happened when I has not in the room . I did not give permission for the removal of items and I was not told the date of removal . I got angry and upset and went to the nurse's station .they did not tell me when they were going to clean my room .I was not present when they entered my room and did not give permission .I was upset .I was crying in the lobby .I wanted to be present if they wanted to clean my room .I never got clothing returned .they did not do anything .they threw away my colored pencils . I am still upset .I do not trust staff .[resident teared during the interview].<BR/>During an interview on 6/26/24 at 3:19 PM, the ADON stated: 5/31/24 the resident's room [Resident #29] was search by the former administrator [A]. The ADON stated that the resident was not present when the room was searched on 5/31/24 and it is not right to search a resident's room without permission and throw out items . The ADON stated Resident #29 was upset on 5/31/24 because personal belongings were thrown out by the former Administrator [A]. The ADON expressed the opinion based on observations of the resident and monitoring for days after the incident the resident did not exhibit signs and symptoms of psychosocial harm. The ADON stated that the actions of the Administrator [A] could be a violation of resident rights; given the resident was not present. <BR/>During a joint interview on 6/26/24 at 3:32 PM with Hospitality Aide D and LVN C, LVN C stated: they both saw Resident #29 crying at the Nurse Station on 5/31/24 between 2-3 PM. LVN C stated, the resident alleged that the Administrator [A] threw away stuff from her room without permission. LVN C and Hospitality D both stated that based on resident rights a staff member cannot entered a resident's room without permission and throw things away. Hospitality Aide D stated that Resident #29 cried about one hour. LVN C stated she [Resident #29] was pretty upset. Both the Hospitality Aide D and LVN C stated the resident was upset but did not show after the event signs and symptoms of psychosocial harm. <BR/>During an interview on 6/26/24 at 3:39 PM, LVN B stated that he was present on 5/31/24 around 2-3 PM and the resident [Resident 329] was crying at the nurse station. LVN B stated, The resident was hollering and crying and alleged that the previous Administrator [A] had thrown away personal items; valued around $300. LVN B stated, the Administrator [A] and Resident #2 had a brief encounter for less than a minute at the nurse station and the resident left for the TV room; the administrator returned to her office. LVN B stated that staff cannot enter and search a resident's room without a resident's permission and the resident being present. LVN B stated that the resident was upset but did not suffer psychosocial harm. <BR/>During an interview on 6/24/24 at 4:16 PM, the DON stated: she was not present at the time of the incident. The DON stated, the facility attempted to recover some of Resident #29's missing items and purchased for Resident #29 items of similar value costing $170. The DON stated that no staff member can enter a resident's room without permission in violation of resident rights. The DON stated, the resident did not suffer psychosocial harm except at the time of the incident staff witnessed the resident crying. <BR/>During an interview on 6/26/24 at 4:24 PM, the Administrator [E] stated: stated that permission was required to enter a resident's room and the resident should be present if a search of the room was planned. Administrator E stated that he could not give an explanation as to why Administrator A entered a resident's room without permission and the resident was not present and misappropriated personal property. The Administrator E stated the actions of Administrator A fell in the realm of resident rights. <BR/>During an interview on 6/26/24 at 4:40 PM, the Activity Director stated she purchased $170 of items for the resident after the incident on 5/31/24; and the resident was satisfied with the purchase. The Activity Director stated that after the incident the resident did not reveal signs or symptoms of psychosocial harm. <BR/>During telephone interview on 6/26/24 at 5:05 PM, the former Administrator [A]stated: she told the resident [#29] the previous week that hall 200 to include her room were going to be cleaned for trash and food items. The former administrator stated she went into Resident #29's room who was not present and threw away trash, expired foods, and sent dirty linen to the laundry room. The former administrator stated that around 12:30 PM she heard the resident yelling that someone had entered her room and threw away her items. The former administrator when asked about resident rights responded, the resident was not present when the cleaning of the room occurred. The former administrator stated that the resident was told that cleaning of her room would occur sometime in late May 2024. The former administrator stated the resident did not like things thrown away. The former administrated stated that Resident [#29] room had to be cleaned out of safety and infection control concerns. <BR/>Record review of facility's Resident [NAME] of Rights undated read: .You have the right to be free of interference, coercion, discrimination, or reprisal .You have the right to retain and use personal possessions .unless to do so would infringe upon the health and safety of other residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat residents with dignity and respect of personal possessions for 1 of 17 residents (Resident #17) reviewed for resident rights, in that:<BR/>Hospitality Aide D turned off, on 12/23/23 at 3:44 PM, Resident #17's electronic monitoring device, a personal possession, without asking for permission to turn off the device. <BR/>This deficient practice could affect residents who reside at the facility and result in a loss of personal property, frustration and loss of dignity. <BR/>The findings were: <BR/>Record review of Resident #17's face sheet, dated 6/27/24 revealed, a [AGE] year old male who was admitted on [DATE] and discharged [DATE] home with diagnoses that included: HEMIPLEGIA AND HEMIPARESIS ( paralysis of one side of the body), FOLLOWING CEREBRAL INFARCTION (stroke), DEMENTIA, and PARANOID PERSONALITY DISORDER. Resident was his own RP. <BR/>Record review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 10 (moderately impaired). <BR/>Record review of Intake #472623, dated 12/13/23, the facility's self report revealed a family member alleged that staff would turn off Resident's electronic monitoring devise and would neglect the resident.<BR/>Record review of Resident17's Care Plan, undated, revealed, the resident had sexual acting out behaviors, exposed himself, and was racially inappropriate. Interventions included medications, monitoring, and interacting with the resident in a positive manner. The CP also revealed that the resident was non-compliant with medications.<BR/>Record review of Resident #17's Nurse Notes from 12/23/23 to 1/15/24 revealed that call lights were answered by staff and resident would engage in appropriate sexual behaviors directed at staff. [no mention of electronic devise turned off]<BR/>Record review of Resident #17's Nurse Note dated 12/24/23 revealed that resident was calm and cooperative with a skin assessment. [intervention after a family member alleged the resident's camera was turned off on 12/23/23]<BR/>Record review of Resident #17's skin assessment dated [DATE] revealed no injuries, bruises or skin tears .<BR/>Record review of Resident #17's skin assessment on 12/26/24 revealed: skin intact.<BR/>Record review of Resident #17's weekly nurse note dated 12/28/23 revealed: refuses meds, refused showers and refused care by CNAs . <BR/>Record review of Resident #17's ADL sheets for the month of December 2023 revealed resident was given ADLs in bathing, toileting, changing, and peri-care. Resident did not refused ADLs. <BR/>Observation of Resident #17's video dated 12/23/23 at 3:44 PM revealed Hospitality Aide D was observed adjusting resident's position in the bed while the resident had no brief on, on the left side of the bed, and the resident made some un-audio statements. Hospitality Aide D maneuvers to the right side of the resident's bed and hovers over the resident and responds to the resident with the question of what did you say? Hospitality Aide D then leaves the resident's bedside towards the camera and turned off resident's camera; and is seen with his hand over the camera lens, video stream then disconnected.<BR/>During an interview on 7/1/24 at 3:11 PM, LVN G stated the resident was sexually inappropriate with staff; and would expose himself. LVN G stated that call lights were answered and she had no knowledge that any staff member would turn off the camera when interacting with the resident or providing treatments and services. <BR/>During an interview on 7/2/24 at 8:20 AM, LVN C stated: the resident was sexually inappropriate with staff and received treatment with 2 staff present. Treatment and services given to the resident included: medication management with refusal of psychotropics, assessments and vital signs, monitoring , behavior management, and rehabilitation. LVN C stated that the resident was not neglected and discharged home. LVN C stated that she had no information that staff interfered with Resident #17 and denied him his dignity and denied the respect of personal possessions. <BR/>During an interview on 7/2/24 at 8:25 AM, LVN B stated: the resident was sexually inappropriate with staff and received treatment with staff present. Treatment and services given to the resident included: medication management with refusal of psychotropics, assessments and vital signs, monitoring , behavior management, and rehabilitation. LVN B added that the resident also refused labs and medical recommendations. LVN B was not aware of any staff turning off the resident's camera as the resident's personal possession. <BR/>During an interview on 7/2/24 at 1:31 PM, Hospitality Aide H stated he had interactions with the resident in December 2023 and he did not witness or perpetrate abuse against the resident. Hospitality Aide H stated that Resident #17 resident would unplug his camera. Hospitality Aide H stated that the resident never made any allegations of abuse. <BR/>During an interview on 7/2/24 at 1:45 PM Hospitality Aide D stated he never witnessed or saw any staff being rough with Resident #17. Hospitality Aide D stated that no staff member turned off the resident's camera in the room. Hospitality Aide D stated that the resident never alleged abuse to him. Hospitality Aide D denied ever turning off Resident #17's camera and not respecting the resident's personal possessions. <BR/>During an interview on 7/2/24 at 2:10 PM, the DON stated: the roommate was unplugging the camera; the facility responded by having the Resident #17 room by himself. Regarding rough treatment, the DON stated there was no evidence of the resident being abused. Preventative measures included: monitoring, and no roommate. Staff was in-service on abuse and neglect. <BR/>Record review of facility's Resident [NAME] of Rights undated read: .You have the right to be free of interference, coercion, discrimination, or reprisal .You have the right to retain and use personal possessions .unless to do so would infringe upon the health and safety of other residents . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 17 residents (Resident #29) reviewed for misappropriation and exploitation, in that:<BR/>The facility did not prevent Resident #29's personal belongings from being lost when the former Administrator (A) without the resident's permission or the resident being present removed personal items from the resident's room. <BR/>This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings. <BR/>The findings included:<BR/>Record review of Resident #29's face sheet, dated 06/26/24, revealed a [AGE] year-old female resident who was re-admitted on [DATE] with diagnoses that included: end stage renal disease, anxiety, major depressive disorder, HTN (hypertension). Resident was her own RP. <BR/>Record review of Resident #29's quarterly MDS dated [DATE] revealed BIMS score was 15 (cognitively intact).<BR/>Record review of Resident #29's Care Plan, undated, revealed the resident had major depression and interventions included: monitor feelings of worthlessness.<BR/>Record review of facility's self report dated 5/31/24 revealed that on 5/31/24 at 3:12 PM Resident #29 complained that Administrator B threw out some of her personal belongings while she (the resident) was away at a dialysis appointment. Resident #29 reacted when she returned to the facility by crying and expressing feelings of being nothing. There were three witnesses to the incident on 5/31/24 (LVN B, LVN C and Hospitality Aide D). <BR/>Record review of Resident #29's General Note noted dated 5/31/24 at 1:28 PM authored by Administrator A revealed: the administrator and housekeeping entered Resident #29's room to throw away trash and expired foods. The Administrator had informed Resident #29 about one month ago that the room needed to be cleaned. The administrator stated that clothing on the floor was sent to the laundry. <BR/>Record review of Resident #29's Dialysis Center Communication Form revealed on 5/3/124, Resident went to dialysis and returned; vital signs were normal and assessment completed on access port.<BR/>Record review of facility's internal investigation file revealed:<BR/>Employee [Administrator A] disciplinary Report revealing suspension on 5/31/24 for alleged abuse of a resident. <BR/>Written Statements revealed: <BR/>o 6/3/24: Housekeeper F wrote that the Administrator [A] was cleaned Resident #29's room and threw out trash.<BR/>o 6/2/24: ADON, wrote: Resident #29 was in emotional distress . The resident was upset and traumatized because items were thrown away from her room. <BR/>o 6/1/24: The Admissions Coordinator wrote: she follow-up with Resident #29 and the resident was still upset over items from her room thrown in trash bags. The admission Coordinator in the written statement that the resident [#29] had sentimental value to some of the items thrown away.<BR/>o 5/31/24: Hospitality Aide D wrote: Resident #1 was upset over items thrown away from her room. The resident estimated the value of the items thrown away at $300. The Administrator [A] told Resident #29 that items were thrown away and put in a trash bag. Resident #29 yelled at the administrator and the administrator left the scene.<BR/>o 5/31/24: LVN C wrote: Resident #29 was yelling at the Nurse Station and alleged that $300 worth of items were thrown away from her room. The Resident and the administrator had a brief argument which resulted in the administrator going to her office and the resident to the dining hall. <BR/>o 5/31/24: Admissions Coordinator wrote: Resident #29 yelled at the administrator over items taken from her room. The resident was upset. <BR/>o 5/31/24: SW wrote: she witnessed resident [#29] and the administrator arguing over items thrown away from the resident's room. The resident was very upset.<BR/>o 5/31/24: Resident# 29 wrote: the items thrown away were valued at $300 which included clothing and figurines and foodies. The resident stated, She made me feel like I was noting and that she could do whatever she want with my things.<BR/>o 5/31/:24: LVN B wrote: the resident [#29] was upset at the nurse station alleging that the administrator threw away items from her room. The administrator and the resident had a brief argument where the administrator stated she only threw away trash. The resident was visibly upset. <BR/>o 6/3/24: Activity Director wrote: she purchased for the resident [#29] some of the missing items at a local store. Receipt 5/3/23 from resident purchase of figurines worth $69. Receipt 4/21/23 from resident purchase of figurines worth $105. <BR/>Record review of Resident #29's vitals taken 0n 5/31/24 at 10:31 AM revealed: normal ranges.<BR/>Record review of Resident 29's Psychiatric Note authored by a community mental health provider dated 6/10/24 revealed: the resident did not exhibit any distress and denied depression. The report read: .Currently reports feeling well and denies having any problems with other residents. Depression: Patient denies symptoms of sad moods, loss of interest, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing, decreased concentration, suicidal ideation/intent/plan and appetite change. Patient denies a history of sad moods, loss of interest, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing, decreased concentration, suicidal ideation/intent/plan and appetite change .[psychotropic medications medication revealed] patient at this time is currently well controlled .<BR/>During an interview on 6/26/24 at 1:45 PM, Corporate RN stated: the incident reported to HHS read resident complain[ed] that Administrator [A] threw out some of her personal belongings, making her feel like she was nothing and could just do whatever she wanted to do with her stuff. Corporate RN stated that an investigation revealed the Administrator [A] was cleaning trash and food and a bag with trash and clothing were removed from the room. The Corporate RN stated that initially the resident did not approve of the trash removal. The former administrator [A] showed the bag to the resident and the resident was able to remove some of her belongings. The Corporate RN added, the trash bag was thrown out and the resident claimed trinkets were missing. The facility purchased for the resident the missing trinkets [valued at $172] and the resident was satisfied. The Corporate RN stated that she does not know why the former administrator[A] did not stop taking the trash out of the room because of resident rights and the resident was not present. The Corporate RN stated that if a resident said stop regarding a trash bag that may contained clothing the former administrator should have stopped and assess what other options were available. The Corporate RN stated the former administrator [A] was not terminated because of the incident; but rather other events at the time of the incident contributed to the administrator's suspension pending an investigation. The Corporate RN stated that she could not confirm the General Note dated 5/31/24 that Resident #29's clothing on the floor was sent to the laundry. Corporate RN stated at the time of the incident the resident was not present in the room when the Administrator[A]entered the room and threw out personal items from the room belonging to the resident. <BR/>Observation and interview on 6/26/24 at 2:15 PM, Resident #29 was in her room, in bed, watching TV; alert and oriented to time, person, and place. The room was cluttered with many items to include: clothing, trinkets, trash, and bottle of apple juice on the floor; and other items on the window sill. The resident stated she had dialysis that morning (6/26/24. The resident stated, I was in dialysis on 5/31/24 in the morning and returned around 10:30 am-11:00 am .when I returned I went to the dining room and returned to my room in the afternoon .I saw that my red bag on the floor was missing and saw it near a trash bag near the kitchen .in the bag I had foodies .and Activity Director purchased about $300 of staff [after the grievance was filed on 5/3/124]. Resident added, the Administrator [A] threw away my crayons and color pencils and anything she felt was trash .this happened when I has not in the room . I did not give permission for the removal of items and I was not told the date of removal . I got angry and upset and went to the nurse's station .they did not tell me when they were going to clean my room .I was not present when they entered my room and did not give permission .I was upset .I was crying in the lobby .I wanted to be present if they wanted to clean my room .I never got clothing returned .they did not do anything .they threw away my colored pencils . I am still upset .I do not trust staff .[resident teared during the interview].<BR/>During an interview on 6/26/24 at 3:19 PM, the ADON stated: 5/31/24 the resident's room [Resident #29] was search by the former administrator [A]. The ADON stated that the resident was not present when the room was searched on 5/31/24 and it is not right to search a resident's room without permission and throw out items . The ADON stated Resident #29 was upset on 5/31/24 because personal belongings were thrown out by the former Administrator [A]. The ADON expressed the opinion based on observations of the resident and monitoring for days after the incident the resident did not exhibit signs and symptoms of psychosocial harm. <BR/>During a joint interview on 6/26/24 at 3:32 PM with Hospitality Aide D and LVN C, LVN C stated: they both saw Resident #29 crying at the Nurse Station on 5/31/24 between 2-3 PM. LVN C stated, the resident alleged that the Administrator [A] threw away stuff from her room without permission. LVN C and Hospitality D both stated that based on resident rights a staff member cannot entered a resident's room without permission and throw things away. Hospitality Aide D stated that Resident #29 cried about one hour. LVN C stated she [Resident #29] was pretty upset. Both the Hospitality Aide D and LVN C stated the resident was upset but did not show after the event signs and symptoms of psychosocial harm. <BR/>During an interview on 6/26/24 at 3:39 PM, LVN B stated that he was present on 5/31/24 around 2-3 PM and the resident [Resident 329] was crying at the nurse station. LVN B stated, The resident was hollering and crying and alleged that the previous Administrator [A] had thrown away personal items; valued around $300. LVN B stated, the Administrator [A] and Resident #2 had a brief encounter for less than a minute at the nurse station and the resident left for the TV room; the administrator returned to her office. LVN B stated that staff cannot enter and search a resident's room without a resident's permission and the resident being present. LVN B stated that the resident was upset but did not suffer psychosocial harm. <BR/>During an interview on 6/24/24 at 4:16 PM, the DON stated: she was not present at the time of the incident. The DON stated, the facility attempted to recover some of Resident #29's missing items and purchased for Resident #29 items of similar value costing $170. The DON stated that no staff member can enter a resident's room without permission in violation of resident rights. The DON stated, the resident did not suffer psychosocial harm except at the time of the incident staff witnessed the resident crying. <BR/>During an interview on 6/26/24 at 4:24 PM, the Administrator [E] stated: stated that permission was required to enter a resident's room and the resident should be present if a search of the room was planned. Administrator E stated that he could not give an explanation as to why Administrator A entered a resident's room without permission and the resident was not present and misappropriated personal property. <BR/>During an interview on 6/26/24 at 4:40 PM, the Activity Director stated she purchased $170 of items for the resident after the incident on 5/31/24; and the resident was satisfied with the purchase. The Activity Director stated that after the incident the resident did not reveal signs or symptoms of psychosocial harm. <BR/>During telephone interview on 6/26/24 at 5:05 PM, the former Administrator [A]stated: she told the resident [#29] the previous week that hall 200 to include her room were going to be cleaned for trash and food items. The former administrator stated she went into Resident #29's room who was not present and threw away trash, expired foods, and sent dirty linen to the laundry room. The former administrator stated that around 12:30 PM she heard the resident yelling that someone had entered her room and threw away her items. The former administrator when asked about resident rights responded, the resident was not present when the cleaning of the room occurred. The former administrator stated that the resident was told that cleaning of her room would occur sometime in late May 2024. The former administrator stated the resident did not like things thrown away. The former administrated stated that Resident [#29] room had to be cleaned out of safety and infection control concerns. <BR/>Record review of facility's Resident [NAME] of Rights undated read: .You have the right to be free of interference, coercion, discrimination, or reprisal .You have the right to retain and use personal possessions .unless to do so would infringe upon the health and safety of other residents . <BR/>Record review of facility's Abuse/Neglect policy dated 3/19/18 read: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 facility reviewed for safe, clean, comfortable environment, in that: <BR/>1. In room [ROOM NUMBER], there were loose tiles around the toilet, the bolt securing the toilet to the flood was rusted, there was an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser, and the vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening.<BR/>2. A light above the sink in the Secured Unit shower room was not functioning. <BR/>3. In the bathroom of room [ROOM NUMBER], the toilet seat had a broken hinge. <BR/>4. In room [ROOM NUMBER], there were broken window blinds, there were large water marks on the ceiling panels of the bathroom, and the ceiling exhaust fan in the bathroom was separated from the ceiling. <BR/>5. In room [ROOM NUMBER], 2 of the 3 lights in the bathroom above the sink were not functioning, and the toilet was not properly secured to the floor allowing the toilet to move in place. <BR/>These failures could place residents who reside at the facility at risk of decreased quality of life due to living spaces in need to repairs. <BR/>The findings were:<BR/>1. Observation on 07/09/2024 at 11:10 AM in room [ROOM NUMBER] revealed four loose tiles around the toilet, and the bolt securing the toilet to the floor was rusted and not covered with a plastic cap. Further observation revealed an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser. The vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening.<BR/>During an interview on 07/09/2024 at 11:11 AM, the resident in room [ROOM NUMBER] stated, dirty, dirty over and over and stated the dirt made her upset. The resident appeared visibly anxious as she pointed to several areas on the floor and walls inside the bathroom with visible dirt and dust.<BR/>During an interview on 07/12/2024 at 11:20 AM , the Corporate RN stated the tiles on the floor required replacing and there was excessive dust in the bathroom that should not be there. The Corporate RN stated she heard the resident in room [ROOM NUMBER] complain about the dirt and it was apparent the resident was bothered by it. The Corporate RN also noted the vent outside the bathroom had an accumulation of debris indicating it had not been cleaned. <BR/>During an interview on 07/12/2024 at 11:45 AM, the Maintenance Director stated he was waiting on tiles to replace the ones in the bathroom of room [ROOM NUMBER]. He also stated the entire area around the toilet needed to be re-caulked and he would take care of that as well.<BR/>During an interview on 07/12/2024 at 11:50 AM, the Housekeeping Supervisor, stated room [ROOM NUMBER] needed additional cleaning service and it would be addressed.<BR/>2. During an observation tour on the 500 Hall on 07/10/24 from 9:55 AM. to 10:25 AM with the Maintenance Director revealed the following:<BR/>a. The Secured Unit shower room had a 1 of 3 lights above the sink that were not working.<BR/>b. Resident room [ROOM NUMBER] had a bathroom toilet with a broken seat hinge.<BR/>3. During an observation tour on the 2300 Hall on 07/10/24 from 9:55 AM to 10:25 AM revealed the following:<BR/>a. room [ROOM NUMBER] had 11 broken window blind slats.<BR/>b. room [ROOM NUMBER] had a bathroom ceiling panel measuring approximately 25 x 46 inches that had water markings on the panel.<BR/>c. room [ROOM NUMBER] had a bathroom ceiling exhaust fan that was separated from the ceiling.<BR/>d. room [ROOM NUMBER] had 2 of 3 lights above the sink that were not working.<BR/>e. room [ROOM NUMBER] had a bathroom toilet that was not properly seated allowing the toilet to move in place.<BR/>During an interview with the Maintenance Director on 7/10/24 at 10:15 AM, the Maintenance Director stated that he would repair all of the maintenance concerns revealed during the observation tour. The Maintenance Director stated that the repairs would improve resident safety and homelike environment.<BR/>During an interview with the Administrator on 7/10/24 at 10:30 AM, the Administrator stated that completing the maintenance repairs would improve the resident's quality of life.<BR/>Record review of the facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, revealed, The facility will repair or replace damaged/broken equipment or building amenities as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 7 of 28 residents (Resident #13, #15, #17, #25, #37, #54, and #61) reviewed for palatable and appetizing food, in that:<BR/>1. The facility served Resident #25 a breakfast meal 1 hour and 2 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident.<BR/>2. The facility served Resident #13 a breakfast meal 58 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident.<BR/>3. The facility served Resident #61 a breakfast meal 56 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident.<BR/>4. The facility served Resident #37 a breakfast meal 54 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident.<BR/>5. The facility served Resident #15 a breakfast meal 45 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident.<BR/>6. Residents #17 and #54 were food served cold food, and was not palatable to the resident. <BR/>These failures could place residents at risk for harm by demoralization, diminished quality of life, and weight loss. <BR/>The findings included:<BR/>1. A record review of Resident #25's admission record dated 07/11/2024 revealed an admission date of 11/18/2022 with diagnoses which included muscle wasting. <BR/>A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was a [AGE] year-old male admitted for long term care. Resident #25 was assessed with a BIMS score of 15 out of 15 which indicated no cognitive impairment. <BR/>A record review of Resident #25's care plan dated 07/11/2024 revealed, current diet: regular diet with regular texture and thin liquids . Monitor/record/report to MD signs and symptoms of malnutrition <BR/>A record review of Resident #25's physicians orders dated 07/11/2024 revealed the physician ordered Resident #25 to receive nursing facility care.<BR/>2. A record review of Resident #13's admission record dated 07/11/2024 revealed an admission date of 07/10/2024 with diagnoses which included muscle wasting.<BR/>A record review of Resident #13's quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of a possible 15 which indicated moderate cognitive impairment.<BR/>A record review of Resident #13's care plan dated 07/11/2024 revealed, the resident has nutritional problem or potential nutritional problem current diet: regular with regular consistency fluids . Monitor/record/report to MD signs and symptoms of malnutrition <BR/>3. A record review of Resident #61's admission record revealed an admission date of 05/01/2024 with diagnoses which included protein-calorie malnutrition.<BR/>A record review of Resident #61's admission MDS assessment dated [DATE] revealed Resident #61 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 12 out of a possible 15 which indicated no cognitive impairment. <BR/>A record review of Resident #61's care plan dated 07/11/2024 revealed, Potential Risk for Malnutrition . Notify the physician for any negative findings, abnormal labs, or resident non-compliance . Offer diet as ordered by the physician . Update food preferences as needed <BR/>4. A record review of Resident #37's admission record dated 07/11/2024, revealed an admission date of 05/17/2024 with diagnoses which included protein-calorie malnutrition.<BR/>A record review of Resident #37's quarterly MDS assessment dated [DATE] revealed Resident #37 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. <BR/>A record review of Resident #37's care plan dated 07/11/2024 revealed, Potential Risk for Malnutrition . Offer diet as ordered by the physician . Update food preferences as needed <BR/>5. A record review of Resident #15's admission record dated 07/11/2024 revealed an admission date of 04/08/2020 with diagnoses which included protein-calorie malnutrition. <BR/>A record review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 09 out of a possible 15 which indicated moderate cognitive impairment. <BR/>A record review of Resident #15's care plan dated 07/11/2024 revealed, current diet: regular diet, regular texture and thin liquids . Monitor/record/report to MD signs and symptoms of malnutrition <BR/>6. A record review of Resident #17's face sheet dated 7/12/24 revealed Resident #17 was admitted on [DATE] had diagnoses's of primary glaucoma ( a condition of increased pressure in the eye), end stage renal disease( a condition of significant kidney failure), and type 2 diabetes mellitus ( a condition in which the body has difficulty controlling blood sugar).<BR/>Record review of Resident #17 quarterly MDS dated [DATE] revealed resident #17 with a BIMS of 15 indicating intact cognitive functioning.<BR/>7. Record review of Resident #54's face sheet dated 7/12/24 revealed resident #54 was admitted on [DATE] with diagnoses of schizoaffective disorder (a condition having symptoms of delusions and hallucinations), major depressive disorder (a condition with symptoms of persistent low mood and self-esteem), and generalized anxiety disorder (a condition with severe ongoing anxiety).<BR/>Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed resident #54 with a BIMS score of 8 which indicated moderate cognitive impairment.<BR/>During an observation on 07/09/2024 at 12:46 PM revealed CNA K was attending 13 residents in the second-floor dining room. Further observation revealed the kitchen delivered residents meals on open uncovered racks, although each individual meal was set upon plastic trays and covered plates. <BR/>During an observation from 07/09/24 12:47 PM to 07/09/2024 at 01:30 PM revealed CNA's I and K along passed out meal trays to residents in the kitchen and then proceeded to pass out meals to residents who were in their rooms down their respective hallways. The last meal was observed to be passed out at 01:30 PM, 07/09/2024, by CNA I to Resident #25. <BR/>During an observation and interview on 07/10/2024 at 07:35 AM through 07/10/2024 at 08:31 AM, revealed the kitchen delivered the breakfast meal at 08:15 AM. The meals were delivered on open uncovered racks, although each individual meal was set upon plastic trays and covered plates. LVN A was observed checking the meals for accuracy and was repositioning meals from one rack to another. LVN A stated she was checking the meals for accuracy of diet textures, likes, and dislikes, as well as allergies. LVN A stated she also repositioned trays from 1 rack to another to segregate the meals for residents who were not in the dining room. Residents in the dining room were heard to verbally call out Hurry up! Resident #4 was observed to call out and complain stating she could see her meal and complained hurry up . please Continued observation revealed no CNA's in the dining room. LVN A stated there were two CNA's, CNA I and CNA K, on duty for the 2nd floor.<BR/>During an observation on 07/10/2024 at 08:32 AM revealed LVN A on the phone speaking to kitchen staff regarding meal errors. Continued observation revealed CNA I and CNA K arrived and continued repositioning residents' meal trays from one rack to another. Continued observation revealed on 07/10/2024 at 08:40 AM the 15 residents in the second-floor dining room were served their breakfast meals 25 minutes after the kitchen delivered the residents meals. Continued observation revealed CNA K, CNA I and LVN A continued serving residents in the dining room. <BR/>During an observation on 07/10/2024 at 08:52 AM revealed the residents who were not in the dining room had their meal trays awaiting on the open uncovered racks by the dining room. Continued observation revealed Resident #15 ambulated, in his wheelchair, out of his room and approached MA B and complained his food was on the rack, it was getting cold, and he wanted his meal now. MA B replied, we have to wait .until the dining room gets served first .rules and regulations. Resident #15 continued complaining and stated I AM tired of getting cold food . I won't eat cold food! MA B continued to redirect Resident #15 and stated she would microwave residents' food if needed.<BR/>During an observation on 07/10/2024 at 09:00 AM revealed CNA I and CNA K began serving residents meal trays continued observation revealed CNA I and CNA K began serving residents who were not in the dining room and were in their rooms, 45 minutes after the kitchen delivered the meals to the dining room. <BR/>During an observation and interview on 07/10/2024 at 09:04 AM revealed Resident #15 leaving the second floor. Resident #15 stated he did not eat his meal, it was cold, I won't eat cold food, I am going to smoke a cigarette! <BR/>During an observation and interview on 07/10/2024 at 09:09 AM revealed CNA K served Resident #37 her breakfast meal. Resident #37 stated her meal was cold and unappealing. Resident #37 stated she preferred to stay in her room and most of her meals were served cold. Resident #37 stated, this is a regular practice and happens almost every day for most meals especially breakfast.<BR/>During an observation and interview on 07/10/2024 at 09:11 AM revealed CNA I served Resident #61 his breakfast meal. Resident #61 stated the food was cold. <BR/>During an observation and interview on 07/10/2024 at 09:13 AM revealed CNA I served Resident #13 his breakfast meal. Resident #13 stated the food was cold and it usually is cold. Resident #13 stated the breakfast included a cold chorizo and egg taco served with hash browns. <BR/>During an observation and interview on 07/10/2024 at 09:17 AM revealed Resident #25 was served the last meal tray 1 hour and 2 minutes after the kitchen delivered the meal. Resident #25 stated the meal was cold, the meals are always cold, something needs to be done <BR/>During an interview on 07/10/2024 at 01:00 PM the facility Administrator stated he would be looking into improving the quality and timeliness of the meal service. <BR/>During a group interview on 07/10/2024 at 02:30 PM at the Resident council meeting Resident #17 and Resident #54 stated meals served over the last several weeks have been served cold.<BR/>During an observation of breakfast meal service on 7/11/24 at 08:10 AM revealed Residents' food trays were brought to the second-floor residents' hallway in an open food rack that was not covered.<BR/>During an observation of breakfast meal service on 7/12/24 at 07:45 AM revealed that the Resident food trays were brought to the second-floor residents' hallway in an open food rack that was not covered.<BR/>During an interview on 7/12/24 at 10:50 AM Resident #37 stated her meals served in her room have been served cold over the last several weeks. When asked about the meals being cold, she stated, I have had worse. When asked if she told the CNA nursing staff about the cold meals she stated, I don't want to hurt their feelings.<BR/>Record review of the facility's undated admission packet, under the section entitled Food and Nutrition services revealed, We hope you enjoy the meals while you stay with us.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #44) reviewed for advanced directives, in that:<BR/>The facility failed to ensure Resident #44's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was signed by the appropriate witnesses. <BR/>This failure could place residents at-risk for residents' rights not being honored. <BR/>The findings were:<BR/>Record review of Resident #44's face sheet, dated 06/02/2023, revealed the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, congestive heart failure, diabetes, and bipolar disorder.<BR/>Record review of Resident #44's quarterly MDS assessment, dated 03/13/2023, revealed the resident had a BIMS score of 13, which indicated borderline/intact cognitive impairment. <BR/>Record review of Resident #44's physicians orders, dated 06/02/2023, revealed an order entered on 04/14/2023 that read: DNR. <BR/>Record review of Resident #44's care plan, undated, reflected Resident has an order for Do Not Resuscitate (DNR); Resident/Responsible party's decision for DNR will be; All aspects of DNR will be explained to resident or responsible party. Date initiated: 04/14/2023.<BR/>Record review of Resident #44's OOH-DNR, signed 04/14/2023, revealed [name of] Activity Director as witness #2 and [name of] Social Worker as witness #1. <BR/>Record review of the facility staff roster, undated, revealed [name of] Activity Director hired on 08/01/2019 and [name of] Social Worker hired on 04/03/2023. Further record review revealed no other AD nor SW assigned to the facility. <BR/>During an interview and record review on 06/02/2023 at 5:11 p.m., the SW stated he was unaware that a staff member in a director position was not allowed to sign an OOH-DNR as a witness. The SW stated there was no-one assigned to overlook his daily duties. He also stated he was the only SW in the facility, ultimately making him a department head. The SW stated the potential harm to the resident was Resident #44's wishes were not followed. <BR/>During an interview on 06/02/2023 at 6:06 p.m., the Administrator stated she was unaware that a staff member in a director position was unable to be a witness on a resident's OOH-DNR. The Administrator stated she was the SW's supervisor. The Administrator was unable to state what the potential harm to the resident was by not having the OOH-DNR executed correctly.<BR/>Record review, of page two, titled INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER, revised 07/01/2009, reflected under Qualified Witnesses: [ .] One of the witnesses must meet the qualifications in HSC &sect;166.003(2), which requires that at least one of the witnesses not: [ .] (be) (7) an employee of a health care facility in which the person is a patient if the employee is providing direct patient care to the patient or is an officer, director, partner, or business office employee of the health care facility or any parent organization of the health care facility.<BR/>Record review of facility policy titled Do Not Resuscitate Order, revised 10/12/2013, reflected The facility will honor two types of Do Not Resuscitate orders: a physician's order for Do Not Resuscitate and the Texas Out-of-Hospital DNR Order.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 hallways (hallway 2300) observed for accidents and hazards: The facility failed to ensure hallway 2300 did not have a capped lancet lying in the middle of the floor. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: During an observation on 8/28/2025 at 11:07 AM, a capped lancet was observed lying on the floor of hallway 2300. Twenty minutes later at 11:27 AM, the capped lancet was still observed lying on the floor of hallway 2300. Between 11:07 AM and 11:27 AM, Housekeeper A was observed walking up and down hallway 2300 past the capped lancet cleaning restrooms and resupplying rooms with soap and paper towels. Housekeeper A did not pick up the capped lancet or bring it to the attention of staff nurses during the observation period. During an interview with Housekeeper A on 8/28/2025 at 11:30 AM, Housekeeper A stated she did not know what the capped lancet was, and that it should be cleaned up. Housekeeper A further stated she did not know where the item should be disposed. Housekeeper A stated when something is on the floor and she does not know what it is or how to dispose of it, she should ask the nurse. Housekeeper A stated if a capped lancet was left on the ground a resident could slip and fall on it.During an interview with the DON on 8/29/25 at 1:23 PM the DON stated her expectation is for staff to keep a clean house, and if a staff member walks down a hall and sees trash, the staff member should pick it up, especially if it is something that can injure a resident. The DON further stated if a staff member did not know how to dispose of an item, she expects them to ask for guidance from a nurse.Record review of the facility policy titled Fall Policy, undated, documented Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family, Appropriate education will be provided to all staff members as needed on fall prevention, and Remove clutter from floors/hallways.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light:<BR/>Resident # 214's call light was not placed within reach.<BR/>This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident's # 214 face sheet dated, 6/2/23, revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that included: <BR/>Hemiplegia on Left side [loss of strength on left side arm and leg] <BR/>Hyperlipidemia [abnormally high concentration of fats in the blood<BR/>Hypertension [blood pressure that is higher than normal]<BR/>Review of Resident # 214's admission MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact.<BR/>Review of Resident #214's admission MDS dated [DATE] revealed that under section G, G0300, option # 2 was selected, stating the patient is unsteady on their feet and required assistance X 2. <BR/>Record review of Resident # 214's care plan dated 5/22/2021 revealed: keep call light within reach of resident .<BR/>Observation and interview on 05/30/2023 at 10:51 AM in Resident #214's room revealed that the call light was not visible. Further observation revealed that Resident #214's call light was on the floor. Resident #214 stated that he did not have a call light or know where his call light was. He added, They (staff) took the switch. He last saw the call light a while back. Resident #214 further commented, The switch is for when you need something .today I will YELL if I need something.<BR/>During an interview on 05/30/2023 at 10:55 AM with CNA B, she stated that Resident #214's call light was on the floor; she stated it must have fallen to the floor when providing incontinent care this morning. She noted that the lack of accessibility of a call light could negatively affect any resident if they needed assistance. <BR/>During an interview on 05/30/2023 at 11:05 am with LVN A, He stated that resident #214's call light was out of reach of Resident #214. However, he confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN A remarked that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency.<BR/>During an interview on 05/30/22 at 11:49 AM with the DON, she stated that the facility had a call light policy and staff has been in-serviced many times to keep call light within residents reach. The DON also confirmed that Resident # 214's care plan addressed the need for a call light within reach. She said she did not know why it was not within Resident #214's reach but would ensure all staff was in-serviced on this process again. DON stated that the lack of call lights within reach risked possible negative patient outcomes . <BR/>Record review of facility policy. Dressing and grooming, dated 2003, revealed, Place call light is within easy reach.

Based on observations, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Laptop) of three medication cart computers reviewed for confidential medical records. The facility failed to ensure a laptop A was not left open with patient information on the screen. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included:<BR/>Observation on 08/26/25 at 11:21 a.m. revealed laptop A was on top of a medication cart was left open in hallway displaying Resident #25's appointment information for a medical appointment with the date, time, and location for the appointment for anyone passing by to see. No staff was at the cart with laptop A and no staff returned to Laptop A before it timed out and turned off on its own. <BR/>Interview on 8/29/25 at 1:05 p.m. the DON stated the laptop was used by all staff. The DON stated the computer should not be left on displaying patient information because it was a HIPPA violation and anyone could access patient health records. <BR/>Record review of the facility's policy titled Resident Rights, revised 11/28/16, stated .Privacy and confidentiality- the resident has a right to personal privacy and confidentiality of his or her personal and medical records .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that:<BR/>The facility failed to ensure opened items in the reach in refrigerators were dated or discarded correctly. <BR/>This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.<BR/>The findings were:<BR/>During an observation and interview with the DM, in the refrigerator storage areas, on 05/30/2023 at 09:02 a.m., revealed an opened container of mushrooms (received 05/21/2022) with no opened date; an opened container of jalapenos (received 05/21/2022) with no opened date; an opened container of sour cream (received 05/17/2023) with no opened date; and an opened container of flavored sauce (received 10/12/2022 and opened 10/18/2022). The DM stated opened food items, per facility policy, were supposed to be discarded seven days after being opened. The DM also stated items were supposed to be dated after being opened. <BR/>During an interview on 06/02/2023 at 5:29 p.m., the DM stated the food was supposed to be dated when they came in [the kitchen] and then when they were opened. The DM stated the potential harm to residents was food expiring. <BR/>Record review of Storage Refrigerators, dated 2012, revealed 5. Food must be covered when stored, with a date label identifying what is in the container. Further record review revealed the policy did had not address when to date received items, when items were opened or when an opened item needed to be discarded. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified under $3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5*C (41*F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication rooms reviewed for medication storage, in that:<BR/>The medication room on the second floor was left unattended and unlocked.<BR/>This failure could place residents at risk for harm by not receiving the medications due to misappropriation. <BR/>The findings included:<BR/>Observation on 7/10/24 at 09:50 AM revealed the medication room on the facility's second floor, located at the beginning of the resident's hallway, was left unattended and unlocked. Further observation revealed multiple residents' medications which were stored inside the room. The medication room had a key latch door handle which was unlocked. <BR/>During an interview on 07/10/2024 at 09:55 AM LVN A stated she was the nurse on duty for the second floor. LVN A stated she was busy serving Resident's breakfasts and was unaware the medication room was unattended and unlocked. <BR/>During an interview on 7/10/24 at 10:00 AM MA B stated she was unaware the medication room was unattended and unlocked. MA B stated she was busy administering medications to residents.<BR/>During an interview on 07/10/2024 at 10:35 AM the Administrator and RN C stated having a medication room which was unattended and unlocked would be a safety concern for residents.<BR/>Record review of the facility's policy titled, Storage of Medication, dated 2003, revealed, . medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 1 of 24 residents (Resident #25) reviewed for call light accessibility and functionality, in that:<BR/>On 07/09/2024 at 01:00 PM Resident #25 utilized his call light which did not illuminate the nurse call light directly outside and above of his room door.<BR/>This failurs could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach.<BR/>The findings included:<BR/>Record review of Resident #25's admission record dated 07/11/2024 revealed an admission date of 11/18/2022 with diagnoses which included left sided hemiparesis (left sided semi paralysis) and general anxiety disorder. <BR/>A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was a [AGE] year-old male admitted for long term care, assessed as medically complex, and needed support for his diagnosed schizophrenia, semi paralysis, and anxiety. Resident #25 was assessed with a BIMS score of 15 out of 15 which indicated no cognitive impairment. <BR/>A record review of Resident #25's care plan dated 07/11/2024 revealed, Resident #25 has Hemiplegia/Hemiparesis . Assist with ADLs/Mobility as needed . Reposition at least every 2 hours . Resident #25 has had an actual fall . Be sure Resident #25's call light is within reach and encourage Resident #25 to use it for assistance as needed . Resident #25 needs a safe environment with . a working and reachable call light <BR/>A record review of Resident #25's physicians orders dated 07/11/2024 revealed the physician ordered Resident #25 to receive nursing facility care.<BR/>During an observation and interview on 07/09/24 at 01:00 PM revealed the nurses station call light panel sounded a nurse call light alarm and illuminated the light designated for Resident #25's room. Further observation revealed the light immediately outside and above Resident #25's room was not illuminated. Resident #25 stated he needed assistance, and no one was coming to his aid. <BR/>During an observation and interview on 07/09/2024 at 01:08 PM CNA I stated the call light above Resident #25's door was not working and entered Resident #25's room to answer his verbal shouts for care. CNA I stated she would report the call light failure to the maintenance director. CNA I stated she did not know how long the light was not functioning and stated she responded to Resident #25's verbal calls. <BR/>During an interview on 07/11/2024 at 03:10 PM the maintenance director stated he was not aware the call light for Resident #25's room was not working and would correct the problem as soon as possible. <BR/>During an interview on 07/12/2024 at 11:00 AM the regional DON RN C stated the facility's call light system should be available and functioning for all residents. RN C stated the facility did not have a policy for the nurse call light system and the facility followed the CMS and state agency guidelines for the nurse call light system.

Based on observations, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Laptop) of three medication cart computers reviewed for confidential medical records. The facility failed to ensure a laptop A was not left open with patient information on the screen. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included:<BR/>Observation on 08/26/25 at 11:21 a.m. revealed laptop A was on top of a medication cart was left open in hallway displaying Resident #25's appointment information for a medical appointment with the date, time, and location for the appointment for anyone passing by to see. No staff was at the cart with laptop A and no staff returned to Laptop A before it timed out and turned off on its own. <BR/>Interview on 8/29/25 at 1:05 p.m. the DON stated the laptop was used by all staff. The DON stated the computer should not be left on displaying patient information because it was a HIPPA violation and anyone could access patient health records. <BR/>Record review of the facility's policy titled Resident Rights, revised 11/28/16, stated .Privacy and confidentiality- the resident has a right to personal privacy and confidentiality of his or her personal and medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy.<BR/>The facility failed to transcribe Resident #3's order for Morphine correctly.<BR/>This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. <BR/>The findings were: <BR/>Record review of Resident #3's face sheet, dated 6/20/2024 revealed, the resident was admitted initially on 7/132018 with readmission on [DATE] with diagnoses that included: chronic systolic heart failure(specific type of heart failure that occurs in the heart's left ventricle. The left and right ventricles are the bottom chambers of the heart. In a person with systolic heart failure, the heart is weak, and the left ventricle can't contract (squeeze) normally when the heart beats), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), generalized anxiety disorder ,major depressive disorder, dementia, and chronic pain.<BR/>Record review of Resident #3's comprehensive MDS dated [DATE] revealed, the resident BIMS score was a 3 which indicated cognitively impaired.<BR/>Record review of Resident #3's MAR dated 6/1/2024-6/30/2024 revealed Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>Observation on 6/21/2024 of bottle of Morphine prescribed to Resident #3 read give up to 1 ml of 20 mg Morphine in 5 ml liquid. The bottle contained a concentration of Morphine 20 mg in 5 ml liquid. The EHR read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid.<BR/>Record review of Resident #3's Physician Orders provided by hospice dated revealed an order for Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>During an interview on 6/21/2024 at 3:15 pm RN I stated she was aware of Resident #3 receiving Morphine for pain. She stated the concentration of the bottle of morphine that was being given was ok because the dose was correct. The documentation in Resident #3's EHR should have read the same as what the bottle had on it. She further revealed it is very important to have the correct concentration and documentation of medication so the resident received rigght amount ordered by physician. <BR/>During an interview on 6/21/2024 at 5:15 PM The DON stated the morphine concentration from the bottle on the cart was for 20 milligrams in one ML. The DON stated the order read for 20 milligrams per five MLs. She further revealed the nurse who entered the order into the EHR should have transcribed the correct concentration. She stated Resident #1 was getting the right dosage it was just transcribed wrong in the EHR. <BR/>During an interview on 6/21/2024 at 10:45 AM Hospice patient care manager stated the order from the hospice physician read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. The pharmacy sent a higher concentration (of Morphine in 5 ml of liquid) and the facility did not enter in to EHR of give up to 1 ml of 20 mg Morphine in 5 ml liquid. <BR/>During a telephone interview on 6/21/2024 at 12:14 PM Hospice MD stated his order was for Morphine 20 mg/1 ml give up to 1 ml as needed. He further revealed he did not know why the concentration was different from the morphine bottle to the electronic record. This was a transcription error and not a medication error because the resident was receiving the right dose. <BR/>During an interview on at 6/21/2024 2:15 PM primary care physician stated the resident had appropriate doses of morphine and he had no concerns with the dose of morphine. He stated did not know why the dose transcribed in EHR was incorrect, but the 20 mg/1ml morphine was an appropriate dose for the resident. Stated resident was fairly tolerant of opioids and need frequent doses for pain mgt at the end of his life.<BR/>Record review of facility's policy titled: Medication Administration Procedures undated, section 20. The five rights of medication should always be adhered to. 1. Right drug, right dose, right resident, right time, right route.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy.<BR/>The facility failed to transcribe Resident #3's order for Morphine correctly.<BR/>This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. <BR/>The findings were: <BR/>Record review of Resident #3's face sheet, dated 6/20/2024 revealed, the resident was admitted initially on 7/132018 with readmission on [DATE] with diagnoses that included: chronic systolic heart failure(specific type of heart failure that occurs in the heart's left ventricle. The left and right ventricles are the bottom chambers of the heart. In a person with systolic heart failure, the heart is weak, and the left ventricle can't contract (squeeze) normally when the heart beats), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), generalized anxiety disorder ,major depressive disorder, dementia, and chronic pain.<BR/>Record review of Resident #3's comprehensive MDS dated [DATE] revealed, the resident BIMS score was a 3 which indicated cognitively impaired.<BR/>Record review of Resident #3's MAR dated 6/1/2024-6/30/2024 revealed Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>Observation on 6/21/2024 of bottle of Morphine prescribed to Resident #3 read give up to 1 ml of 20 mg Morphine in 5 ml liquid. The bottle contained a concentration of Morphine 20 mg in 5 ml liquid. The EHR read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid.<BR/>Record review of Resident #3's Physician Orders provided by hospice dated revealed an order for Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>During an interview on 6/21/2024 at 3:15 pm RN I stated she was aware of Resident #3 receiving Morphine for pain. She stated the concentration of the bottle of morphine that was being given was ok because the dose was correct. The documentation in Resident #3's EHR should have read the same as what the bottle had on it. She further revealed it is very important to have the correct concentration and documentation of medication so the resident received rigght amount ordered by physician. <BR/>During an interview on 6/21/2024 at 5:15 PM The DON stated the morphine concentration from the bottle on the cart was for 20 milligrams in one ML. The DON stated the order read for 20 milligrams per five MLs. She further revealed the nurse who entered the order into the EHR should have transcribed the correct concentration. She stated Resident #1 was getting the right dosage it was just transcribed wrong in the EHR. <BR/>During an interview on 6/21/2024 at 10:45 AM Hospice patient care manager stated the order from the hospice physician read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. The pharmacy sent a higher concentration (of Morphine in 5 ml of liquid) and the facility did not enter in to EHR of give up to 1 ml of 20 mg Morphine in 5 ml liquid. <BR/>During a telephone interview on 6/21/2024 at 12:14 PM Hospice MD stated his order was for Morphine 20 mg/1 ml give up to 1 ml as needed. He further revealed he did not know why the concentration was different from the morphine bottle to the electronic record. This was a transcription error and not a medication error because the resident was receiving the right dose. <BR/>During an interview on at 6/21/2024 2:15 PM primary care physician stated the resident had appropriate doses of morphine and he had no concerns with the dose of morphine. He stated did not know why the dose transcribed in EHR was incorrect, but the 20 mg/1ml morphine was an appropriate dose for the resident. Stated resident was fairly tolerant of opioids and need frequent doses for pain mgt at the end of his life.<BR/>Record review of facility's policy titled: Medication Administration Procedures undated, section 20. The five rights of medication should always be adhered to. 1. Right drug, right dose, right resident, right time, right route.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy.<BR/>The facility failed to transcribe Resident #3's order for Morphine correctly.<BR/>This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. <BR/>The findings were: <BR/>Record review of Resident #3's face sheet, dated 6/20/2024 revealed, the resident was admitted initially on 7/132018 with readmission on [DATE] with diagnoses that included: chronic systolic heart failure(specific type of heart failure that occurs in the heart's left ventricle. The left and right ventricles are the bottom chambers of the heart. In a person with systolic heart failure, the heart is weak, and the left ventricle can't contract (squeeze) normally when the heart beats), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), generalized anxiety disorder ,major depressive disorder, dementia, and chronic pain.<BR/>Record review of Resident #3's comprehensive MDS dated [DATE] revealed, the resident BIMS score was a 3 which indicated cognitively impaired.<BR/>Record review of Resident #3's MAR dated 6/1/2024-6/30/2024 revealed Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>Observation on 6/21/2024 of bottle of Morphine prescribed to Resident #3 read give up to 1 ml of 20 mg Morphine in 5 ml liquid. The bottle contained a concentration of Morphine 20 mg in 5 ml liquid. The EHR read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid.<BR/>Record review of Resident #3's Physician Orders provided by hospice dated revealed an order for Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>During an interview on 6/21/2024 at 3:15 pm RN I stated she was aware of Resident #3 receiving Morphine for pain. She stated the concentration of the bottle of morphine that was being given was ok because the dose was correct. The documentation in Resident #3's EHR should have read the same as what the bottle had on it. She further revealed it is very important to have the correct concentration and documentation of medication so the resident received rigght amount ordered by physician. <BR/>During an interview on 6/21/2024 at 5:15 PM The DON stated the morphine concentration from the bottle on the cart was for 20 milligrams in one ML. The DON stated the order read for 20 milligrams per five MLs. She further revealed the nurse who entered the order into the EHR should have transcribed the correct concentration. She stated Resident #1 was getting the right dosage it was just transcribed wrong in the EHR. <BR/>During an interview on 6/21/2024 at 10:45 AM Hospice patient care manager stated the order from the hospice physician read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. The pharmacy sent a higher concentration (of Morphine in 5 ml of liquid) and the facility did not enter in to EHR of give up to 1 ml of 20 mg Morphine in 5 ml liquid. <BR/>During a telephone interview on 6/21/2024 at 12:14 PM Hospice MD stated his order was for Morphine 20 mg/1 ml give up to 1 ml as needed. He further revealed he did not know why the concentration was different from the morphine bottle to the electronic record. This was a transcription error and not a medication error because the resident was receiving the right dose. <BR/>During an interview on at 6/21/2024 2:15 PM primary care physician stated the resident had appropriate doses of morphine and he had no concerns with the dose of morphine. He stated did not know why the dose transcribed in EHR was incorrect, but the 20 mg/1ml morphine was an appropriate dose for the resident. Stated resident was fairly tolerant of opioids and need frequent doses for pain mgt at the end of his life.<BR/>Record review of facility's policy titled: Medication Administration Procedures undated, section 20. The five rights of medication should always be adhered to. 1. Right drug, right dose, right resident, right time, right route.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: <BR/>1. The facility failed to ensure medications prescribed to Resident #1 were documented on the MAR for multiple dates in August 2024.<BR/>2. The facility failed to ensure medications prescribed to Resident #2 were documented on the MAR for multiple dates in August 2024. <BR/>These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.<BR/>The findings included: <BR/>1. Record review of Resident #1's face sheet, dated 8/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, lack of coordination, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), conversion disorder with seizures or convulsions (a mental health disorder that can cause physical symptoms, including seizures, that a person can't control), and pain.<BR/>Record review of Resident #1's comprehensive care plan, with revision date 8/14/24 revealed the resident had a potential for uncontrolled pain with interventions that included to monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, monitor/document for side effects of pain medication and, the resident prefers to have pain controlled by medication, treatment.<BR/>Record review of Resident #1's Order Summary Report, dated 8/16/24 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG Give 1 capsule by mouth three times a day for pain, with order date 7/22/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain NTE (not to exceed) 3 GM of APAP (acetaminophen) in 24 HOURS FROM ALL SOURCES, end date 8/14/24<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain, WHILE AWAKE NTE 3 GM of APAP IN 24 HOURS FROM ALL SOURCES, with order date 8/14/24 and no end date<BR/>Record review of Resident #1's MAR (medication administration record) for August 2024 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG capsule was coded 7 on 8/8/24 and scheduled at 1:00 p.m. was not administered because the resident was sleeping<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, with end date 8/14/24 was missing documentation for a nursing assessment of Pain Level and administration of the medication on 8/2/24, 8/9/24, 8/10/24, and 8/13/24 all scheduled at 6:00 a.m.<BR/>During an interview on 8/14/24 at 1:50 p.m., Resident #1 stated nursing had refused to administer gabapentin two days ago because the dosage was too high. Resident #1 stated he was prescribed the hydrocodone-acetaminophen and the gabapentin to deal with knee pain. <BR/>2. Record review of Resident #2's face sheet, dated 8/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included psychotic disorder with delusions and hallucinations, Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), lack of coordination, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (elevated blood pressure), localized edema (swelling), pain in left hand, and hyperlipidemia (elevated cholesterol).<BR/>Record review of Resident #2's most recent quarterly MDS assessment, dated 4/30/24 revealed the resident was cognitively intact for daily decision-making skills and was treated with diuretics, antipsychotics, antianxiety and antidepressant medications and had pain.<BR/>Record review of Resident #2's comprehensive care plan, with revision date 5/22/24 revealed the following:<BR/>- resident required antidepressant medication with interventions to give antidepressant medications ordered by physician and monitor/document side effects and effectiveness<BR/>- resident has Parkinson's with interventions that included to give medications as ordered by the physician and monitor/document side effects and effectiveness<BR/>- resident has hypertension with interventions that included to give anti-hypertensive medications as ordered and monitor/document side effects and effectiveness<BR/>- resident required anti-psychotic medications with interventions that included to administer medications as orders and monitor/document for side effects and effectiveness<BR/>- resident on diuretic therapy with interventions that included to administer medication as orders and to monitor vital signs as ordered and report to the physician if abnormal for this resident<BR/>- resident has a potential for uncontrolled pain with interventions that included to administer analgesia as per orders<BR/>Record review of Resident #2's Order Summary Report dated 8/19/24 revealed the following:<BR/> - Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day for edema to low extremities edema to low extremities with start date 6/20/22 and no end date<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 with start date 4/22/24 and no end date<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain with order date 6/27/24 and no end date<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 5/4/24 and no end date <BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day for Sexual Inappropriate Disorder with order date 7/2/24 and no end date<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day related to PARKINSON'S DISEASE: PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION with order date 8/10/23 and no end date<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day related to OVERACTIVE BLADDER with order date 7/12/23 and no end date<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Give along with the 300 mg to equal 500 mg with order date 6/10/24 and no end date<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 2/17/23 and no end date<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day for parkinson's disease with order date 9/11/23 and no end date<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day for dementia give 2 caps to equal 6 mg BID (twice a day) with order date 10/17/23 and no end date<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION give with 600 mg tab to equal 900 mg total BID with order date 2/12/24 and no end date<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED with order date 1/17/24 and no end date<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain with order date 1/25/22 and no end date<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a day for pain NTE (not to exceed) 3gm in 24 hours from all sources with order date 6/27/24 and no end date<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day for restless leg syndrome with order date 4/11/24 and no end date<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours for pain APPLY IN AM AND REMOVE AT BEDTIME and remove per schedule with order date 4/7/24 and no end date<BR/>Record review of Resident #2's MAR for August 2024 revealed the following:<BR/>- Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 was missing documentation on 8/4/24 and 8/13/24<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain was missing documentation on 8/4/24<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime was missing documentation on 8/16/24 and 8/17/24<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day was missing documentation on 8/4/24<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m. and 8:00 p.m.<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m., and 1:00 p.m., 8/10/24 at 1:00 p.m., 8/13/24 at 1:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 1:00 p.m. and 8:00 p.m.<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 9:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m., and 9:00 p.m.<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day was missing documentation on 8/2/24 at 12:00 a.m., and 6:00 a.m., 8/3/24 at 12:00 a.m., and 6:00 a.m., 8/4/24 at 6:00 a.m., and 12:00 p.m., 8/5/24 at 6:00 a.m., 8/8/24 at 6:00 a.m., 8/9/24 at 6:00 a.m., 8/10/24 at 12:00 p.m., 8/11/24 at 6:00 a.m., 8/13/24 at 6:00 a.m., and 12:00 p.m., 8/14/24 at 6:00 a.m., 8/14/24 at 6:00 a.m., and 8/17/24 at 12:00 p.m.<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours was missing documentation on 8/4/24, 8/13/24 and 8/17/24<BR/>During an interview on 8/16/24 at 10:45 a.m., Resident #2 stated she had lived in the facility for about 3 &frac12; years and did not take medication for pain very often, but if in pain and wanted medication, they would give it to me.<BR/>During an interview on 8/16/24 at 12:59 p.m., LVN A revealed, the facility policy was to administer scheduled medications within a two-hour window. LVN A stated, if a resident missed a scheduled medication because the resident was not in the facility or the resident refused the medication, then a reason why the medication was not given had to be documented in the clinical record. LVN A revealed there should not be any empty spaces in the MAR because it looked like the dosage was skipped. LVN A stated, you still have to give a reason why it was not given.<BR/>During an interview on 8/16/24 at 1:26 p.m., RN B revealed there was an opportunity to administer a scheduled medication an hour before or an hour after the medication was scheduled. RN B stated, a pain medication required a pain assessment by the nurse and documentation when the medication was given. RN B stated, we notify the resident if the medication is given late and we should notify the doctor if the medication was late or missed. RN B stated, there should not be any holes in the MAR. There should be some kind of documentation because it not it will look like the medication was not given and the nurse ignored it.<BR/>During an interview on 8/16/24 at 2:09 p.m., LVN C stated, there should not be any holes in the MAR and if there is no explanation why there was no documentation, you might assume the medication was not given. If it's not documented, it was not given. LVN C further stated, the missing documentation made it appear as if the medication was not administered and that was not acceptable. LVN C stated, I know some of the nurses don't know how to document in the electronic record.<BR/>During an interview and record review on 8/16/24 at 3:33 p.m., the DON revealed, Resident #1 had scheduled hydrocodone-acetaminophen and had it prn (as needed). The DON stated she believed nursing staff were not administering the scheduled hydrocodone-acetaminophen medication because the resident would be sleeping and nursing staff were waiting to administer the prn dose. The DON, after reviewing Resident #1's MAR and the narcotic log stated Resident #1 was given the medication according to the narcotic log, but it was incorrect because it was not documented in the computer that it was given and there was no pain assessment for the actual time the medication was given, so it's a clinical record issue. The DON revealed there should not be any holes in the MAR because there was a doctor's order to assess for pain and no documentation looks like the medication was not given. The DON stated, she and the ADON were responsible for doing routine audits on documentation on the MAR but admitted they had not kept up with it.<BR/>During an interview and record review on 8/16/24 at 4:20 p.m., LVN D stated, missing documentation on the MAR looks like the medication was not given. LVN D, after reviewing Resident #1's MAR stated, there should be documentation in the resident's record that explained why the medication was not given. If there's no documentation it wasn't done. LVN D, referring to the blanks on the MAR then stated, on the 9th (of August) I probably got sidetracked, maybe working with another resident and I guess when I counted with the nurse the narcotic log at the end of the shift, the count was correct, I just left. LVN D stated Resident #1 had not complained to her about not getting pain medication and had never seen the resident in pain.<BR/>Record review of the facility policy and procedure titled, Medication Administration Procedures 2003, revealed in part, .All medications are administered by licensed medical or nursing personnel .administer the medication and immediately chart doses administered on the medication administration record .If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record .An explanation as to symptoms prior to administration and results are to be documented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: <BR/>1. The facility failed to ensure medications prescribed to Resident #1 were documented on the MAR for multiple dates in August 2024.<BR/>2. The facility failed to ensure medications prescribed to Resident #2 were documented on the MAR for multiple dates in August 2024. <BR/>These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.<BR/>The findings included: <BR/>1. Record review of Resident #1's face sheet, dated 8/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, lack of coordination, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), conversion disorder with seizures or convulsions (a mental health disorder that can cause physical symptoms, including seizures, that a person can't control), and pain.<BR/>Record review of Resident #1's comprehensive care plan, with revision date 8/14/24 revealed the resident had a potential for uncontrolled pain with interventions that included to monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, monitor/document for side effects of pain medication and, the resident prefers to have pain controlled by medication, treatment.<BR/>Record review of Resident #1's Order Summary Report, dated 8/16/24 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG Give 1 capsule by mouth three times a day for pain, with order date 7/22/24 and no end date<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain NTE (not to exceed) 3 GM of APAP (acetaminophen) in 24 HOURS FROM ALL SOURCES, end date 8/14/24<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG give 1 tablet by mouth four times a day for pain, WHILE AWAKE NTE 3 GM of APAP IN 24 HOURS FROM ALL SOURCES, with order date 8/14/24 and no end date<BR/>Record review of Resident #1's MAR (medication administration record) for August 2024 revealed the following:<BR/>- Gabapentin Oral Capsule 300 MG capsule was coded 7 on 8/8/24 and scheduled at 1:00 p.m. was not administered because the resident was sleeping<BR/>- HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, with end date 8/14/24 was missing documentation for a nursing assessment of Pain Level and administration of the medication on 8/2/24, 8/9/24, 8/10/24, and 8/13/24 all scheduled at 6:00 a.m.<BR/>During an interview on 8/14/24 at 1:50 p.m., Resident #1 stated nursing had refused to administer gabapentin two days ago because the dosage was too high. Resident #1 stated he was prescribed the hydrocodone-acetaminophen and the gabapentin to deal with knee pain. <BR/>2. Record review of Resident #2's face sheet, dated 8/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included psychotic disorder with delusions and hallucinations, Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), lack of coordination, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (elevated blood pressure), localized edema (swelling), pain in left hand, and hyperlipidemia (elevated cholesterol).<BR/>Record review of Resident #2's most recent quarterly MDS assessment, dated 4/30/24 revealed the resident was cognitively intact for daily decision-making skills and was treated with diuretics, antipsychotics, antianxiety and antidepressant medications and had pain.<BR/>Record review of Resident #2's comprehensive care plan, with revision date 5/22/24 revealed the following:<BR/>- resident required antidepressant medication with interventions to give antidepressant medications ordered by physician and monitor/document side effects and effectiveness<BR/>- resident has Parkinson's with interventions that included to give medications as ordered by the physician and monitor/document side effects and effectiveness<BR/>- resident has hypertension with interventions that included to give anti-hypertensive medications as ordered and monitor/document side effects and effectiveness<BR/>- resident required anti-psychotic medications with interventions that included to administer medications as orders and monitor/document for side effects and effectiveness<BR/>- resident on diuretic therapy with interventions that included to administer medication as orders and to monitor vital signs as ordered and report to the physician if abnormal for this resident<BR/>- resident has a potential for uncontrolled pain with interventions that included to administer analgesia as per orders<BR/>Record review of Resident #2's Order Summary Report dated 8/19/24 revealed the following:<BR/> - Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day for edema to low extremities edema to low extremities with start date 6/20/22 and no end date<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 with start date 4/22/24 and no end date<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain with order date 6/27/24 and no end date<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 5/4/24 and no end date <BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day for Sexual Inappropriate Disorder with order date 7/2/24 and no end date<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day related to PARKINSON'S DISEASE: PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION with order date 8/10/23 and no end date<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day related to OVERACTIVE BLADDER with order date 7/12/23 and no end date<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Give along with the 300 mg to equal 500 mg with order date 6/10/24 and no end date<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day related to UNSPECIFIED PROTEIN-CALORIE MALNUTRITION with order date 2/17/23 and no end date<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day for parkinson's disease with order date 9/11/23 and no end date<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day for dementia give 2 caps to equal 6 mg BID (twice a day) with order date 10/17/23 and no end date<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION give with 600 mg tab to equal 900 mg total BID with order date 2/12/24 and no end date<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED with order date 1/17/24 and no end date<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain with order date 1/25/22 and no end date<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a day for pain NTE (not to exceed) 3gm in 24 hours from all sources with order date 6/27/24 and no end date<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day for restless leg syndrome with order date 4/11/24 and no end date<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours for pain APPLY IN AM AND REMOVE AT BEDTIME and remove per schedule with order date 4/7/24 and no end date<BR/>Record review of Resident #2's MAR for August 2024 revealed the following:<BR/>- Lasix Tablet 40 MG **DAW** (dispense as written) Give 40 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Lisinopril Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension old if SBP (systolic blood pressure) more than 110 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60 was missing documentation on 8/4/24 and 8/13/24<BR/>- Meloxicam Oral Tablet 7.5 MG Give 1 tablet by mouth one time a day for pain was missing documentation on 8/4/24<BR/>- Multivitamin Oral Tablet Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Naltrexone Oral Tablet 50 MG Give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Nuplazid Oral Capsule 34 MG **DAW** Give 34 mg by mouth one time a day was missing documentation on 8/4/24<BR/>- Oxybutynin Chloride ER (extended release) Tablet 24 hour 15 GM give 1 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Seroquel Oral Tablet 200 MG Give 1 tablet by mouth at bedtime was missing documentation on 8/16/24 and 8/17/24<BR/>-Vitamin D3 Oral Tablet 25 MCG (1000 UT) Give 2 tablet by mouth one time a day was missing documentation on 8/4/24<BR/>- Carbidopa-Levodopa Oral Tablet 10-100 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Rivastigmine Tartrate Oral Capsule 3MG Give 2 capsule by mouth two times a day was missing documentation on 8/4/24<BR/>- Trileptal Oral Tablet 300 MG Give 1 tablet by mouth two times a day was missing documentation on 8/4/24<BR/>- Buspirone Oral Tablet 15 MG Give 1 tablet by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m. and 8:00 p.m.<BR/>- Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day was missing documentation on 8/4/24 at 8:00 a.m., and 1:00 p.m., 8/10/24 at 1:00 p.m., 8/13/24 at 1:00 p.m., 8/16/24 at 8:00 p.m., and 8/17/24 at 8:00 a.m., 1:00 p.m. and 8:00 p.m.<BR/>- Tylenol Extra Strength Oral Tablet 500 MG Give 1 tablet by mouth three times a was missing documentation on 8/4/24 at 8:00 a.m. and 2:00 p.m., 8/10/24 at 2:00 p.m., 8/13/24 at 2:00 p.m., 8/16/24 at 9:00 p.m., and 8/17/24 at 8:00 a.m., 2:00 p.m., and 9:00 p.m.<BR/>- Ropinirole Oral Tablet 1 MG Give 1 tablet by mouth four times a day was missing documentation on 8/2/24 at 12:00 a.m., and 6:00 a.m., 8/3/24 at 12:00 a.m., and 6:00 a.m., 8/4/24 at 6:00 a.m., and 12:00 p.m., 8/5/24 at 6:00 a.m., 8/8/24 at 6:00 a.m., 8/9/24 at 6:00 a.m., 8/10/24 at 12:00 p.m., 8/11/24 at 6:00 a.m., 8/13/24 at 6:00 a.m., and 12:00 p.m., 8/14/24 at 6:00 a.m., 8/14/24 at 6:00 a.m., and 8/17/24 at 12:00 p.m.<BR/>- Lidocaine Patch 4% Apply to lower back topically every 24 hours was missing documentation on 8/4/24, 8/13/24 and 8/17/24<BR/>During an interview on 8/16/24 at 10:45 a.m., Resident #2 stated she had lived in the facility for about 3 &frac12; years and did not take medication for pain very often, but if in pain and wanted medication, they would give it to me.<BR/>During an interview on 8/16/24 at 12:59 p.m., LVN A revealed, the facility policy was to administer scheduled medications within a two-hour window. LVN A stated, if a resident missed a scheduled medication because the resident was not in the facility or the resident refused the medication, then a reason why the medication was not given had to be documented in the clinical record. LVN A revealed there should not be any empty spaces in the MAR because it looked like the dosage was skipped. LVN A stated, you still have to give a reason why it was not given.<BR/>During an interview on 8/16/24 at 1:26 p.m., RN B revealed there was an opportunity to administer a scheduled medication an hour before or an hour after the medication was scheduled. RN B stated, a pain medication required a pain assessment by the nurse and documentation when the medication was given. RN B stated, we notify the resident if the medication is given late and we should notify the doctor if the medication was late or missed. RN B stated, there should not be any holes in the MAR. There should be some kind of documentation because it not it will look like the medication was not given and the nurse ignored it.<BR/>During an interview on 8/16/24 at 2:09 p.m., LVN C stated, there should not be any holes in the MAR and if there is no explanation why there was no documentation, you might assume the medication was not given. If it's not documented, it was not given. LVN C further stated, the missing documentation made it appear as if the medication was not administered and that was not acceptable. LVN C stated, I know some of the nurses don't know how to document in the electronic record.<BR/>During an interview and record review on 8/16/24 at 3:33 p.m., the DON revealed, Resident #1 had scheduled hydrocodone-acetaminophen and had it prn (as needed). The DON stated she believed nursing staff were not administering the scheduled hydrocodone-acetaminophen medication because the resident would be sleeping and nursing staff were waiting to administer the prn dose. The DON, after reviewing Resident #1's MAR and the narcotic log stated Resident #1 was given the medication according to the narcotic log, but it was incorrect because it was not documented in the computer that it was given and there was no pain assessment for the actual time the medication was given, so it's a clinical record issue. The DON revealed there should not be any holes in the MAR because there was a doctor's order to assess for pain and no documentation looks like the medication was not given. The DON stated, she and the ADON were responsible for doing routine audits on documentation on the MAR but admitted they had not kept up with it.<BR/>During an interview and record review on 8/16/24 at 4:20 p.m., LVN D stated, missing documentation on the MAR looks like the medication was not given. LVN D, after reviewing Resident #1's MAR stated, there should be documentation in the resident's record that explained why the medication was not given. If there's no documentation it wasn't done. LVN D, referring to the blanks on the MAR then stated, on the 9th (of August) I probably got sidetracked, maybe working with another resident and I guess when I counted with the nurse the narcotic log at the end of the shift, the count was correct, I just left. LVN D stated Resident #1 had not complained to her about not getting pain medication and had never seen the resident in pain.<BR/>Record review of the facility policy and procedure titled, Medication Administration Procedures 2003, revealed in part, .All medications are administered by licensed medical or nursing personnel .administer the medication and immediately chart doses administered on the medication administration record .If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record .An explanation as to symptoms prior to administration and results are to be documented .

Based on observation, interview and record review, the facility failed to post the daily nursing staffing formation that included the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides and resident census in a prominent place readily accessible to residents, staff, and visitors for 61 residents in that: The facility failed to post the daily staff posting information on 10/01/2025 and 10/02/2025. This failure could place residents and visitors at risk of not being able to review the facility's daily staffing hours. The findings included: During an observation, 10/01/2025 at 8:28 a.m., a daily staffing poster was observed on top of the receptionist desk in a plastic display holder that was titled, Daily report of nursing staff directly responsible for resident care and was dated 09/10/2025. During an observation, 10/02/2025 at 12:02 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed. During an observation, 10/02/2025 at 4:00 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed. Record review of a facility staff schedule, dated 10/01/2025, revealed the facility had 5 licensed nurses, 2 MAs and 11 CNAs scheduled throughout the day. Record review of a facility staff schedule, dated 10/02/2025, revealed the facility had 5 licensed nurses, 2 MAs and 10 CNAs scheduled throughout the day. During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated the ADON was responsible for updating the daily staffing posters daily and the ADON had received a directive to complete the daily staffing form and post it daily at the reception desk. The Administrator said it was important to post the daily staffing posters because it gives families and visitors the ability to know how many staff are present for the patients and gives us a visual number of staff available and it is part of our regulatory requirements. The Administrator stated the facility did not have a policy on posting staffing information daily but followed the regulatory guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy.<BR/>The facility failed to transcribe Resident #3's order for Morphine correctly.<BR/>This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. <BR/>The findings were: <BR/>Record review of Resident #3's face sheet, dated 6/20/2024 revealed, the resident was admitted initially on 7/132018 with readmission on [DATE] with diagnoses that included: chronic systolic heart failure(specific type of heart failure that occurs in the heart's left ventricle. The left and right ventricles are the bottom chambers of the heart. In a person with systolic heart failure, the heart is weak, and the left ventricle can't contract (squeeze) normally when the heart beats), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), generalized anxiety disorder ,major depressive disorder, dementia, and chronic pain.<BR/>Record review of Resident #3's comprehensive MDS dated [DATE] revealed, the resident BIMS score was a 3 which indicated cognitively impaired.<BR/>Record review of Resident #3's MAR dated 6/1/2024-6/30/2024 revealed Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>Observation on 6/21/2024 of bottle of Morphine prescribed to Resident #3 read give up to 1 ml of 20 mg Morphine in 5 ml liquid. The bottle contained a concentration of Morphine 20 mg in 5 ml liquid. The EHR read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid.<BR/>Record review of Resident #3's Physician Orders provided by hospice dated revealed an order for Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. <BR/>During an interview on 6/21/2024 at 3:15 pm RN I stated she was aware of Resident #3 receiving Morphine for pain. She stated the concentration of the bottle of morphine that was being given was ok because the dose was correct. The documentation in Resident #3's EHR should have read the same as what the bottle had on it. She further revealed it is very important to have the correct concentration and documentation of medication so the resident received rigght amount ordered by physician. <BR/>During an interview on 6/21/2024 at 5:15 PM The DON stated the morphine concentration from the bottle on the cart was for 20 milligrams in one ML. The DON stated the order read for 20 milligrams per five MLs. She further revealed the nurse who entered the order into the EHR should have transcribed the correct concentration. She stated Resident #1 was getting the right dosage it was just transcribed wrong in the EHR. <BR/>During an interview on 6/21/2024 at 10:45 AM Hospice patient care manager stated the order from the hospice physician read Morphine give up to 1 ml, 20 mg Morphine in 1 ml liquid. The pharmacy sent a higher concentration (of Morphine in 5 ml of liquid) and the facility did not enter in to EHR of give up to 1 ml of 20 mg Morphine in 5 ml liquid. <BR/>During a telephone interview on 6/21/2024 at 12:14 PM Hospice MD stated his order was for Morphine 20 mg/1 ml give up to 1 ml as needed. He further revealed he did not know why the concentration was different from the morphine bottle to the electronic record. This was a transcription error and not a medication error because the resident was receiving the right dose. <BR/>During an interview on at 6/21/2024 2:15 PM primary care physician stated the resident had appropriate doses of morphine and he had no concerns with the dose of morphine. He stated did not know why the dose transcribed in EHR was incorrect, but the 20 mg/1ml morphine was an appropriate dose for the resident. Stated resident was fairly tolerant of opioids and need frequent doses for pain mgt at the end of his life.<BR/>Record review of facility's policy titled: Medication Administration Procedures undated, section 20. The five rights of medication should always be adhered to. 1. Right drug, right dose, right resident, right time, right route.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication rooms reviewed for medication storage, in that:<BR/>The medication room on the second floor was left unattended and unlocked.<BR/>This failure could place residents at risk for harm by not receiving the medications due to misappropriation. <BR/>The findings included:<BR/>Observation on 7/10/24 at 09:50 AM revealed the medication room on the facility's second floor, located at the beginning of the resident's hallway, was left unattended and unlocked. Further observation revealed multiple residents' medications which were stored inside the room. The medication room had a key latch door handle which was unlocked. <BR/>During an interview on 07/10/2024 at 09:55 AM LVN A stated she was the nurse on duty for the second floor. LVN A stated she was busy serving Resident's breakfasts and was unaware the medication room was unattended and unlocked. <BR/>During an interview on 7/10/24 at 10:00 AM MA B stated she was unaware the medication room was unattended and unlocked. MA B stated she was busy administering medications to residents.<BR/>During an interview on 07/10/2024 at 10:35 AM the Administrator and RN C stated having a medication room which was unattended and unlocked would be a safety concern for residents.<BR/>Record review of the facility's policy titled, Storage of Medication, dated 2003, revealed, . medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier .

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #2) reviewed for disposal of garbage, in that: <BR/>The facility failed to ensure Dumpster #2's door was completely shut, had a drain plug, and was free of pests.<BR/>These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>The findings were: <BR/>Observation on 07/11/2024 at 11:50 AM revealed Dumpster #2 did not have drainage plug, the door was open, and there were ants present.<BR/>During an interview on 07/11/2024 at 11:51 AM, the DM stated the door to Dumpster #2 was open and should not have been, as it presented an unsanitary condition and an opportunity for the proliferation of rodents. The DM also noted the presence of ants crawling on the rear side of the Dumpster.<BR/>During an interview on 07/11/2024 at 12:15 PM, the Maintenance Director stated the drain plug was missing from Dumpster #2 and he would ensure it was replaced. The DM also noted the presence of ants and indicated he would ensure the Dumpster was free of pests.<BR/>During an interview on 07/11/2024 at 3:30 PM, the Administrator stated the facility did not have a policy on maintaining the Dumpsters and the dumpster area.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns, in that:<BR/>The ceiling fan in the Soiled Utility Room on th 2300 Hallway had dust and dirt particles in the vent slats.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. <BR/>The findings included:<BR/>Observation on the 500 Hall on 07/10/24 from 9:55 AM to 10:25 AM with the Maintenance Director revealed the soiled utility room on the 2300 resident hallway had a ceiling fan measuring approximately 2 x 2 feet that had dust and dirt particles in the vent slats.<BR/>During an interview with the Maintenance Director on 7/10/24 at 10:15 AM he stated that he would repair all of the maintenance concerns revealed during the observation tour. The Maintenance Director stated that the repairs would improve resident safety and homelike environment.<BR/>During an interview with the Administrator on 7/10/24 at 10:30 AM he stated that completing the maintenance repairs would improve the resident's quality of life.<BR/>Record review of the facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, revealed, The acility will repair or replace damaged/broken equipment or building amenities as needed.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns, in that:<BR/>The ceiling fan in the Soiled Utility Room on th 2300 Hallway had dust and dirt particles in the vent slats.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. <BR/>The findings included:<BR/>Observation on the 500 Hall on 07/10/24 from 9:55 AM to 10:25 AM with the Maintenance Director revealed the soiled utility room on the 2300 resident hallway had a ceiling fan measuring approximately 2 x 2 feet that had dust and dirt particles in the vent slats.<BR/>During an interview with the Maintenance Director on 7/10/24 at 10:15 AM he stated that he would repair all of the maintenance concerns revealed during the observation tour. The Maintenance Director stated that the repairs would improve resident safety and homelike environment.<BR/>During an interview with the Administrator on 7/10/24 at 10:30 AM he stated that completing the maintenance repairs would improve the resident's quality of life.<BR/>Record review of the facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, revealed, The acility will repair or replace damaged/broken equipment or building amenities as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 1 of 15 residents reviewed for ADLs (activities of daily living). Resident # 54 <BR/>The facility did not ensure Resident #54 received grooming for their facial hair.<BR/>This failure could place residents who required assistance with activities of daily living, and who were dependent on staff to perform personal hygiene at risk for embarrassment and or decreased self-esteem or decreased quality of life.<BR/>Findings included: <BR/>Record review of Resident #54's face sheet, dated 6/2/23, revealed a [AGE] year-old female with an admission date of 10/12/22 with diagnoses that included: <BR/>Diabetes type II [is a condition that happens because of a problem in how the body regulates and uses sugar as a fuel].<BR/>Dementia [is a condition characterized by progressive or persistent loss of intellectual functioning]<BR/>Mild Intellectual Disability [slower in all areas of conceptual development and social and daily living skills]<BR/>Review of quarterly MDS for Resident #54 dated 04/26/23, reviewed 6/2/23, revealed a BIMS score of 9, indicating moderately impaired cognition. <BR/>Review of Resident #54's Quarterly MDS dated [DATE], reviewed 6/2/23, revealed that under section G,0110, ADL, J, Personal Hygiene, one-person physical assist. <BR/>Record Review of care plan for Resident # 54 updated 12/12/22, reviewed 6/2/23, indicated Resident #54's had a self-care performance deficit; requires assistance X 1 for Activities of Daily Living. <BR/>During an observation on 05/30/23 at 1:46 p.m., Resident #54 was sitting in her wheelchair in the room. She had very long hair growing out of her chin (approximately 1 -1 1/2 cm). <BR/>During an observation on 06/01/23 at 9:09 a.m., Resident #54 was sitting in her bed and had long chin hair. She said she had asked staff to shave her, but they had not done it. Resident #54 stated that her long chin hair makes her feel ugly. <BR/>During an interview on 06/01/23 at 10:35 a.m., CNA A was asked who shaved hair on the chin. CNA A said she thought nursing was responsible, as CNAs perform all daily activities for residents who cannot perform them. <BR/>During an interview on 06/01/23 at 10:38 a.m., CMA C said nursing was responsible for shaving both females and males. <BR/>During an interview on 6/02/23 at 1:45 p.m., LVN A said the CNAs would be responsible for shaving and trimming facial hair on Residents during the shower. <BR/>During an interview on 06/02/23 at 3:00 p.m., the DON said the CNAs should assist residents with shaving if requested and Residents could be a risk for decreased self-esteem or decreased quality of life if requested shaving is not performed. <BR/>Record Review of Facility Policy self-care activities, dated January 2023, revealed: Self-care activities are offered at a variety level of assistance to meet each resident's individual needs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that:<BR/>The facility failed to ensure opened items in the reach in refrigerators were dated or discarded correctly. <BR/>This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.<BR/>The findings were:<BR/>During an observation and interview with the DM, in the refrigerator storage areas, on 05/30/2023 at 09:02 a.m., revealed an opened container of mushrooms (received 05/21/2022) with no opened date; an opened container of jalapenos (received 05/21/2022) with no opened date; an opened container of sour cream (received 05/17/2023) with no opened date; and an opened container of flavored sauce (received 10/12/2022 and opened 10/18/2022). The DM stated opened food items, per facility policy, were supposed to be discarded seven days after being opened. The DM also stated items were supposed to be dated after being opened. <BR/>During an interview on 06/02/2023 at 5:29 p.m., the DM stated the food was supposed to be dated when they came in [the kitchen] and then when they were opened. The DM stated the potential harm to residents was food expiring. <BR/>Record review of Storage Refrigerators, dated 2012, revealed 5. Food must be covered when stored, with a date label identifying what is in the container. Further record review revealed the policy did had not address when to date received items, when items were opened or when an opened item needed to be discarded. <BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified under $3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5*C (41*F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light:<BR/>Resident # 214's call light was not placed within reach.<BR/>This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Record review of Resident's # 214 face sheet dated, 6/2/23, revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that included: <BR/>Hemiplegia on Left side [loss of strength on left side arm and leg] <BR/>Hyperlipidemia [abnormally high concentration of fats in the blood<BR/>Hypertension [blood pressure that is higher than normal]<BR/>Review of Resident # 214's admission MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact.<BR/>Review of Resident #214's admission MDS dated [DATE] revealed that under section G, G0300, option # 2 was selected, stating the patient is unsteady on their feet and required assistance X 2. <BR/>Record review of Resident # 214's care plan dated 5/22/2021 revealed: keep call light within reach of resident .<BR/>Observation and interview on 05/30/2023 at 10:51 AM in Resident #214's room revealed that the call light was not visible. Further observation revealed that Resident #214's call light was on the floor. Resident #214 stated that he did not have a call light or know where his call light was. He added, They (staff) took the switch. He last saw the call light a while back. Resident #214 further commented, The switch is for when you need something .today I will YELL if I need something.<BR/>During an interview on 05/30/2023 at 10:55 AM with CNA B, she stated that Resident #214's call light was on the floor; she stated it must have fallen to the floor when providing incontinent care this morning. She noted that the lack of accessibility of a call light could negatively affect any resident if they needed assistance. <BR/>During an interview on 05/30/2023 at 11:05 am with LVN A, He stated that resident #214's call light was out of reach of Resident #214. However, he confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN A remarked that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency.<BR/>During an interview on 05/30/22 at 11:49 AM with the DON, she stated that the facility had a call light policy and staff has been in-serviced many times to keep call light within residents reach. The DON also confirmed that Resident # 214's care plan addressed the need for a call light within reach. She said she did not know why it was not within Resident #214's reach but would ensure all staff was in-serviced on this process again. DON stated that the lack of call lights within reach risked possible negative patient outcomes . <BR/>Record review of facility policy. Dressing and grooming, dated 2003, revealed, Place call light is within easy reach.