**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #115 and Resident #61) reviewed for accidents and hazards. 1. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #115 who was at medium risk for eloping from the facility. On 03/24/25, Resident #115 eloped out of the facility and the facility was not aware the resident eloped. Resident #115 was found in his wheelchair at the intersection of the service road off a major highway. The noncompliance was identified as PNC. The IJ began on 03/24/24 and ended on 03/25/24. The facility had corrected the noncompliance before the survey began. 2. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #61 from sustaining a hot liquid burn on 04/20/25 when she spilled hot coffee and sustained a second-degree burn (partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days) to her chin and chest. The noncompliance was identified as PNC. The IJ began on 04/20/25 and ended on 04/29/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death. Findings include: 1. Review of Resident #115's quarterly MDS assessment dated [DATE] reflected Resident #115 was a [AGE] year-old male with an admission date of 12/08/22 and readmission date of 12/05/24. Resident #115 had a BIMS of 9 indicating he was moderately cognitively impaired. He required moderate assistance with ADLs. He had no wandering behaviors and used a wheelchair for mobility. Active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #115's comprehensive care plan with an initialization date of 10/23/23 reflected, Resident has impaired cognitive loss related to impaired decision-making ability, is not always understood or able to understand verbal and non-verbal expression .The resident is a smoker .Interventions .Cue, reorient and supervise as needed .The resident requires SUPERVISION while smoking . Record review of Resident #115's quarterly elopement assessment completed by the ADON on 03/05/25 reflected resident was at medium risk for elopement. The assessment indicated the resident had no history of leaving the facility without supervision, had not expressed a desire to go home, no history of leaving the facility without informing the staff, and was not wander seeking. Interventions in place included exit and stairwell alarms, frequent monitoring, utilization of check in/out log, information in wander book and staff aware of resident's wander risk. Record review of Resident #115's progress notes by RN G dated 03/24/25 at 07:22 p.m. reflected, This nurse was on her lunch break, driving on [name] Street when I spotted the resident in his wheelchair being pushed by a Hispanic man who lives on the corner. This nurse put her car in park and escorted the resident to the grassed area and contacted the CNA to help assist this nurse to escort the resident back to the facility. This nurse assessed the resident for injuries once the resident was back in the building. No injuries observed at this time. VS BP 132/72, P 72, T 97.4, R 17, o2 sat 94%. Resident unable to give details as to how he got to the stop sign. Another resident stated this resident was let out the front door by a family member of another resident. MD, DON, administrator, and family member notified of the incident. One on one monitoring of the resident started and completed every 15 min. Record Review of the PIR initiated on 03/24/25 reflected, RN G completed head to toe assessment on Resident #115 with no injuries, marks or bruises noted. All vital signs in normal limits. No change in resident's behavior noted. Resident did not miss any medications or treatments Provider response .3 day follow-up by Social Worker with no change in base line behavior noted .Resident placed on one-one supervision .Facility completed Elopement drill in-Service with staff as a precautionary measure .Signs posted at exits instructing visitors to not assist others to exit the facility .Facility reported the alleged incident to TXDHHSC .Facility completed review of resident's medical record, including medications, treatment record and care plan .Completed safe survey with no other allegations reported .Investigation summary .[Resident 116] observed another resident's family member assist Resident # 115 to exit the facility .Resident had no history of elopement or exit seeking behavior .Provider action taken Post-Investigation .Resident's Care plan was reviewed by the Director of Clinical operations and updated as required. Family member was educated not to assist residents to exit the facility. Resident #115's medication reviewed by Director of Clinical operations. Elopement assessment completed on residents. Facility completed Abuse prevention in-service . Record Review of Progress notes for Resident #115 from 03/24/25 through 04/18/25 reflected the resident remained on every 15-minute checks until his discharge to another facility with a locked unit on 04/18/25. Record review of the facility census dated 05/05/25 revealed Resident #115 was not a resident at the facility. In an interview with RN G on 05/06/25 at 03:15 p.m. she stated she was working the evening Resident #115 eloped from the building. She stated he had been in the dining room eating supper and then he went out on smoke break with the other smokers. She stated after smoke break, he had come back and was in the lobby visiting which was his normal routine. She stated she took her lunch break around 06:00 p.m. and had left the building to get something to eat. She stated she spotted the resident about a block down the road being pushed in his wheelchair by an unknown male who was trying to assist him across the intersection of the service road off Highway 75. She stated she placed her car in the intersection to stop the traffic until she could push the resident off the road. She stated she called the facility and told the CNAs to come and assist. She stated Resident #115 stated he did not know where he was going. She stated she assessed him when she got him back to the facility and notified the MD, family and the Administrator and DON. She stated they placed him on one-on-one supervision. She stated they knew the door alarm and not gone off and later discovered it was the family member of another Resident in the building who had opened the door and asked him if he wanted to go outside. She stated she was not sure how the family member had the code, but stated the codes had all been changed and they had been in serviced on elopement, which included not giving the access code to anyone but staff. She stated Resident #115 had never been exit seeking prior to this incident. In an interview with MA S on 05/05/25 at 08:40 p.m. she stated she was working the night Resident #115 had left the building. She stated she had seen him in the dining room eating his dinner around 06:00 p.m. and he had gone to the front lobby which was his normal activity. She stated the next thing she heard was he was out of the building, and they were bringing him back to the facility. She stated she was told another Resident's family member had held the door open for him and let him out. She stated they had placed the resident on one-on-one monitoring, and they had changed the door code. She stated they were not allowed to give the door code to anyone. She stated the code had been changed several times since the incident with Resident #115. She stated she had received elopement training before this incident and again after the incident. In an observation on 05/05/25 at 6:10 p.m. revealed the front door was locked with code posted outside for entry. Sign posted next to the keypad alerting visitors not to assist residents in leaving the building. Upon entering the facility, the door alarm began to ring. Staff responded promptly and reset the code. Sign was posted above the inside keypad alerting visitors not to assist residents in leaving the building. In an interview with the Administrator on 05/05/25 at 07:50 p.m. he stated Resident #115 had no previous history of exit seeking or elopement. He stated he was mobile with a wheelchair. He stated when the incident occurred the staff immediately notified him after they had returned the resident to the facility. He stated he was able to look at the camera in the lobby area and observed another Residents' family member opening the door and letting Resident #115 out the front door. He stated this was also confirmed by another resident who had witnessed the family member letting Resident #115 out the front door. He stated they immediately changed the code on the doors and placed the resident on one-on-one supervision and started looking for placement in male locked unit. He stated he also educated the other Resident's family member about not assisting other residents out of the building. He stated he placed signs on both the outside of the front door and inside the front door alerting visitors not to let anyone out of the building unless they had come with them. He stated all staff were re-educated on elopement and re-instructed not to give out the access code to visitors or vendors. He stated they used to change the code monthly but had increased the frequency to daily changes and will continue to monitor compliance with staff for the next 30 days. In an interview with LVN B on 05/05/25 at 08:25 p.m. she stated she had worked here 3 weeks and was a PRN nurse. She stated she had been trained on elopement when she was hired. She stated the access codes to the front door were only to be given to staff. She stated they were responsible for letting visitors out of the building. She stated she had not had anyone exit seek or attempt elopement on her shift. She stated they did have a new admit over the weekend (05/03/25) that was moved to the locked unit because she was at risk and was making verbal comments about wanting to leave. She stated they had the resident on one-on-one supervision until they could get the necessary approvals to move her to the locked unit today (05/05/25). LVN B stated Resident #115 was discharged before she started working at the facility. In an interview on 05/05/25 at 08:30 p.m. with RN W, she stated she was a PRN nurse that had been here since December 2024. She stated she had received training on elopement upon hire and again in March 2025. She stated any exit seeking behavior they were to immediately increase the monitoring of the resident. She stated they would place the resident on one on one or q 15-minute checks until they determined if the resident needed to be placed on a secured unit. She stated she had never seen Resident #115 attempt to exit seek. She stated only staff were allowed to have the codes to the doors and were not to give the codes to the family members or vendors. She stated they were expected to round on the residents every 2 hours and CNAs round every 2 hours, so someone saw the residents at least every hour. In an interview with LVN A on 05/06/25 at 10:15 a.m. she stated Resident #115 had never exhibited exit seeking behaviors since he had been at the facility. She they do an elopement assessment on every new admission and then complete one quarterly on all the residents. She stated they had an elopement drill and in service in March. She stated anytime a door alarm goes off staff are to immediately go to the door, look outside to see if they see anyone and then come and do a head count of residents. She stated they an elopement binder at the nurse's station that has all the resident's information and contact numbers. She stated Resident #115 was let out by another resident's family member, who had the code to the front door. She stated they had since changed the codes numerous times since the incident and had informed family and vendors they were not allowed to give the code out. She stated staff were required escort family or vendors out of the front door. In an interview with the ADON on 05/06/25 at 01:15 p.m. she stated they had in serviced all the staff on the elopement protocol, which included keeping the codes to the doors confidential. She stated in the past some long term family members had to the codes to the door but stated since this incident no one was allowed the code except the staff. She stated they do elopement drills at least twice a year. She stated they had done 2 drills since the first of the month. She stated anytime a resident attempted an elopement or started asking to go home or leave the staff were to place the resident on one-on-one supervision until they determined if the resident was going to require placement in a secured unit, which was what they decided was best for Resident #115. She stated it took a few weeks to find placement for him and stated they kept him on one-on-one until he discharged . In an interview with CNA N on 05/06/25 at 03:00 p.m. she stated she was working the 02:00 p.m. to 10:00 p.m. shift on 03/24/25. She stated she had seen Resident #115 in the dining room at dinner time. She stated the resident was mobile with his wheelchair. She stated after dinner he would usually go to the front lobby and visit. She stated Resident #115 had never attempted to leave the facility. She stated she went, and assisted RN G bring the resident back to the facility. She stated the resident did not know where he was and just stated he was going for a stroll. She stated they had an elopement Inservice right after the incident and the codes to the door were changed. She stated they were instructed to not give the code to anyone other than staff. In an interview with the DON on 05/06/25 at 04:00 p.m. she stated they had re-assessed all of the residents for their elopement risk on 03/25/25. She stated they had in serviced the staff on the elopement protocol which included warning signs of residents seeking to leave and what to do when the door alarms and they initiate a search. She stated through their investigation they determined the resident had not been exit seeking but was allowed out the front door by another resident's family member. She stated the staff had been instructed they were never to give out the access code to anyone but other staff members. She stated they were currently changing the code daily to help ensure compliance. She stated they had done elopement education on 12/20/24, 01/29/25 and again on 03/25/25. In an observation on 05/07/25 at 03:40 p.m. a family member was observed going to the front door attempting to put in the code. Family member came to the nurse's station and asked if the code had been changed. LVN B informed the family member she would assist her and went and entered the code to allow the family member to exit. The family member was heard asking for the new code and was informed by LVN B they were not allowed to give out the codes to the doors, that a staff member would assist them anytime they were ready to leave to the facility. Record review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .3. The entire search process of the facility and grounds, from the time the patient/resident is missing, should be competed withing 30 minutes .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress .If a resident is not located during a search of the facility, facility grounds, and immediate vicinity, and there are circumstance that place the resident health, safety, and/or welfare at risk, a report HHSC must be made as soon as the facility becomes aware the resident is missing and cannot be located . Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those with dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities. Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. The Administrator and DON was notified and provided the IJ template on 05/07/25 at 01:43 p.m. of PNC IJ. The facility implemented the following interventions: Record Review of Resident #115's comprehensive care plan with a revision date of 03/24/25 reflected, Resident is an elopement risk/wanderer and is at risk for possible injury related to impaired safety awareness and diagnosis of dementia. 03/24/25 -exited the facility .Interventions .Place 1:1 due to safety until referrals can be made if placement is needed . Record review of Staff in-services reflected on 03/25/25-Staff in serviced on elopement education including elopement drill and limiting access to the door codes. Record Review of the Facility's Assessment Scoring report dated 05/06/25 reflected all the residents in the facility, including Resident #115, had a new elopement assessment completed on 03/25/25. Record review of staff in-service reflected the staff had been in serviced on Abuse and Neglect on 03/27/25. In interviews covering all three shifts (6 AM- 2PM, 2 PM-10 PM, and 10 PM- 6 AM), revealed they had been in-serviced on preventing and responding to elopements, participated in elopement drills, knew the alert code for an eloped resident, were aware of where to find the elopement book at the nurses' station and had been instructed not give the access code to the front door to anyone other than staff and had been in serviced on abuse and neglect and were aware of the different forms of abuse and neglect and the reporting requirements. The following interviews were conducted on the following dates: *05/06/25-10:15 a.m. to 02:05 p.m. LVN A, ADON, CNA J, CNA X, CNA H, CNA Y, and CNA P *05/07/25- 03:00 to 04:00 p.m. CNA Q and the Activity Director. *05/08/25-08:15 a.m. to 03:10 p.m. CNA L, CNA Z, RN F, LVN C, LVN E and the Treatment Nurse. *05/09/25 from 5:10 AM to 5:45 a.m. LVN HH, LVN II, CNA GG and CNA JJ. *05/09/25-10:14 a.m. to 10:45 a.m. - CNA K and CNA U The noncompliance was identified as PNC. The IJ began on 03/24/24 and ended on 03/25/24. The facility had corrected the noncompliance before the survey began. 2. Review of Resident #61's admission MDS assessment dated [DATE] reflected Resident #61 was a [AGE] year-old female with an admission date of 03/20/25. Resident #61 had a BIMS of 12 indicating she was moderately cognitively impaired. She required partial to moderate assistance with ADLs. Active diagnoses included osteomyelitis of right radius and ulna (Inflammation of bone caused by infection of the 2 bones located in the forearm) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #61's Diet order and Communication sheet dated 03/20/25 reflected an order for Regular diet, Mechanical soft (makes food softer, easier to chew). Record review of Resident #61's care plan initiated on 04/07/25 reflected, [Resident #61] have an ADL self -care performance deficit related disease process. Activity intolerance, dementia, impaired balance, limited mobility .Interventions .Bed mobility: The resident requires supervision touching assistance by 1 staff to turn and reposition in bed as necessary .Eating: The resident is able to: setup clean-up assistance . Record review of Resident #61's progress notes by LVN C dated 04/20/25 at 2:24 p.m. reflected, Resident stated wanted coffee, aide went to get coffee out of machine in the dining room, upon return resident stated, Not hot enough, make it hotter. Aide went to get another cup and returned to resident. Moment's past, resident spilled coffee onto self, some slight redness. Aide and nurse called to room, treatment nurse assessed, and provider and POA notified. Record review of Resident #61's incident report dated 04/20/25, completed by LVN C reflected, Injury type- Burn to chest and face .Resident is alert and oriented to person, place, time and situation .Predisposing situation factors .Resident difficulty to grasp cup . Record review of Resident #61's Change of Condition report by the DON on 04/20/25 at 02:30 p.m. reflected, Primary Care Provider responded with the following orders .Silver Sept Silver Antimicrobial gel (ointment used to treat abrasions and burns) BID and leave open to air. Record review of Resident #61's progress note dated 04/21/25 at 08:35 a.m. by the DON reflected, LATE ENTRY Head to toe assessment completed at this time. Redness noted to R corner of bottom lip that extends down the R side of resident's chin and neck. Redness noted to Right side of upper chest measuring 10cm x 2cm. This area has two blistered areas that appear to be in healing phase. Blister 1 measures 1.75cm X 1cm. Blister 2 measures 1cm X 0.5cm. Wound care on board. No other injuries, bruising, marks, or skin concerns noted during assessment. MD and family aware of findings. Resident has no c/o pain or discomfort at this time. All anticipated needs met. Call light within reach. Record Review of Resident #61's TAR from 04/21/2025 through 05/02/2025 reflected, Silver Sept Silver Antimicrobial Skin and Wound Gel two times a day for Wound Healing Apply to Chin, Neck, and Rt Upper Chest. Treatment was provided twice a day until wounds were healed on 05/02/25. Record Review of the facility PIR (Provider Investigation Report) initiated on 04/21/25 reflected, .Investigation summary, resident requested coffee to be heated in microwave. Resident spilled coffee on herself and had red area and small blister to lower lip and chest. Staff were instructed not to heat coffee in the microwave. Facility reviewed coffee temperature logs in kitchen, all documentation revealed proper temperatures .Post-investigation- The Director of Clinical Operations assess resident on 04/21/25 .The Director of Clinical Operations reviewed resident's mediations to ensure proper medication administration .Residents care plan was reviewed by Director of Clinical operations and updated as required .Facility completed an Abuse Prevention-in-service as precautionary measure and not reheating beverages .Facility completed Inservice with CNA L on Abuse Prevention and Proper Positioning of residents for feeding and beverages .Facility ordered air pots for coffee service on halls . Record review of Resident #61's updated care plan dated 04/21/25, reflected, Resident has current skin concerns. Burn to right side of lip, chin, and neck. Right upper chest .Interventions .Perform treatments per MD orders. Silver Sept Silver Antimicrobial skin and wound gel. Apply BID for wound healing .Keep MD and RP informed of resident's progress . In an interview with CNA L on 05/08/25 at 08:15 a.m. she stated the day of the incident with Resident #61 she had answered her call light. She stated the resident had requested her coffee be reheated, stating it was not hot enough. She stated she took it to the breakroom and placed it in the microwave for about one minute and took it back to the resident. She stated the resident had lowered the head of her bed. She stated she placed the coffee on her overbed table and told the resident it was hot, and to be sure and raise her head up before she tried to drink it. She stated the resident told her okay. She stated she left the room and a few minutes later her call light was on again. She stated she went to her room and saw where she had tried to drink the coffee without raising her head up and had spilled some down her chin onto her chest. She stated she immediately called for the nurse who came and assessed her. She stated she was in serviced after the incident and told they were not to reheat any food or drink until they were skills checked off on the proper temperature. She stated she has had that Inservice and stated coffee was not to exceed 150 degrees and food was not to exceed 165 degrees. She stated she also learned a valuable lesson and stated she would raise the resident's bed up before she left any food or drink for a resident. She stated Resident #61 was able to feed herself and she just did not think about her trying to drink the coffee with her head down. She stated the resident had a lidded cup now for her drinks. In an interview with LVN C on 05/08/25 at 02:10 p.m. she stated she was working the night of the incident with Resident #61. She stated CNA L had come a got her and told her the resident had spilled hot coffee on her. She stated she assessed her noted redness on her chin, neck, and upper chest with a few small blisters. She stated she notified the DON, and they contacted the MD and obtained orders and started treatments on her. She stated they received in-services the next day telling them they were not to reheat any food or drinks for residents until they were skills checked off on the proper food temperatures for food and coffee. She stated she had been skills checked and knew coffee was not to be over 150 degrees and food was not to exceed 170 degrees. She stated they have thermometer at the nurse's station with the temperatures posted for the staff to use when reheating items. She stated Resident #61 ate independently and just required some set up assistance. In an interview and observation of the breakroom on 05/05/25 at 06:20 pm. where the microwave was stored, revealed a locked door with a keypad. A sign posted indicating door was to be kept always locked. Interview with MA V stated the code had recently been changed on the breakroom door to ensure only staff had access to the microwave. In an observation and interview with Resident #61 on 05/05/25 at 07:00 p.m. the Resident was sitting up in bed eating her supper. No hot beverages were observed on the tray. She stated she remembered the incident that happened a few weeks ago and stated she got a burn on her collar bone. She stated she had asked the CNA to heat up her coffee and she spilled it on her when she went to take a drink. She stated the burn had healed up and proceeded to show the surveyor where the burn was. The area was observed to be healed with slight pink color noted at the burn site. Resident #61 was observed with a wrist splint on her right wrist. She stated she was right-handed and had to learn to use her left hand. She stated her left hand gets a little shaky at times, but stated she was able to feed herself. She stated the facility had provided her a cup with a lid and handles after the incident. In an interview with [NAME] T on 05/05/25 at 07:30 p.m. he stated they had been in- serviced on food temperatures and were to keep a log of the coffee temperature when it was placed in the air pots in the dining room. He stated the temperature was not to exceed 150 degrees. He stated they do not re-heat food or drinks for the residents. He stated once the tray leaves the kitchen it cannot come back into the kitchen area for reheating. He stated the nursing staff had always used the microwave in the break room for reheating items for the resident. In an interview with the Administrator on 05/05/25 at 07:55 p.m. He stated the incident with Resident #61 was the result of CNA L reheating the resident's coffee and not knowing how hot it was. He stated he immediately stopped all staff from reheating residents' food or coffee until they were all skills checked on safe food temps. He stated he also in serviced the kitchen staff to ensure they were keeping a temperature log for the coffee not to exceed 150 degrees Fahrenheit. He stated they replaced the coffee urn in the dining room with two air pots which will hold the temperature but will not continue to heat up. He stated the coffee was checked by kitchen staff every time and ensured it did not exceed 150 degrees before placed in the air pots. He stated they changed the lock on the breakroom because they were not able to change the code. He stated they can now change the code on the breakroom where the microwave is located. He stated the door was to be kept closed and always locked as well. He stated the Food Service Director in serviced and skills checked the nursing staff on proper temperatures for reheating residents' food and coffee and had placed a digital thermomotor at the nurse's desk with instructions on safe temperatures for food and drinks. In an observation and interview with Dietary Aide AA on 05/08/25 at 08:30 a.m. she was observed checking the temperature of the coffee from one of two air pots in the dining room. The temperature was 136.8 degrees. She stated they check the temperature every time they fill the air pots, and it was not to exceed 150 degrees Fahrenheit. She stated she had been in serviced about the temperatures and the logs for the coffee a few weeks ago. In an interview with the Director of Rehabilitation on 05/07/25 at 11:50 a.m. he stated they have had Resident #61 on service since she had admitted . He stated she had progressed well and could feed herself. He stated after the incident they did request a lidded cup for her since she still had some weakness in her grasp in her left hand. In an interview with the DON on 05/08/25 at 03:10 p.m. she stated CNA L received on one training on ensuring a resident was sitting up in the bed at least at a 45-degree angle before serving food or drink. She stated all the staff were told to immediately stop reheating food and drinks until they had been skills checked on checking temperature and knowing the appropriate temperature for food and coffee. She stated the Food Service Manager had conducted that in-service and training with all the nursing staff. She stated they also updated the resident's care plan and therapy had requested a lidded cup for the resident to prevent

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for one (Resident #4) of 10 residents reviewed for abuse and neglect. 1.The facility failed to prevent Resident #4 from neglect and possible abuse when she was fearful of Resident #13 and remained in the room when she did not know who the resident was any longer. 2.The facility failed to investigate Resident #4's concerns and allegations. 3. LVN A, LVN B, the ADON and the DON failed to recognize aa possible allegation of abuse/neglect. 4. The facility failed to identify and intervene for Resident #4. 5. The facility failed to report and protect Resident #4 from additional psychosocial harm. An Immediate Jeopardy (IJ) was identified on 05/07/25. The IJ template was provided to the facility on [DATE] at 1:43 PM. While the Immediate Jeopardy was removed on 05/09/25, the facility remained out of compliance at a scope of pattern and a severity level of no harm that is not Immediate Jeopardy due to facility continuation of in-servicing and monitoring the plan of removal. These failures could place residents at risk for not having measures in place to protect them from serious harm and mental anguish. Findings included: Record review of the facility's freedom from abuse and neglect policy, titled Abuse, dated effective 02/01/17 and revised 0/01/23, reflected: .each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal code chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents . .Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation . Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s) . The abuse coordinator with the Director of Nursing/ designee will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences, and determine what changes, if any, are needed to prevent further occurrence. All documentation of investigation must be protected and made available upon request. Protection: It is utmost important that resident(s) suspected of being abused, and all other residents must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . In the event of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The Director of Nursing will coordinate this and set up monitoring. If a threat does not exist then an assessment will be completed, and behavior will be care planned to meet resident's needs and protect others. Record review of the inservice record dated 04/21/25 revealed the facility inserviced staff on the Long Term Care Regulation Provider Letter with emphasis on the timeliness of reporting. Review of the Long-Term Care Regulation Provider Letter, PL 2024-14 issued August 29, 2024 revealed .HHSC rules define neglect as the failure to prvide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. CMS defines neglect as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of Resident #4's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. She had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), major depressive disorder (persistent feelings of sadness or loss of interest), bi-polar disorder (periodically intense emotional states), schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 8 (moderately impaired cognition). Record review of Resident #4's care plans revised 11/17/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #13. Further review reflected she had impaired cognitive function or thought process due to dementia, interventions included cue and reorient and supervise as needed, dated initiated 02/02/25. Further review revealed she identified as a trauma survivor with trauma category of: Serious illness, childhood trauma, neglect, psychological trauma, dated initiated 7/21/21, and interventions included ask for permission to enter resident's room . be conscious of resident position when in groups, activities, dining room to promote proper communication with others and feelings of safety .behavioral health consults as needed, psychiatrist or counselor . Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. He had the diagnoses of dementia (loss of cognition), anxiety disorder (sudden feelings of intense worry), bi-polar disorder (periodic intense emotional states), psychotic disorder (episodes of disrupted thoughts and perceptions), and schizophrenia (mental health condition that affects how people think, feel and behave) and a BIMS score of 11 (moderately impaired cognition). Record review of Resident #13's care plan revised 10/23/23 revealed there was no care plan area for the resident's cohabitation and relationship with Resident #4. Further review reflected he had impaired cognitive function or impaired thought process due to confusion to time and a short-term memory deficit, dated initiated 09/20/18, interventions included engage in simple, structured activities, keep his routine constant, present just one thought, idea, question, or command at a time. Further review revealed he had a behavioral problem due to anxiety and had delusions including he believed he was a prisoner of war and yelled out to relieve stress, dated revised 12/19/21, interventions included .caregivers provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, if reasonable, discuss behavior .explain/reinforce why behavior is inappropriate . Record review of Resident #4's census report revealed she moved in room [ROOM NUMBER] on 4/28/22. Record review of Resident #13's census report revealed he moved to room [ROOM NUMBER] on 01/19/23. Record review of Resident #4's progress notes reflected: Dated 04/14/25 at 6:45 AM by LVN A: .Resident stated to night shift staff, There's a man in my room! Staff attempted to redirect and inform her that he is her roommate and boyfriend [Resident #13]. Resident responded, I don't know him! Resident would not go back to her room. Resident repeatedly asked staff, How do I get out of here? Resident then sat on the couch, waiting for her ride. Resident stayed on the couch and slept. At this time, resident continuing to sleep on couch. Dated 04/14/25 at 9 AM by LVN A: Resident woke up @ 0830 (8:30am) on the couch and came to the nurse's station asking, How do I get out of here? Nurse redirected resident to her room. Resident remembered who her boyfriend was [Resident #13]. Resident came back to the nurse's station immediately after entering her room and again asked, How do I get out of here? Nurse redirected resident for a second time. Whenever resident would enter her room, she would immediately come back up to the hall to the nurse's station asking how to leave. Nurse able to redirect resident to eat breakfast. Notified DON, ADON, and MD. Resident placed on Q(every)15 min elopement monitoring. Dated 04/15/25 at 1:30 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Dated 04/16/25 at 12:35 PM by LVN A: Resident has had no attempted elopement this shift. Resident did come to staff members multiple times this shift asking, How do I get out of here? Resident redirected successfully each time. Resident has had continuous bouts of confusion and has had barely any appetite since being treated for UTI. N/O UA PCR to ensure that resident's UTI has fully been treated. Dated 04/16/25 at 6:28 PM by LVN A reflected the urine PCR was collected and Resident #4 did not have any signs or symptoms of distress. Dated 04/17/25 at 7:45 AM by LVN A: When delivering breakfast tray to resident, resident asked CNA, 'How far away will you be?' CNA explained that she was passing breakfast trays on the hall. Resident explained, 'That creepy man over there keeps staring at me and I just wanted to know where you will be if I need you.' Resident was referring to her boyfriend [Resident #13]. Resident has had persistent confusion past normal baseline. Pending UA PCR results for f/u on previous UTI. Resident continuing Q15 min monitoring for elopement. Dated 04/17/25 at 8:10 AM by LVN A: Resident and her boyfriend, another resident, were ambulating up the hallway and they stopped so her boyfriend could use the bathroom. When boyfriend came back, resident yelled out to nurse's station, Where did my boyfriend go? Boyfriend looked back at her and said, It's me! Resident then stated, No you're not my boyfriend! Nurse reoriented resident successfully. Dated 04/17/25 at 12:10 PM by the Director of Resident Support Services: .Resident has been experiencing increased confusion and has expressed a desire to leave the facility. Nursing staff have been consistently redirecting her during these episodes . Dated 04/17/25 at 1:27 PM by LVN A reflected Resident #4 was assessed by behavioral health services regarding increased confusion, 15 minute checks were discontinued and medications adjusted. Dated 04/23/25 at 12:09 PM by LVN A: Resident confused and does not remember her boyfriend. Resident refusing to sit with boyfriend at lunch. Dated 04/23/25 at 8:12 PM by LVN B: .Resident very confused today and could not remember boyfriend and refused to be left in the same room with him. Dated 04/23/25 at 11:23 PM by the ADON: Upon start of shift, this resident was up in dining area sitting in a chair alone. Previous shift reported that she did not want to go into the room with her boyfriend. This nurse went to speak to this resident and assisted her to her room. No issues with assisting resident to bed. This nurse spoke with resident's boyfriend/roommate and asked that he give her some time and explained that she is just confused right now. Boyfriend/roommate verbalized understanding . Dated 04/24/25 at 12:45 PM by LVN A: During lunch, resident refused to sit with her boyfriend/roommate. Resident stating he is not her boyfriend and that he is weird. Resident ate with another resident while her boyfriend/roommate ate at a different table. Resident continues to exhibit increased confusion. Resident unable to find her room or the dining room without assistance from staff. Dated 05/05/25 at 9:25 PM by LVN B: Resident was exit seeking earlier today so we implemented 15 minute checks at 9:30pm. Record review of Resident #4's Q15 elopement monitoring, start dated 04/14/25-04/17/25 reflected Resident #4 was monitored every 15 minutes. Record review of Resident #4 lab results revealed a UTI panel, dated collected 03/21/25 and reported 03/24/25, tested positive for Escherichia coli (bacteria). Further review revealed another UTI panel, dated collected 04/16/25 and reported 04/18/25, tested negative for Escherichia coli (bacteria) and positive for Staphyloccus spp (bacteria). Record review of Resident #4's physician's orders revealed the following orders: -Ciprofloxacin 500 mg, one tablet by mouth, for 10 days for a UTI, start dated 02/25/25 and end dated 04/04/25. -urine analysis PCR for follow up of previous UTI, dated 04/16/25. -Ciprofloxacin 500 mg, one tablet by mouth, for 7 days for a UTI, start dated 04/21/25 and end dated 04/28/25. In an interview and observation on 05/05/25 at 7:17 PM with Resident #4 and Resident #13 revealed she was sitting up in bed and stated she was doing well. Resident #13 entered the room and he stated that he lived with his girlfriend (Resident #4) and they were married. He stated to Resident #4 Tell her that we are married. Resident #4 looked at Resident #13 and did not reply. In an interview on 05/05/25 at 8:36 PM with MA S, she stated Resident #4 and Resident #13 were boyfriend and girlfriend and resided in the same room for years and the family was aware and they were happy together. She stated it was not a sexual relationship and had not seen the residents in the same bed for at least a year and especially with Resident #4's incontinence. She stated Resident #4 had dementia and recently had increased confusion of her surroundings and more frequent incontinence. She stated they were monitoring her frequently. In an interview on 05/06/25 at 9:14 AM with Resident #4, she stated she had a roommate who was male and she did not like it. She stated she had girlfriends and did not want a boyfriend because it made her feel uncomfortable because sometimes boyfriends were mean. She stated there was no physical or sexual contact between them, and she denied that Resident #13 harmed her in any way. She stated he liked to sit on her bed and look out the window. She stated she didn't like him and didn't want to spend time with him but was not sure why, when he was around her she felt pretty bad. She stated she felt safe at the facility. In an interview on 05/06/25 at 9:29 AM with Resident #4's responsible party revealed she had last seen Resident #4 about 2 months ago and spoke with her over the phone on 05/05/25 and was unaware that Resident #4 voiced any discomfort with her roommate, Resident #13. She stated that she spoke with staff about 10 days ago about Resident #4's advanced directives and there was no mention Resident #4 was uncomfortable with Resident #13. She stated Resident #4 had a cognitive decline in the last few months but she found it hard to believe that Resident #4 felt uncomfortable with Resident #13. In an interview on 05/06/25 at 11:48 AM with Resident #13 revealed he and Resident #4 broke up last week and they were just companions now and it was not a sexual relationship for at least a year. He stated he planned to discharge from the facility and had just purchased a helicopter. He stated he was a prisoner of war. In an interview on 05/06/25 at 10:16 AM with LVN A revealed Resident #4 and Resident #13 developed a friendship that developed into a relationship, and they eventually moved into the same room with the approval of both resident representatives. She stated Resident #4 recently had a cognitive decline and had two courses of antibiotics for a UTI and was frequently incontinent. She stated there were some days Resident #4 knew who Resident #13 was; and other days she did not know who he was. She stated that Resident #4 asked her why there was a random man in her room (Resident #13). She stated that Resident #4 would sit and waited for a ride in the lobby area and she was being monitored with 15 minute checks until the behavioral health services assessed her for a secure unit placement. She stated she remembered writing the progress notes and it was discussed in a morning meeting about possibly moving Resident #4 to a different room. She stated in the meeting it was determined if they moved her to a different room then Resident #13 would have still sought her out and if Resident #4 was placed on the secure unit, they would be able to ensure they were separated; Resident #4 had also displayed more exit seeking behaviors. She stated behavioral health services determined she was not at a high enough risk to be admitted to the secured unit and it had not been discussed again. She stated she did believe Resident #4 could have felt unsafe and Resident #13 was also upset that Resident #4 did not remember who he was. In an interview on 05/06/25 at 12:30 PM with the Director of Resident Support Services revealed Resident #4 had dementia, was confused and doesn't understand why she was at the facility, her last BIMS score was a 3 (severe cognitive impairment). She stated Resident #13 also had confusion and had a low BIMS score. She stated she spoke with Resident #4 on 05/05/25 and had not heard any concerns about Resident #13. She stated a resident who did not remember their significant other or started to call them creepy, refused to go into their room or refused to sit with each other at mealtimes was a cause of concern regarding consent and abuse and could cause a resident to physically lash out at the other roommate if they invaded their space. In an interview on 05/06/25 at 12:41 PM with the DON revealed Resident #4 had a significant change in her cognition a couple of weeks ago and was more confused, was not sure where she was and stated she wanted to leave, did not recognize nursing staff or Resident #13, they placed her on 15 minute checks and tested her for a UTI- it was positive and had to go through several rounds of antibiotics and had medications adjusted. She stated that she was not aware of the progress notes that used the words creepy or weird and only remembered they discussed Resident #4's general confusion. She stated if she had known she would be concerned with resident safety and would have intervened and temporarily moved her to ensure she felt safe, informed the Executive Director, and reevaluated any causes. She stated there was not an assessment for resident consent for relationships and there was not a policy regarding resident cohabitation or relationships and did not know if it would be something to be care planned. In an interview on 05/06/25 at 1:03 PM with the ADON revealed Resident #4 and Resident #13 had been roommates for years and it had been good for a while, they typically sat together for every meal. She stated that recently Resident #4 had a UTI and was confused about where she was and who Resident #13 was and she reoriented Resident #4 to her room and to Resident #13. She stated that there were times Resident #13 came to her and was concerned because Resident #4 did not recognize who he was and was refusing to go to their room, she told Resident #13 to give Resident #4 some time and explained Resident #4 was confused. She stated that in a morning meeting LVN A brought up possibly moving Residents #4 and #13 to a separate rooms but there were concerns that Resident #13 would go into whatever room they moved Resident #4 to. Interview revealed there was a discussion about possibly admitting Resident #4 to the secured unit . The ADON could not remember why a change was not made. In an interview on 05/06/25 at 2:35 PM with the Executive Director revealed he started working at the facility in April of 2024 and Resident #4 and Resident #14 were already established roommates and were alright, as far as he knew it was a companionship. He stated he knew that Resident #4 had confusion and did not know the details. He stated Resident #4's progress notes would be a cause for concern for possible abuse and if he had known then he would have involved the Director of Resident Support Services and at least temporarily separated the residents or offered to separate the resident. He stated that he expected staff to report concerns to him and for the DON to inform him during morning meeting of any concerns so that they know what was going on with residents and make sure the facility addressed all their needs. He stated the facility did not have a policy for resident capacity or consent or regarding resident relationships. He stated that consent concerns would be assessed as needed, when there were concerns from family or friends, or the resident then they reassessed the situation. In an interview on 05/06/25 at 2:59 PM with LVN B revealed she started working at the facility about 3 weeks ago, and staff told her Resident #4 and Resident #13 were boyfriend and girlfriend and roommates. She stated Resident #4 did not want to go into her room with Resident #13 and she told LVN B that she did not want to be in the same room as Resident #13 and that she did not know him. LVN B stated she took Resident #4 to an empty room and suggested she sleep there. She stated Resident #4 asked LVN B why would she not want to sleep in her room and LVN B replied that Resident #4 said she felt uncomfortable with her boyfriend (Resident #13). She stated she notified the oncoming shift and continued to check on Resident #4 every 15 minutes due to her elopement risk. She stated that Resident #4's comments were concerning because it showed she felt like he was a threat to her. She stated she was not aware of the progress note where Resident #4 called Resident #13 creepy and stated she would have questioned Resident #4 more on why she used the word creepy because it sounded like she felt frightened to be alone with him. In an interview on 05/06/25 at 4:49 PM with the Director of Rehabilitation revealed Resident #4 recently had a decrease in her cognition level due to a UTI and suddenly started to dislike her roommate (Resident #13) and did not recognize him. He stated that about a week ago Resident #4's wandering, confusion, and not remembering Resident #13 was brought up during a morning meeting with the department heads. He stated he suggested they move Resident #4 to another room due to dementia and the male-female dynamic and was not sure why the residents were not moved. He stated that he could not remember if the Executive Director was present at the time. In an interview on 05/08/25 at 11:55 AM with CNA H (worked all shifts) revealed Resident #4 started to not recognize Resident #13 around January 2025 and then more consistently in the past month. CNA H stated Resident #4 said things like there's a strange or weird man in her room and she didn't know who he was. She stated she took her to LVN A who reoriented Resident #4 to Resident #13 and told her that's your boyfriend- you live with him. CNA H stated sometimes Resident #4 remembered who Resident #13 was and other times she would say no, I don't know him and went to the lobby and stayed there about an hour or so then came back and did the same thing again. CNA H stated staff redirected Resident #4 with coffee, snacks, activities, smoking breaks and eventually Resident #4 went back to her own room. She stated Resident #4 did seem afraid and confused and she saw now that it could have been a sign of abuse. An Immediate Jeopardy was identified on 05/07/25. The Administrator and DON were notified on 05/07/25 at 1:43 PM of the Immediate Jeopardy. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 05/08/25 at 6:26 PM. The accepted plan of removal for the Immediate Jeopardy included the following: The following is a plan of removal, which has been immediately implemented at [the facility], to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on May 7, 2025 at 1:55pm.? On 5/7/2025 at 10am [Resident #4] was removed from the same room and placed on a separate unit away Resident #13. Resident #4 placed on enhanced supervision on 5.5.25. Resident #13 was placed on enhanced supervision 5.6.25. Resident #4 and Resident #13 assessed for signs/symptoms of abuse/neglect, physical or mental, harm by Regional Director of Clinical Services. No negative findings identified. Psych service vendor contacted by Social Services and [DON] 5.7.25 to conduct off cycle visit on 5.8.25 and/or medication review for resident #4 and resident #13 who are currently already on services with this provider per physician orders. Medical Director contacted by facility on 5.7.25 to conduct on-site assessment for Resident #4 and Resident #13 on 5.8.25. On 5.7.2025 [Executive Director], [DON], [ADON], received one to one education from Regional Director of Clinical Services on abuse/neglect/exploitation/identifying and reporting, adhering and following policy and procedures, and complying with State and Federal Guidelines. [Executive Director], [DON], and [ADON] will be in-serviced on resident to resident relationships upon the development of the policy and procedure on 5.8.25, On 5.7.25 [the facility] contacted the legal team to assist with the development of a policy and procedure for resident to resident relationships. Completion date for the development and adoption of such policy and procedure will be 5.8.25. All staff will be staff in-serviced on Resident to Resident relationships on May 8, 2025 by [Executive Director/DON], and/or designee. In-service education included but not limited to, who to report suspected relationships to, facility obligations to serve residents participating in a resident to resident relationships, resident capacity and consent for relationships, and facility response when a potential relationship is identified. Facility will communicate changes in resident relationship statuses during routine morning meetings with the IDT team and clinical staff members. All staff not present at time of in-service will not be permitted back to work until in-service is complete. All staff in-serviced on abuse, neglect, and exploitation on May 7, 2025 by [Executive Director] and [DON]. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. Completion date 5.8.25. LVN A, LVN B, ADON, DOR and DON received one to one in-service for resident to resident relationships and abuse/neglect/exploitation identifying and reporting on 5.7.25 by Regional Director of Clinical Services. All residents with the ability to communicate interviewed by [Director of Resident Support Services] and/or designee on 5/7/2025 for potential safety concerns. Nonverbal residents assessed on 5.7.25 for signs and symptoms of abuse/neglect/exploitation. The Medical Director was initially made aware May 7, 2025 of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA (Quality Assurance).These conversations are considered a part of the QA process. All in-servicing began 5/7/2025. No staff will be permitted to work until in-serviced. Completion date for all in-servicing will be May 8, 2025. This plan was initially implemented 5/7/2025 and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation, Regional Director of Clinical Services. Monitoring included: Record review of facility's resident relationship policy titled Consensual Intimate Relationships Between Residents, undated, reflected: Purpose: To establish guidelines and procedures regarding consensual intimate relationships between residents in the skilled nursing facility while ensuring the safety, dignity, and rights of all residents. Policy Statement: The facility recognizes and respects the personal rights of residents to engage in consensual intimate relationships with one another. This policy aims to provide a framework for supporting such relationships while maintaining a safe and respectful environment for all residents. Definitions: Consensual Intimate Relationship: A mutual relationship between residents that includes emotional, romantic, or sexual components, characterized by the voluntary agreement of both parties. Nonconsensual Intimate Relationship/Sexual Contact: If a resident appears to want the intimate relationship/sexual contact to occur, but lacks the cognitive ability to consent; or Does not want the intimate relationship/sexual contact to occur. Procedures: Residents will be informed of their rights regarding intimate relationships and the facility's policies. Both parties must be capable of providing informed consent, free from coercion or undue influence. Staff should assess the cognitive and emotional capacity of both residents to ensure they understand the nature of the relationship. Assessment of cognitive and emotional capacity will be assessed by either a licensed nurse, licensed social worker or psychiatrist/psychologist and will occur when a resident indicates a desire to engage in an intimate relationship or exhibits behaviors of engaging in an intimate relationship. Re-assessment of a resident's cognitive and emotional capacity who wish to continue in an intimate relationship will occur as needed or on certain changes of condition such as stroke, dementia, depression/psychiatric illnesses, illness, or other impacts such as medication(s), hearing/visual loss, and stress. Documentation of informed consent and assessment will be in the resident's electronic health record. Residents engaging in intimate relationships will be provided with adequate privacy. Staff will facilitate private spaces for such interactions, respecting residents' dignity and confidentiality. Staff will document any significant developments in the relationship, including any concerns raised by residents, family members, or staff and will intervene when appropriate to ensure the safety of residents. Monitoring included: Record review of an in-service, dated 05/07/25, reflected staff on all shifts were in-serviced on identifying abuse and neglect and reporting requirements, signed by nursing staff including the DON, ADON, LVN A, LVN B, occupational/speech/physical therapy staff and the DOR, Director of Resident Support Services, Director of Life Enrichment, housekeeping staff and the Director of Environmental Services. Record review of an in-service, dated 05/07/25, reflected an in-service on identifying and reporting abuse and neglect and resident to resident relationships was signed by the Executive Director, DON, ADON, DOR, LVN A and LVN B. Record review of an in-service dated 05/08/25, reflected staff on all shifts were in-serviced on the consensual intimate relationships policy was signed by nursing[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm or death. Findings include: Review of Resident #1's face sheet undated reflected Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility with diagnoses of Muscle Wasting and Atrophy (significant shortening of the muscle fibers and loss of overall muscle mass), Syncope and Collapse (fainting), Dementia (loss of cognitive functioning that interferes with daily life and activities), Depression, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Glaucoma (eye disease that can cause vison loss and blindness and blindness), Hypertension, Osteoarthritis (chronic degenerative joint disease), Generalized Muscle Disease, Unsteadiness on feet, lack of coordination and cognitive communication deficit. Resident #1 was not her own responsible party. Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 had wandering behavior daily. Resident #1 was independent with ambulation with no assistive devices. Resident #1 required supervision with ADLs except she required partial/moderate assistance with bathing. Review of Resident #1's Admitting paperwork from previous facility discharge summary reflected: [Resident #1] has cognitive impairments and requires redirection for orientation, care and safety. [RP] would like to secure placement in a long-term care facility that can assist with redirection for wandering/exit seeking and a secure unit as needed. Review of Resident #1's baseline care plan dated 12/06/24 reflected Resident #1 was an elopement risk. Resident #1 was cognitively impaired due to forgetfulness and dementia. Review of Resident #1's Comprehensive Care Plan dated 12/20/24 reflected the following: -dated 12/20/24 Resident #1 had impaired cognitive function or impaired thought processes related to impaired decision making abilities, is not always understand or able to understand verbal and non-verbal expression related to dementia. -revised 12/31/24 Resident #1 is an elopement risk/wanderer and is at risk for possible injury [related to] impaired safety awareness and diagnosis of dementia 12/20/24 Resident had elopement event. Interventions included Distract resident from wandering ., Provide structured activities ., secure unit placement for increased monitoring. -revised 02/06/25 Resident #1 resides on the facility security unit [due to] wander/elopement risks related to history of attempts to leave facility unattended, impaired safety awareness, resident wanders aimlessly. Interventions included Identify pattern of wandering: Is wandering purposeful, aimless or escapist? .Intervene as appropriate. Review of Resident #1's Incident Report dated 12/20/24 reflected elopement incident for Resident #1. It reflected received phone call that resident was at a nearby house. Resident of the home was able to retrieve this resident's cell phone and call resident's[RP]. [RP] picked resident up and returned resident to facility. Resident states 'the girls and I went to a dance and got lost. Head to toe assessment performed, with no injuries noted. Resident on one-on-one monitoring until moved to secure unit on this day .Admin initiated self-report. Medical Director informed. Resident #1 was oriented to person only. Resident #1 had predisposing physiological factor s of confused and impaired memory. Review of Resident #1's 24 Hour report dated 12/20/24 reflected Resident #1 elopement 12/20/24. One to one monitoring until moved to unit moved to 509B. Observation and Interview on 03/12/25 at 10:28 AM revealed Resident #1 was sitting on her bed in her room on the secure unit. Resident #1 was confused and could not recall the incident. She stated she felt safe at the facility. Review of Resident #1's progress note for December 2024 reflected the following: Dated 12/05/24 12:45 PM by RN A resident admitted to facility ambulatory has dx of dementia and wondering alzheimers .very pleasant oriented to room .will continue to monitor and assess will update [medical doctor] family and admin prn status changes. Dated 12/06/24 12:40 PM by LVN B Resident exit seeking and attempting to exit out of 200 hall exit door. Resident redirected to eat lunch. Dated 12/06/24 1:55 PM by LVN B Resident continuing to attempt to exit seek. Resident pushing on exit doors. Staff attempting to redirect resident. Resident confused. [Alert and Oriented] x1. DON notified. Review of Incident/Accident Reports December 2024 to March 2025 reflected no other elopement incidents for any other residents in the facility. Interview on 03/12/24 at 1:54 PM with LVN C revealed Resident #1 eloped on 12/20/24 but he was not working when the incident occurred. He stated Resident #1 was confused, had wandering behavior and would ask about leaving the facility. He stated he had been in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. He was knowledgeable about his role as a charge nurse for a missing resident. He stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/12/24 at 3:22 PM with LVN B revealed Resident #1 had expressed desire to go home constantly, would say her family member was coming to pick her up, and asked LVN B what door do I exit from. She stated she would redirect Resident #1 when she expressed wanting to leave and go home. She stated on the morning of 12/20/24 before the incident Resident #1 was confused and did not understand why she was at facility. She stated Resident #1 required redirection and distraction from wanting to leave. She stated on 12/06/24 Resident #1 did have 2 occurrences of exit seeking on pushing on hall 200 doors and she documented it in the nurse's note. She stated she redirected Resident #1 when she attempted to exit seek and distracted her. She stated she was not aware of Resident #1's history if she was an elopement risk upon admission. She stated on 12/06/24 she was not Resident #1's charge nurse and could not recall who she notified about the exit seeking behavior for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. She was unaware of any elopement incidents since Resident #1's elopement on 12/20/24. Follow-up Interview on 03/13/25 at 10:15 AM with LVN B revealed on 12/20/24 Resident #1 was last seen at the facility's Christmas party at 1:45 PM or 2 PM. She stated 2:00 PM is shift change so she was not working when Resident #1 returned to the facility after the elopement. She stated she documented Resident #1's exit seeking behavior on 12/06/24 in a nurse's note since she was not Resident #1's charge nurse. Interview on 03/12/24 at 3:40 PM with MDS Coordinator revealed Resident #1 admitted from another skilled nursing facility. She stated Resident #1 did have wandering behavior and the baseline care plan reflected she was at risk for elopement. She could not find an elopement assessment upon admission for Resident #1. She stated she was not working the day of Resident #1's elopement. She stated the charge nurse who admits a resident was responsible to ensure elopement assessment completed to determine resident's elopement risk level. She stated she was in-serviced after the incident in December 2024 on elopement policy and signs/symptoms of residents at risk for elopement. Interview on 03/13/24 at 8:45 AM with RN A revealed Resident #1 was oriented to her self only but confused about the place. Resident #1 was ambulatory and wandered within the facility. She stated Resident #1 would go to the door but was not aware of her attempting to exit prior to the elopement. She stated Resident #1 was a risk for elopement due to confusion and wandering behavior. She stated she was the admitting nurse for Resident #1 and she could not recall why elopement assessment was not done at admission. She stated she could not recall reviewing Resident #1's discharge paperwork from the previous facility. She was not aware Resident #1 was an elopement risk. She stated she was not aware Resident #1's baseline care plan showed Resident #1 as an elopement risk. She stated the DON was the charge nurse at time of elopement incident for Resident #1. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement. She stated after being in-serviced she was aware all residents upon admission should have elopement assessment completed to determine elopement risk. Interview on 03/13/25 at 9:25 AM with CNA D revealed Resident #1 was confused and would misplace her phone asking for assistance from facility staff to find it. She stated Resident #1 had occasional exit seeking behavior of going towards the exit doors. She stated Resident #1 constantly wandered within the facility and would ask to go to go with Resident #1's RP. She stated nurses were aware of Resident #1's wandering, confusion and exit seeking behavior. She stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/13/25 at 9:32 AM with Med Aide E revealed she did could not recall Resident #1 prior to being on the secure unit and did not recall elopement incident for Resident #1 in December 2024. She stated Resident #1 was currently on the secure unit for resident safety. She stated she had been in-serviced on elopement policy and signs/symptoms of residents at risk for elopement. Interview on 03/13/25 at 9:55 AM with Resident #1's RP revealed at the previous facility she exhibited behavior of wandering and would go to the exit doors to look out. She stated Resident #1 was confused and had dementia. She stated Resident #1 had not eloped at previous facility but they had Resident #1 moved to this facility for the resident safety and risk for elopement. She stated she had not had a care plan meeting with the facility. She stated nursing had not reached out to her prior to this incident of any exit seeking behavior for Resident #1. She stated she did not meet with facility staff to review the baseline care plan and facility had not discussed with her secure unit until after this elopement incident. She stated on 12/20/24 when she was shopping at a local store she received a phone call from a stranger using Resident#1's phone informing Resident #1 was walking the streets in a residential area. She stated she responded by telling the stranger the resident could not be there she was a resident at the facility. She stated she immediately left to go get Resident #1. She attempted to call the facility and was not able to get through but called a friend who called the facility to inform them Resident #1 was found walking the streets. She stated when she got to Resident #1 it was about like 10 minutes from when she first received the phone call. She stated she found her about 3 blocks away from the facility in a black sweatshirt with pants, socks and shoes on. Resident #1 told her she was dancing with her friends and got lost. She stated Resident #1 was cold and shivering with a blanket covering her provided by the bystander. She stated the bystander told her Resident #1 had flagged them down on the street saying she knew them and was walking the streets in residential area. She stated the facility had informed her later she must have gone out the door after the Christmas party when other visitors were exiting. She stated she took Resident #1 back to the facility in her car and nurse assessed her. She stated Resident #1 was not injured and was mad when Resident #1's RP left. She stated Resident #1 was placed on the secure unit after the elopement incident. Interview on 03/13/25 at 10:29 AM with CNA F revealed she saw Resident #1 at the facility's Christmas party eating but she had to leave about 2 pm to transport another resident to an appointment. She stated Resident #1 did have exit seeking behavior and would express her desire to leave the facility especially after her family would visit. She stated she had been in-serviced after Resident #1's elopement on elopement policy, signs/symptoms of residents at risk for elopement, abuse/neglect. Interview on 03/13/25 at 10:48 AM with Activity Director revealed on 12/20/24 facility had a Christmas party in the dining room including facility staff, residents and visitors from 1:30 PM to 2:00 PM. She stated she saw Resident #1 at the Christmas party but she did not recall seeing her after that. She stated she was not at the facility when Resident #1 returned to facility after elopement incident later that day. She stated Resident #1 was ambulatory on her own, had some confusion and looked like a visitor. She stated she was not aware of Resident #1 exit seeking behavior. She stated there was like 60 people at the Christmas party and maybe she had followed visitors out the door after the party. Interview on 03/13/25 at 10:35 AM with CNA K revealed she was knowledgeable on elopement policy, signs of residents with elopement risk, abuse/neglect and would immediately report to Charge Nurse, Administrator and DON if a resident was found missing. She had been recently in-serviced on elopement protocol and abuse/neglect policy. Interviews on 03/12/25 at 1:21 PM and 03/13/25 at 11:45 AM with CNA G revealed she had been recently in-serviced on elopement policy and signs of residents with elopement risk. She was aware she needed to notify Charge Nurse, Administrator and DON when resident is found missing. She was knowledgeable of types of abuse/neglect and had been in-serviced on abuse/neglect recently. Interview on 03/13/25 at 11:28 AM with ADON revealed she was working today as a charge nurse and works the floor as needed as the charge nurse. She stated she was in-serviced on elopement protocol including signs of residents at risk for elopement and the nurse's role when resident is found missing. She stated she had been in-serviced on nurse responsibility to complete elopement assessment upon admission and as needed when resident exhibits exit seeking behavior. She stated when Resident #1 eloped she was at risk of injury. Interviews on 03/13/25 at 12:10 PM with LVN L revealed she worked 2 pm to 10 pm shift on 12/20/24 but was not the charge nurse for Resident #1. She stated she was unaware of resident elopement risk and had not witnessed any exit seeking behavior from Resident #1. She stated Resident #1 was ambulatory on her own and did look like a visitor. She stated Resident #1 had confusion. She stated she was in-serviced after the incident in December 2024 on elopement policy, signs/symptoms of residents at risk for elopement and completing elopement assessment. She was knowledgeable about her role as a charge nurse for a missing resident. Interview on 03/13/25 at 1:13 PM with DON revealed she was unable to provide any witness statements of Resident #1's elopement. She stated she was the charge nurse for Resident #1 on 2 pm to 10 pm shift on 12/20/24. She received a phone call from a friend to Resident #1's RP who also worked for the facility that Resident #1's RP had received a phone call from a stranger that Resident #1 was found at a neighboring house. The DON looked at incident report and stated she had received the phone call at 3:45 PM on 12/20/24 because this is when she initiated the incident report for Resident #1. She stated Resident #1's RP brought Resident #1 back to the facility and Resident #1 was confused saying she went dancing with her friends. She stated she assessed Resident #1 head to toe with no injury noted. She could not recall the specific vitals but stated Resident #1's vitals were within normal limits. She stated facility initiated 1:1 for resident safety when she returned and after consent placed her on the secure unit for exit seeking behavior and elopement incident. She stated when interviewing staff after the elopement Resident #1 was last seen by staff at Christmas party on 12/20/24. She stated Resident #1 did wander within the facility but she was not aware of any exit seeking behavior. She stated when she reviewed Resident #1's progress notes she found the note on 12/06/24 stating Resident #1 had exit seeking behavior and stated she was not made aware of it. She stated she completed the baseline care plan for Resident #1 and stated she put down Resident #1 was an elopement risk based on previous stay at skilled nursing facility. She stated she did not review the baseline care plan with Resident #1's RP and did not look to see if elopement assessment had been completed upon admission. She stated she completed Resident #1's elopement assessment after the incident on 12/20/24 indicating she was high elopement risk due to elopement. She could not recall discussing secure unit placement with Resident #1's RP until after she had eloped on 12/20/24. She stated nursing had been in-serviced on completing elopement assessments upon admission and as needed when residents exhibit exit-seeking behavior. She stated if she had been made aware of Resident #1's exit seeking behavior on 12/06/25 she stated an elopement assessment would have been completed to determine elopement risk and to discuss with team about secure unit placement for safety. She stated the potential risk of elopement was serious injury or accident for Resident #1. She stated Resident #1 had intermittent cognition especially after Resident #1's RP visited and did not understand why she was placed at facility. Interview on 03/13/25 at 1:55 PM with Administrator revealed Resident #1's Previous Facility expressed she would go to the exit door asking about a car. He was not aware of Resident #1 having exit seeking behavior until after elopement incident in December 2024. He stated facility investigation revealed Resident #1 was last seen at the Christmas party on 12/20/24 and may have exited behind visitors or other people at the end of the party. He stated Resident #1 did elope and was immediately placed on 1:1 with staff until placed on secure unit for elopement and resident safety. He stated there have been no other elopements. He stated if he was aware of the exit seeking behavior prior to incident they could have assessed her with elopement assessed and review to determine if she required more supervision. He stated the potential risk to Resident #1 could be injury and serious harm. He stated the facility completed an elopement drill with facility staff to ensure staff were knowledgeable of facility policy on elopement. Review of staff In-services reflected: 12/20/24 and 12/26/24 staff in-serviced on elopement education including elopement drill 12/26/24 nurses in-serviced on completing all admission assessments by DON included RN A, LVN B, LVN C, ADON, MDS Coordinator and other nurses. 12/20/24 and 12/28/24 staff in-serviced on abuse/neglect Review of facility's policy Elopement dated 11/01/19 reflected To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .6. When the patient/resident is located, the nurse completes a head-to-toe assessment. The social service designee assesses the patient/resident for emotional distress. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement .Cognitive impairment (example: those who dementia, Alzheimer's, brain injury) Exit-seeking behaviors (example: confused resident that thinks he/she needs to go pick their kids up from the school) New admission wanting desperately to leave .History of elopement at other communities Review of facility's policy Elopement Risk assessment dated [DATE] reflected facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. PROCEDURE 1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing the elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/social service designee quarterly throughout a patient's/resident's stay and with a significant change .4. The licensed nurse or social service designee completes the elopement risk assessment form and presents to the interdisciplinary team for further intervention.6. The physician and the patient/resident or the patient's/resident's representative are notified of the patient's/resident's risk for elopement and the interventions that are recommended for prevention of elopement and patient/resident safety. 7. The patient's/resident's legal representative should be contacted, if possible, to obtain all pertinent information in relation to elopement risk .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjust as needed. 11. A baseline plan of care should be completed on admission and any elopement risks should be identified. The DON and Administrator were notified and provided the IJ template on 03/13/25 at 6:05 PM of PNC IJ for F689. The DON was provided the IJ template for PNC F689 on 03/13/25 at 6:05 PM. The IJ began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for three of six residents (Resident Residents#15, #174, #71) reviewed for notification of changes. 1. Treatment Nurse and DON failed to notify Resident #15's Primary Physician when the wound care consultant had stopped seeing the resident on a weekly basis and failed to notify the Physician in a change of condition of the wounds. 2. LVN J failed to notify the Physician for wound care orders when Resident #15 re-admitted to the facility on [DATE]. 2. RN EE failed to notify the Physician and responsible party on 01/25/24 when Resident #174 developed a wound on her buttocks. 3. The ADON failed to notify the physician and responsible party of Resident #71's change of condition when a new pressure ulcer on her coccyx and blisters were observed on her leg on 03/10/24. An Immediate Jeopardy (IJ) was identified on 03/12/24 at 12:40 PM. The IJ template was provided to the facility on [DATE] at 12:45 PM and signed by the Administrator. While the IJ was removed on 03/14/24 at 5:17 PM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record Review of Resident #15's Face Sheet dated 03/14/24, reflected a re-admission date of 03/04/24 to the facility. Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an admission date of 09/26/23. The resident had a BIMS of 13 which indicated she was cognitively intact and had not resisted care. She required extensive to dependent care with ADL. She had a foley catheter and was always incontinent of bowel. She had pressure ulcers and was at risk for pressure ulcers. Active diagnoses included diabetes, multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves), paraplegia (paralysis that affects the legs) and seizure disorder. Record review of Resident #15's care plan dated 12/13/24 reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus, left medial malleolus, stage 4 pressure injury to her left ischial and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods . Record review of Resident #15's care plan revised on 03/14/24 reflected, The resident had a stage 3 pressure ulcer to right foot, deep tissue injury to left heal, and left lateral malleolus .Interventions .[Wound Care provider] consultation 03/13/24 .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods . Record Review of Resident #15's Hospital Discharge orders dated 03/04/24, did not reflect any orders for wound care. Record Review of Resident #15's Physician order recap report with date range from 02/01/24 through 03/31/24, reflected, 1. Left Heel- apply skin prep twice daily to scabbed area, with a start date of 03/11/24 ( 7 days post admission) 2. Left Ischium (hip)- Cleanse wound with Dakin's (diluted bleach)solution. Apply Hydrofera Blue(antimicrobial dressing) foam to wound bed and cover with a dry dressing every day and as needed- with a start date of 03/07/24. (3 days post admission) . Order was changed on 03/10/24 to Cleanse wound with Dakin's solution . Apply Santyl (removes dead tissue) to wound bed and calcium alginate (used for exuding wounds). Cover with a dry dressing daily, with a start date of 03/11/24. 3. Left Lateral Malleolus (outside ankle)- Apply skin prep to scabbed area twice daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of 03/11/24. 4. Left Medial Malleolus (inside ankle)- Apply skin prep to scabbed area twice daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of 03/11/24. 5. Right Gluteal Fold (skin crease below the buttocks) - Cleanse with Normal Saline. Apply a thin layer of Santyl to wound bed. Lightly pace wound Kerlix roll moistened with Dakin's solution and cover with a super Absorbent dressing daily and as needed with a start date of 03/07/24. 6. Right Lateral Malleolus(outside ankle)- Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of 03/07/24- Order was changed on 03/10/24 to Cleanse wound with wound cleanser and pat dry. Apply Collagen and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of 03/11/24. 7. Right Lateral (outside )side of foot- Cleanse with wound cleanser, apply a small amount of Santyl to wound bed, then apply Calcium Alginate, cover with dry dressing daily with a start date of 03/12/24. 8. Right Medial Malleolus (inside ankle) Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of 03/07/24- Order was changed on 03/10/24 to Cleanse wound with wound cleanser and pat dry. Apply Santyl and Calcium alginate to wound bed and cover with a dry dressing daily and as needed with a start date of 03/11/24. 9. Sacral wound- Cleanse with wound cleanser. Apply Hydrofera Blue Foam to wound cand cover with a dry dressing daily with a start date of 03/07/24. Order was changed on 03/10/24 to Cleanse with wound cleanser. Apply Collagen(protein used to make connective tissue), and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of 03/11/24. Record Review of Resident #15's TAR for March 2024 reflected no wound care was documented for 03/04/24, 03/05/24, 03/06/24, 03/08/24. Record review of the electronic record for Resident #15 reflected visit was attempted by the Wound Care Consultant on 02/13/24- Resident was involved in activities and declined assessment. There were no additional Wound Care Consultant reports. Record review of Resident #15's admission assessment dated [DATE], completed by LVN J reflected, Skin integrity- was left blank- Under comment section- stated - See wound assessments. Record review of Resident #15's electronic record reflected no Wound Care assessment was completed until 03/13/24, which deferred to the Wound Care Consultants assessment completed on 03/13/24. In an interview with the LVN Treatment Nurse on 03/10/24 at 02:00 PM, she stated she was the one doing the wound care assessments and measuring the wounds on Resident #15. She stated there had not been anyone from the Wound Care consultant company coming to the building for over a month. She stated even before that they were not coming consistently on a weekly basis. She stated the Wound care Nurse Practitioner had told her since Resident #15 was the only one in the building she thought they would just do Telehealth. She stated she told the NP due to the extensive nature of Resident #15's wounds she did not think that was going to be adequate, so the Nurse Practitioner stated she would get someone else to come. She stated another Nurse Practitioner from the wound care company came out, but she only came one time and they never sent anyone else. She stated at some point, Resident #15's wounds had started having more slough, so she added Santyl back to the wound care order. She stated the Nurse Practitioner had taken it off at one time. She stated she had not called the Primary care physician or his NP about any of the resident wounds. She stated Resident #15 was sent to the hospital a few weeks ago unrelated to her wounds, and stated she was told the hospital had not done wound care on her for the 3 days she was in the hospital. She stated she thought the wound on her coccyx had been improving. She stated once Resident #15 gets up she will refuse to lay back down until bedtime which makes healing very difficult. In an interview and observation with Resident #15 on 03/11/24 at 08:55 AM she stated once she got up mid-morning she does not go back to be until around 8 or 9 PM. She stated she knew it was not good for the healing of her pressure injuries, but stated there was not enough staff to lay her down and get her back up throughout the day and she did not want to miss her smoke breaks. She stated part of the problem was the cushion in her wheelchair. She stated she had been asking the facility to get her a Roho cushion ( air filled cushion) but the facility had not provided one. Observation of the cushion in her wheelchair revealed a memory foam cushion that was concaved in the middle of the cushion. In an observation and interview with LVN J on 03/11/24 at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on 03/11/24 at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed gloves, no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed gloves with no hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed gloves- no hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed gloves- no hand hygiene and proceeded to the wound on the residents left Ischial. The wound was approximately the diameter of a orange with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with mechanical lift to her wheelchair. Wheelchair was noted to have a memory foam cushion that was concaved in the middle. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. In an interview with LVN J on 03/11/24 at 10:15 AM she stated Resident #15's ankle wounds looked about the same since she saw them last week, but her wound on her gluteal fold was much worse as well as the sacrum and Ischium wound which appeared to be tunneling. She stated she worked Monday through Friday on the 06:00 AM to 02:00 PM shift. She stated Resident #15 returned from the hospital on [DATE]. She stated there were no wound care orders from the hospital. She stated when she got report from the hospital, they stated they had done wound care on Saturday, but not Sunday stating the resident had refused. She stated she did not assess the wound when she returned to the facility on [DATE], since the Treatment Nurse did the Wound care assessments. She stated she did not find out until this week the treatment nurse had stepped down from that position. She stated she thought the 2:00 PM to 10:00 PM nurse did her wound care on 03/04/24. She stated she had asked the MDS Nurse if she could put in the wound care orders. She stated they were just using the previous wound care orders to provide wound care. She stated she had not contacted the MD to clarify the wound care orders. She stated she did the wound care on Tuesday 03/05/24 and the wounds were not draining like they were today (03/11/24) but stated they did have a lot more slough. She stated she had not contacted the primary care physician about the wounds, stating she assumed the treatment nurse wound be doing that. She stated she had not signed off on the wound care because the orders had still not been put in the system when she did the wound care on Tuesday 03/05/24. In an interview with Resident #15's NP DD on 03/11/24 at 11:40 AM , she stated she had not been contacted about Resident #15's wounds since her return from the hospital. She stated she was on call last weekend. She stated the facility usually had a wound care doctor that comes weekly. She stated she was not aware no one was coming for wound care manage for Resident #15. She stated she did not re-call ordering any wound cultures on the resident, but stated if she were having signs and symptoms of infections, she would order them today (03/11/24). She stated anyone with the extensive nature of Resident #15's wounds needed to be seen weekly by a wound care specialist. She stated the risk of failing to manage Resident #15's wounds could lead to sepsis, further decline of the wound and loss of limbs. She stated they needed to contact the Primary Care physician or herself anytime there was a significant change. Attempted to contact Resident #15's Primary care physician on 03/11/24 at 11:51 AM and was told he was out of the office on vacation. In an interview with the DON on 03/11/24 at 12:45 PM she stated she knew the Wound Care management company had not sent anyone out for several weeks. She stated they originally had wound care NP AA coming weekly, but her visits became less consistent. She stated NP AA had told the Treatment Nurse that she did not want to come for just one resident and wanted to do Telehealth, but the Treatment Nurse and herself felt Resident #15's wounds needed to be seen weekly, so NP AA arranged for someone else to come. She stated wound care NP EE came out about a month ago and had not been back. She stated she was planning on getting with the Treatment Nurse to see what was going on with Resident #15's wounds but stated due to the shortage of staff the Treatment Nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February 2024 letting them know the Treatment Nurse would no longer be doing the weekly skin assessments and the Nurses would be responsible for their assigned residents, but the Treatment Nurse would still be doing the wound care assessments weekly. She stated the staff were also told they would be responsible for doing the wound care if the Treatment Nurse was working the floor. She stated it was her expectation that anytime there was a new skin issues they were to complete a skin assessment, notify the physician and family and get orders. She stated the nurse who identified the issue needed to be the one who reached out to the physician. She stated she was not sure what they were going to do about a wound care physician at this time. She stated wound care orders could only be changed by the physician. She stated it was outside the scope of practice for the nurse to implement her own wound care orders. She stated the risk could be making the wound worse, risk of infection. She stated she had not considered who would complete the wound care assessments if the Treatment Nurse was unavailable, and stated after this week, the Treatment Nurse had stepped down from the position. She stated nurses were not allowed to stage the wounds, only measure them. In an interview with the MDS Coordinator on 03/11/24 at 12:50 PM she stated when Resident #15 returned to the facility on [DATE] she helped put in the hospital discharge medication orders but stated she had told the Treatment Nurse she needed to put in the wound care orders. She stated she was not aware of who the facility Wound care management company was or who to contact about wound care. In an interview with the Treatment Nurse on 03/11/24 at 10:05 PM she stated she was called in at 6:30 PM today to help on the floor as CNA. She stated she had told the nurse's back in January they were going to have to do the wound care when she was off or working the hall. She stated they were also supposed to be doing the skin assessment, but that was not happening, so they did an in-service on 02/21/24 on the requirement of for the weekly skin assessment. She stated the nurses were supposed to complete the skin assessment for any skin condition and if it was pressure or deep tissue injury, they were to report to her, and she would complete the Wound care assessment. She stated the nurse however was to contact the physician, family and obtain any treatment order needed. She stated she had been doing Resident #15's Skin assessment and wound assessment up until she went to the hospital on [DATE] and was trying to do the treatments when she could. She stated her wound assessments were scheduled for Thursdays and she was off on Thursday. She stated when Resident #15 came back to the facility on [DATE], the admitting nurse should have done a skin assessment and called the doctor for orders for the wound. She stated she was not surprised wounds were not getting documented as being done. She stated she was so frazzled by the time she leaves she was not sure what she did and did not do. She stated she did Resident #15's wound care on Wednesday03/06/24 but did not do the wound care assessment. She stated she off on 03/07/24 the day the assessment was due. She stated there was a little bit of odor and drainage. She stated the wounds did not have an odor or drainage before she went to the hospital. She stated she probably could have reached out to the Wound care company, but stated she felt like the wounds had been stable prior to her going to the hospital. She stated when she started in October 2024, she received no training on wound care and was not aware of the facility's policy for wound care. She stated she had previous experience as a treatment nurse in another facility, but stated she was not wound care certified. In an interview with CNA L on 03/12/24 at 01:00 PM she stated she worked the day Resident #15 returned to the facility. She stated her wounds had a very foul smell. She stated the nurse was aware of the smell. She stated if she saw a new skin issue, she would put it in the electronic record and tell the nurse. In an interview with RN G on 03/12/24 at 02:45 PM she stated when she arrived at work on 03/04/24 for her 2-10 PM shift, Resident #15 had been readmitted to the facility. She stated LVN J had re-admitted her but had not had a chance to do her wound care, so she stated she did the wound care that evening. She stated the wounds were terrible and smelled bad. She stated she assumed the Treatment Nurse was taking care of the wound care orders. She stated she just used the previous orders. She stated the wounds on the residents' ankles looked worse to her and she had a new place on the middle of her right foot. She stated she thought she contacted the physician about the new place on the resident right foot but stated she had deleted all her old calls and was not sure what day she called him. She stated she should have written the order and signed the TAR when she did the wounds on 03/4/24, 03/08/24 and 3/10/24. She stated it was so crazy last week she was doing good just to get the care done. She stated she did not feel like she had enough experience to complete the wound care assessments and would need more training before she felt comfortable staging or measuring a wound. 2. Record Review of Resident #174's Significant Change MDS assessment dated on 02/08/24 reflected a [AGE] year-old female with an admission date of 04/17/20. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident had a one unstageable pressure injury listed and was receiving Hospice services. Active diagnoses included heart failure and dementia. Record Review of Resident #174's care plan initiated on 11/20/20 reflected, [Resident #174] is at increased risk for pressure sores due to immobility .Interventions Administer treatments as ordered .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident /family/caregivers of any new area of skin breakdown . Record review of Resident #174's Braden assessment completed on 01/15/24 by MDS Coordinator indicated the resident had a score of 14 which placed her at moderate risk of pressure ulcers. Record Review of Resident #174's progress note dated 01/25/24 at 07:35 PM by RN EE reflected, resident found with medium sized wound to buttocks. Resident denies pain at this time. barrier cream applied and brief changed. [Treatment Nurse], notified of wound and stated she would look into it tomorrow morning. Record Review of Resident #174's progress note dated 01/25/24 at 07:58 PM by RN EE, reflected, resident assessed coughing up green, thick, productive sputum and lung sounds are wet and wheezy. Vitals are stable at this time. resident remains afebrile. [NP CC] notified of cough and sputum . Further review of the progress noted reviewed there was no documentation the NP was notified of the wound to the residents' buttocks. Record review of Resident #174's progress noted dated 01/31/24 at 10:22 AM by RN E reflected, pressure area to coccyx wound nurse is performing dressing changes to area day 4 for zpack (Azithromycin)) and prednisone will continue to monitor, air mattress present on bed with controls available as well as call light and water pitcher. Denies needs or pains at present time will continue to monitor and update md, family and admin(sic) prn status changes. Record review of Resident #174's progress note dated 02/02/24 at 08:15 PM by LVN Treatment nurse, reflected, Unstageable pressure ulcer to sacrum d/t slough present. 5cm x 3cm x 2cm. New order received from Hospice Cleanse with wound cleanser, Apply Santyl to wound bed then apply Hydrofera Blue foam and a dry dressing daily and as needed. Family and MD notified. Resident admitted [company name] Hospice today. Record review of Resident #174's Physician order Summary report date 03/10/24 reflected, Sacrum- Cleanse wound with wound cleanser. Apply Santyl to wound bed. Then lightly pack with Hydrofera Blue and apply Supers absorbent Dressing daily and as needed every day shift with a start date of 02/06/24. Order was changed to Cleanse wound with wound cleanser. Apply Silver Alginate to wound bed and cover with a super absorbent dressing daily and as needed, with a start date of 02/17/24. There were no orders for the Pressure ulcer to the Resident's right heel. There were no orders for January 2024 for wound care to the resident's sacrum. Record review of Resident #174's TAR for January 2024 reflected no documentation of wound care to the residents' sacral wound. Record review of Resident #174's TAR for February 2024, reflected no documentation of wound care from 02/02/24 through 02/09/21, 02/11/24 through 02/14/24, and 02/16/24 for the Resident sacral wound. Further review revealed there was no documentation for wound care to the resident right heel from 02/02/24 through 02/17/24. Record review of Hospice GG's admission assessment dated [DATE] reflected Resident #174 had an unstageable 4x4 cm to her coccyx with bone exposed and bleeding. In addition, she had a Stage 1 pressure injury to her right heel that was red, mushy with a black center. Will follow up for wound care orders. Record review of Hospice GG's assessment dated [DATE] reflected, Wound #1 Sacral is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Closed. Measurements are 5cm length x 6cm width x 1.5 cm depth, with an area of 30 sq cm and a volume of 45 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining (erosion under the skin) has been noted. There is a Moderate amount of drainage noted. Wound bed has 76-100%, granulation, 1-25% slough (yellow/white material in wound bed), no eschar(dry, scab) , and no epithelialization (development of new tissue) present . Wound #2 Right Heel is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Closed. Measurements are 2.5cm length x 2cm width x 0 cm depth, with an area of 5 sq cm and a volume of 0 cubic cm. No tunneling (opening under the skin) has been noted. No sinus tract has been noted. No undermining has been noted. There is a Moderate amount of drainage noted. Wound bed has 26-50%, granulation, 26-50% epithelialization, no slough, and no eschar present . Further record review of Hospice GG's assessment dated [DATE] reflected, Wound Orders- Sacral wound- Cleanse per protocol, pat dry, apply silver alginate and cover with dressing daily and prn. Caregiver or facility nurse to change on days that hospice nurse not present. There was no recommendation documented for the pressure wound to the resident's right heel. Record review of Resident #174's skin assessment completed by LVN Treatment nurse: 01/01/24- no skin issues 01/08/24- no skin issues 01/15/24- no skin issues 01/22/24- no skin issues 01/29/24- 4 cm x 4 cm non blanchable deep tissue area to sacrum. Skin intact. 02/02/21- see wound assessment. 02/09/24-pressure ulcer to buttocks/sacral area.- See wound assessment for details. ( No documentation of the pressure ulcer to her right heel) 02/16/24- pressure ulcer to buttocks/sacral area that has turned into Kennedy ulcer (sores that appear during someone's final hours or days of living.) Review of Resident #174's Wound care assessments completed by LVN Treatment Nurse revealed the following: *02/02/24-Location- Sacrum- 5.0 x 2.0 x2.0 cm Unstageable pressure- Undermining was present- date of onset 2/02/24- wound was open with slough and heavy bloody exudate but no odor. Current wound care orders- Cleanse with wound cleanser. Apply Santyl to wound bed then apply Hydroferra Blue foam and as super absorbent silicone dressing daily and as needed. Physician notified. Responsible party notified. There was no documentation about the resident's right heel. *02/09/24- Location- Sacrum- 6 x 3.5x2 cm Pressure- Kennedy terminal ulcer- undermining present, open, wound bed is red, yellow, and gray with slough and moderate bloody exudate and a mild odor- . Current wound care orders- Cleanse with wound cleanser. Apply Santyl to wound bed then apply Hydroferra Blue foam and as super absorbent silicone dressing daily and as needed- declining wound-Primary physician notified on 02/09/24. There was no documentation about the resident's right heel. In an interview with the LVN Treatment Nurse on 03/10/24 at 02:00 PM, she stated when she was first notified about Resident #174's wound on her bottom it was barely open. She stated RN FF had called her at home about the wound. She stated prior to this the resident had an air mattress, but stated the Administrator had instructed them to remove all the air mattress for anyone who did not currently have a wound. She stated they had taken Resident #174 off the air mattress and within 2 weeks she had a breakdown on her bottom. She stated RN FF should had completed a skin assessment and notified the physician and family when she found the wound. She they were not providing any type of wound care other than barrier cream, offloading her heels, and repositioning her frequently. She stated they day the resident was placed on Hospice the wound had declined. She stated the Hospice stated they had their own wound care and would be taking care of the wound, so she did not contact anyone else about the wound. She stated someone came out one time and stated he would be coming once a week, but then he never came back. She stated the wound progressed rapidly and had a foul odor and drainage toward the end. She stated Hospice did bring out an air mattress for the resident. She stated she was not sure if the family had been notified about the severity of the wound, but stated one of the family members was present one day when she was doing the wound care. She stated she did not stage the wound as a Kennedy ulcer but stated someone [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 4 (Residents #7, #13, #49 and #325) of 12 residents reviewed for resident abuse. 1. The facility failed to ensure Resident #325 was free from physical abuse by CNA O on [DATE] 2. The facility failed to ensure Resident #49 was free from physical abuse by CNA O on [DATE]. 3. The facility failed to ensure Resident #7 was free from physical abuse by CNA O. 4. The facility failed to ensure Resident #13 was free from physical abuse by RN G on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 6:10 PM. While the IJ was removed on [DATE] at 7:00 PM, the facility remained out of compliance at actual harm with a scope identified as pattern. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings included: 1. Record Review of Resident #325's Baseline Care Plan completed by ADON revealed resident admitted on [DATE] for end-of-life care and was on hospice services with Hospice KK and required extensive assistance with ADLs, and was not able to communicate easily with staff and not understood by staff. Record review of Hospice KK medical records for Resident #325 revealed a document titled Visit Report dated [DATE] which stated resident required maximum to total assistance, total assistance with ADLS, and was a two (2) person transfer. Record review of Resident #325's nurse's progress note dated [DATE] completed by ADON revealed resident expired on [DATE]. Review of grievance log for [DATE] revealed grievance dated [DATE] regarding CNA O being rough regarding Resident #325. There were blank spaces for categories of resolved, followed up with resident, or reported to state, or if follow up was needed. Record review of document titled Witness Interview dated [DATE] at 8:30 AM by Resident #325's family member and signed by the DON revealed complaint alleging on the morning of [DATE] [CNA O] was very rough in the way he got her up from the wheel chair and threw her into the bed. Record review revealed grievance complaint form dated [DATE] provided by Administrator on [DATE] for Resident #325 by family member and signed by the Administrator revealed there was an established pattern with complaints of staff members while providing care and CNA O was suspended pending investigation. Record review of Resident #325 nurse progress note dated [DATE] at 4:00 PM by RN G revealed Upon entering the room at 1600 the resident was noted to have her right leg caught in the blinds and her leg was bleeding and there was blood on the blinds and the wall. The resident was noted to be restless and agitated . called [Hospice K] asking for a nurse to come see her and that I needed the comfort kit sent here faster than it seemed to be coming. Resident was cleaned and repositioned. The bed was positioned away from the wall. The blinds were taken down due to being torn and having blood on them. One of the [family member of Resident #325] arrived around 1630 and then shortly after that the Hospice nurse arrived. Resident was given a one-timedose of Lorazepam 0.5mg PO and a short time after that began calming down. Interview on [DATE] at 3:24 PM with RN G revealed she contacted the DON on [DATE] after family member of Resident #325 complained about not receiving the care kits timely for Resident #325 and that CNA O was rough with his transfer of resident and tossed her into the bed. RN G stated she called the DON and was told CNA O tossing resident into the bed was a reportable incident and to contact the Administrator. RN G stated she then called the Administrator on [DATE] and the family spoke with the Administrator over the phone and then was told by the Administrator because the family did not use the word abuse it was not reportable incident to the state and CNA O continued to work and CNA O continued to work despite this allegation. RN G stated she assessed the cut on Resident #325 leg but did not complete a head-to-toe assessment. Interview on [DATE] at 11:59 AM with Resident #325's family member revealed she observed on the morning of [DATE] CNA O picked up Resident #325 from her wheelchair by himself and transferred resident into the bed. Family member stated she would describe the transfer as resident was plopped or tossed into the bed and the resident cried out. Family member stated she asked CNA O if he needed help before transferring resident and he said no. Family member stated she reported incident along with other concerns about care on the evening of [DATE] to RN G and then spoke with the Administrator. Family member stated Resident #325 was heavy and should have been a two person transfer which was why it appeared that resident was tossed into bed, and there was a lack of staff to assist. Family member stated she also arranged a meeting the following morning on [DATE] with the DON to go over her concerns further. Family member stated during her meeting with the DON and was told that they would look into the incident and did not recall filling out a witness statement or a grievance. Family member stated Resident #325 expired the following day and she had not been contacted by facility with an update. Interview on [DATE] at 2:57 PM with DON revealed Resident #325 was admitted to facility for end of life care and expired on [DATE]. DON stated Resident #325 required a significant amount of care and needed assistance to be turned. DON stated on the evening of [DATE] RN G called to report family of Resident #325 stated CNA O roughly picked up and tossed Resident #325 into the bed. DON stated she told RN G that the abuse allegation was reportable and instructed RN G to call the Administrator immediately. DON stated she came to the facility around 8:00 PM and asked Administrator what needed to be done for the investigation. DON stated Administrator told her everything had been done except for the in-services on abuse and neglect. DON stated Administrator printed the abuse and neglect policy and DON went to every CNA and clinical staff member and reviewed the policy with them and had them sign the in-service sheet. DON stated she met with the family member on [DATE], wrote a witness statement, and the Administrator refused to take the statement during the morning meeting in-service on abuse and neglect. Administrator told DON she did not want the statement because she did not think it was abuse, she was already investigating the allegation of abuse by CNA O to Resident #49, and CNA O was already suspended. DON stated Administrator expressed irritation at having to come back to facility the evening on [DATE]. DON stated she took the witness statement back to her office. DON stated the Corporate Nurse DD was onsite on [DATE] and saw the witness statement on her desk and instructed DON to give it to Administrator. DON stated she told Corporate Nurse DD that Administrator refused to take the statement and Corporate Nurse DD suggested she file a grievance for the family of Resident #325 because the Administrator was the abuse coordinator and would have to report and investigate the incident. DON stated she gave the information to SSD who wrote the grievance and put it back on DON's desk. DON stated Corporate Nurse DD gave grievance to Administrator. DON stated she was not aware the allegations regarding CNA O and Resident #325 were not reported to HHSC. DON stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. Interview on [DATE] at 3:42 PM with Administrator revealed she had concerns regarding CNA O handling of Resident #325 during transfer on [DATE] and spoke to family member on [DATE] over the phone but because family member did not use the words abuse she thought it was more of a training issue she did not believe CNA O would intentionally abuse any resident so she did not report the allegation with Resident #325. Administrator stated there were no witness statements for Resident #325. Administrator stated she did not suspend CNA O until a second similar allegation later in the evening on [DATE] about a rough transfer was made by Hospice RN stated she and RN G regarding Resident #49. Administrator commonly would receive conflicting reports from staff regarding different issues and took this report more seriously because Hospice RN was a neutral party. Administrator stated sometimes what may look like abuse was just a transfer and that sometimes staff had to just pick up a resident and it may appear to be rough. Interview on [DATE] at 9:48 AM with MDS Coordinator revealed she was present during the morning meeting on [DATE]. MDS Coordinator stated the Administrator was leading the meeting and reviewing the abuse and neglect policy with the department heads including the DON. MDS Coordinator stated that all allegations of abuse are to be reported to the Administrator who was the abuse coordinator. MDS Coordinator stated when Administrator read aloud examples of neglect the DON interjected and stated- see that was what I am talking about, it was abuse. MDS Coordinator stated Administrator became upset and stated it was not abuse, and ADON had observed CNA O provide care to residents and there were no concerns. MDS Coordinator stated Administrator stated she already recorded all the witness statements and did not want the witness statement from DON. MDS Coordinator stated Administrator and DON began to argue and MDS Coordinator and staff quickly left the room. MDS Coordinator stated she did not know which residents Administrator and DON were talking about. Interview on [DATE] at 2:56 PM with DON revealed she did not provide a thorough physical assessment for Resident #325 or Resident #49 and thought they had been done by the charge nurse and it should be documented in the resident's chart such as the progress notes. DON stated that RN G would have done an assessment and she did not follow up with RN G. DON stated she had asked Administrator the evening of [DATE] after the incident if the assessments had been done and what she could help with and Administrator stated only the in-services were left. Interview on [DATE] at 4:25 PM with Administrator revealed she did not report the family complaint about CNA O's treatment of Resident #325 because she did not think it was abuse at the time and did not think CNA O would intentionally abuse a resident. Administrator stated CNA O admitted to inappropriately transferring residents. Interview on [DATE] at 5:15 PM with Director of Therapy with Director of Therapy revealed Resident #325 was at facility for end of life care and would have concern with a CNA transferring Resident #325 by scooping resident out of bed by themselves and into shower chair because it could result in a resident being dropped or injured. Director of Therapy stated residents who required extensive assistance meant the person required a resident to be transferred with 2 people assisting and with gait belt at a minimum, possibly Hoyer lift. Interview on [DATE] at 11:02 AM with ADON revealed she worked the day of [DATE] until 6:00 PM. ADON stated Resident #325 had admitted to facility on [DATE] for hospice services, was on oxygen and was restless. ADON stated on [DATE] around 3:30 PM, she was in her office and heard RN G call for help and immediately went to assist RN G who was in Resident #325's room. ADON stated she observed RN G in Resident #325 room and Resident #325 was in bed next against the window and Resident #325 appeared confused of her surroundings, restless, agitated, and was flailing her arms around and kicking her legs. ADON stated she did not see any visible injuries on Resident #325 ADON stated she and RN G did not perform a head-to-toe assessment because the resident was restless and they stayed with resident to ensure safety while they waited for hospice services to arrive. ADON stated RN G asked CNA O to assist with moving the bed from the window to against a wall. ADON stated that family members of Resident #325 arrived before hospice services and were talking with RN G about their concerns and ADON left the room to give them privacy. ADON stated she was not aware that an allegation was made against CNA O until the following day at the morning meeting on [DATE]. ADON stated during the morning meeting the Administrator was reviewing the abuse and neglect policy and stated that there was an allegation of abuse of Resident #49 and Resident #325 by CNA O and that Administrator had done an investigation and felt that no abuse occurred. ADON stated DON interjected and said that she believed there was abuse. ADON stated Administrator replied that DON was showing favoritism to the nurse that reported the abuse, RN G. ADON stated DON stated it was the same favoritism the Administrator showed the Maintenance Director and began to leave the meeting and the Administrator told DON not to get in her feelings and that she had done this investigation and talked to family members of the residents and she did not feel like it was abuse. ADON stated she spoke with the Administrator after the meeting and the Administrator told her that she did not believe abuse occurred and that if RN G witnessed abuse then why did she not intervene. ADON stated she was responsible for assessing competencies quarterly of MA's and CNA's and assessed for peri-care, hand washing, and use of Personal Protective Equipment (PPE). ADON stated she had only assessed CNA O for hand washing and PPE use because CNA O used to work full time then switched to only a couple days a week as needed and she had not gotten to him to assess the peri-care. ADON stated she was aware that Administrator spoke with CNA O in the past about not communicating with residents when providing care by not introducing himself and letting them know what care he was going to provide. 2. Record Review of Resident #49's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and diagnoses of dementia (loss of cognition), bi-polar disorder (mood disorder with periods of intense feelings), major depressive disorder (a mood disorder causing persistent feeling of sadness and loss of interest), and pseudobulbar affect (episodes of uncontrollable and inappropriate laughing or crying), unspecified pain, and a BIMS score of 0 (severely impaired cognition). Review revealed Resident #49 was dependent on assistance for ADL care including showers and transfers. Record review of medical record for Resident #49 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident experienced mood swings, visual and auditory hallucinations, had a history of agitation, aggressive behavior and was combative. Record review of physical therapy evaluation or Resident #49 revealed resident was known for grabbing hold of individuals nearby and hit and kicked. Record review of physical therapy evaluation revealed Resident #49 habitually coiled legs into extreme flexion at hip and knees which led to recurrent tightness and contractures and was non-weight bearing on her legs which caused additional challenges with assisted transfers. Review of physical therapy evaluation revealed Resident #49 did not ambulate on her own and used a geri chair. Record review of witness statement by Hospice RN, dated [DATE] at 8:05 PM, and signed by Administrator revealed Resident #49 had vomited multiple times on [DATE] and Hospice RN asked CNA O to shower resident. Hospice RN stated CNA O entered the room and did not say anything to Resident #49 before he rolled resident over and picked her up and roughly sat her in the chair. Hospice RN stated that Resident #49 was startled and was not covered all the way when transported through the hallway. Hospice RN stated she did not think he was abusive, but it was overly rough and aggressive. Record review of witness statement by RN G, dated [DATE] at 8:22 PM, and signed by Administrator revealed RN G witnessed CNA O roughly handled the shower chair as he transported Resident #49 out of shower room and she did not see his hands on physically on Resident #49 at any time. Record review of Resident #49 revealed nurse's progress notes dated [DATE] at 10:51 PM by RN G that resident had frequent vomiting and Hospice nurse gave Resident #49 new order for Zofran. Review of nurse's progress notes from [DATE] through [DATE] revealed no mention of incident with CNA O and no physical assessment. Record review of hospice medical records for Resident #49 revealed visit note report dated [DATE] by Hospice RN that CNA O was aggressive when providing care for Resident #49 and she had redness around her collarbone and incident was reported to Administrator and Hospice Director. Observation on [DATE] at 3:22 PM of Resident #49 revealed she was laying in geri chair wearing a long sleeve shirt, pants, with hair that appeared clean, with her legs curled up and arms in contracture, she was non-interviewable. Interview on [DATE] at 3:24 PM with RN G revealed on the evening of [DATE] she was at the nurses station when she observed Hospice RN appeared upset. RN G stated Hospice RN told her CNA O picked up resident out of bed roughly and put Resident #49 into the shower chair. RN G was unable to explain why she did not intervene. RN G stated she felt startled when the shower door opened and CNA O jerked Resident #49 out of shower room and placed her at the nurses station. RN G stated she had training on Abuse, Neglect, and Exploitation during onboarding and in-services and was not sure if what she witnessed was abuse. RN G stated she called DON and Administrator and was told to have CNA O leave pending investigation. Interview on [DATE] at 6:54 PM with Hospice RN revealed she visually assessed Resident #49 shoulders and demeanor when she was seated in the geri chair at the nurses station after the incident and observed some redness on resident's shoulders. Hospice RN stated she did not complete any additional assessment other than the assessment for pain, nausea and vomiting, and a visual observation of resident. Interview on [DATE] at 3:19 PM with CNA N revealed Resident #49 required a two person transfer or hoyer lift with two people assisting because she was very strong and swings her limbs around and kicks during transfers. CNA N stated CNA O was a male and was stronger than the female CNA's and they would call CNA O when they needed assistance with heavy residents. Interview on [DATE] at 2:57 PM with DON revealed Resident #49 required at least two (2) staff and a Hoyer lift to be transferred. Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #49 was in PT therapy for contraction management and for balance training and had a tendency to grab things like ears, arms, anything within reaching distance and kicked. Director of Therapy stated Resident #49 was totally dependent with care and was a two (2) person assist or hoyer lift. Director of Therapy stated concern with a CNA who lifted Resident #49 by himself by scooping resident out of bed into shower chair would be CNA could have dropped or injured resident. Interview on [DATE] at 9:04 AM with Hospice LL Director revealed she received a phone call from Hospice RN on [DATE] regarding a concern with possible physical abuse of Resident #49 by CNA O and Hospice RN had reported incident to Administrator and RN G, the charge nurse, and CNA O had been removed from facility. Hospice LL Director stated that abuse should be reported to HHSC within 2 hours and did not report it herself because she was told the facility had reported incident. Hospice LL Director stated she received a phone call on [DATE] from Administrator who asked her how often hospice staff receive training on abuse and neglect. Hospice LL Director stated Administrator told her she did not feel that what CNA O did was abuse and that if a hospice nurse was present and believed they witnessed abuse then they should be the one to report the incident. Hospice LL Director stated Administrator told her that sometimes a transfer could look abusive if the observer was not trained to recognize abuse and sometimes staff just needed to pick up residents. Hospice LL Director stated Administrator sounded annoyed to have to conduct an investigation and told her CNA O had been suspended and the incident was self-reported. Hospice LL Director stated she documented her phone call with Administrator and submitted a report of abuse to state following her phone call with Administrator. Hospice LL Director stated that showers for Resident #49 would require two staff members because of Resident #49's functional status. Hospice LL Director stated risk to resident if not properly transferred or are showered with one staff member when they require two staff would be resident could be dropped, injured, or develop a skin tear due to friction or shearing. Interview on [DATE] at 9:49 AM with MDS Coordinator revealed Resident #49 required two people to transfer including a hoyer lift because resident has involuntary movements of her arms and legs and grabs on to anything within reach, kicks, and hits. MDS Coordinator stated the risk to residents when improperly transferred were injury from being dropped or pull on improperly. Interview on [DATE] at 3:33 PM with SSD revealed she was not in-serviced on the facility's abuse and neglect policy before she provided an in-service to staff on abuse and neglect on [DATE] and used the previous Abuse and Neglect policy dated 2020 by mistake instead of the most current policy dated [DATE]. Interview on [DATE] at 11:49 AM with CNA P revealed Resident #49 required two people and a Hoyer lift to transfer because she is a fall risk and commonly grabs anything within reach when being transferred. CNA P stated the risk to residents by not properly transferring would be injury from being dropped. Interview on [DATE] at 6:05 PM with MA Z revealed she had worked at facility since 2019 and typically worked on Hall 200 and 300. MA Z stated Resident #49 was a two (2) person assist and was not aware of her surroundings and would swing her limbs around, hit, and bite the elbows of staff during transfers. MA Z stated hospice usually gave Resident #49 showers with two (2) people assisting and she would always hear Resident #49 yelling during showers. MA Z stated she liked CNA O because he was strong and assisted with transfers of residents and could not recall ever seeing CNA O use a gait belt. MA Z stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. 3. Record review of Resident #48 Discharge MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to facility on [DATE] with diagnoses of chronic pulmonary disease (chronic lung disease obstructing airflow), Parkinson's disease (a chronic and progressive movement disorder), hypotension (low blood pressure), major depressive disorder (mood disorder with persistent feeling of sadness and loss of interest), was hospitalized on [DATE] and had a BIMS score of 14 (cognitively intact). Record review of resident safe surveys performed by SSD on [DATE] revealed Resident #48 reported she witnessed CNA O rip Resident #7's pants off roughly from her hip to her ankles and Resident # 7 was screaming. Observation of Resident #48 on [DATE] at 11:27 AM revealed resident was lying in bed asleep and wearing hospital gown. Surveyor attempted to interview resident #48 but was unable to due to illness. Interview on [DATE] at 3:24 PM with RN G revealed when she left work on [DATE], Resident #48 was smoking outside and talking with someone else about witnessing a CNA O treating Resident #7 roughly. RN G stated she asked Resident #48 about the incident. RN G stated that Resident #48 said she was in the hallway and able to see in Resident #7's room because the door and privacy curtain were not closed and she saw CNA O put Resident #7 in her bed and rip the pants off of Resident #7 when providing care. RN G stated she asked Resident #48 if she reported this incident and Resident #48 stated she told the social worker the previous day, [DATE]. RN G stated she called and let DON know of the conversation and was told it was being investigated. Interview on [DATE] at 5:05 PM with SSD revealed she conducted a safe survey on [DATE], in regard to Resident #49's allegation of abuse by CNA O, and Resident #48 reported she witnessed CNA O rip off the pants of Resident #7 while providing ADL care. SSD stated Resident #48's room was across the hall from Resident #7. SSD stated during safe surveys, Resident #44, who was the roommate of Resident #7, indicated a concern regarding treatment of Resident #7 by CNA O but Resident #44 declined to give further information. SSD stated she did not follow up with Resident #44. SSD stated she attempted to interview Resident #7 but resident was non-interviewable. SSD stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. 4. Record Review of Resident #7 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of late onset Alzheimer's disease (loss of cognitive function), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), spondylolysis (crack or break in the bone of the spine), a BIMS score of 5 (severely impaired cognition). Record review of Resident #7 Care Plan dated [DATE] and revised [DATE] revealed resident required moderate assistance by one (1) staff to move between surfaces. Observation and interview on [DATE] at 2:07 PM of Resident #7 revealed resident was sitting in an electric wheelchair with her hair brushed wearing a long sleeve shirt, pants, and shoes. Resident #7 was non-interviewable due to cognitive impairment and could not recall incident with CNA O. Record review of medical record for Resident #7 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident was confused regarding her surroundings, had difficulty communicating, was a fall risk, and required substantial to maximal assistance with ADL care. Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #7 required moderate assistance with transfers, a one person assist with staff using a gait belt at the minimum. Director of Therapy stated a CNA who lifted Resident #7 under her arms to transfer from wheelchair to bed without gait belt placed the resident at risk of being dropped and injury. Director of Therapy stated improper transfers such as picking up a resident from under their arms when transferring increased risk of resident injury, fracture, and multiplied the fall risk for resident. Interview on [DATE] at 11:38 AM with LVN J revealed Resident #7 was care planned as a one person transfer assist which would mean always use a gait belt. LVN J stated she had seen Resident #7 be transferred from wheelchair to bed and usually the staff member would have Resident #7 put her hands on their shoulders and wrap around the resident and lift while wearing a gait belt. LVN J stated improper transfers of residents increased a resident risk of injury and harm. LVN J stated that if she observed abuse she would immediately inform the Administrator who is the abuse coordinator. 5. Record Review of Resident #44's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of cognition), hypertension (high blood pressure), anxiety disorder (feelings of worry and fear or unease), depression (persistent feelings of sadness) and BIMS score of 10 (moderately impaired cognition). Observation on [DATE] at 11:16 AM revealed Resident #44 was seated upright in wheelchair in 200 Hall wearing shirt, pants, and shoes and her hair was brushed. Interview on [DATE] at 11:18 AM with Resident #44 revealed she was roommates with Resident #7 and about a week ago she was in her room lying in bed and Resident #7 was sitting in an electric wheelchair next to her bed when CNA O entered the room and said he was going to change Resident #7. Resident #44 stated CNA O picked up Resident #7 by lifting from underneath both armpits and placed her roughly in bed. She recalled Resident #7 told CNA O to stop as soon as CNA O began to lift Resident #7 up from the armpits and CNA O continued to transfer resident. Resident #44 stated he roughly and quickly jerked Resident #7's pants off to perform ADL care and recalled Resident #7 screamed and said stop several times and that he was being rough with her and she was going to tell. Resident #44 stated she felt upset when she witnessed this and told CNA O to leave Resident #7 alone and CNA O finished providing ADL care to resident. Resident #44 stated that she told SSD about the incident during a safe survey ([DATE]) and that she was told CNA O was no longer at the facility. Resident #44 stated she had no issues with CNA O and she currently felt safe at facility. Interview on [DATE] at 3:44 PM with Administrator revealed she did not report or investigate allegation of abuse for Resident #7. Administrator stated she did not interview Resident #48 about their allegation from safe survey or the roommate of Resident #7 (Resident #44) because she thought it was more of a dignity issue than abuse allegation. Administrator stated she should have investigated the incidents by including the additional residents because it was a similar allegation to Resident #49. Administrator stated Resident #7 should have been assessed by either the charge nurse or DON and was not aware if an assessment had been completed. Interview on [DATE] at 2:56 PM with DON revealed she was not aware of any abuse allegation for Resident #7 at the time of the safe survey and had only heard about it from other staff recently. DON stated she did not provide a physical assessment of Resident #7. DON stated she did not speak with Resident #44 about the incident. Interview on [DATE] at 3:10 PM with LVN K revealed she began working at facility at the end of [DATE]. LVN K stated that she had observed CNA O transfer Resident #7 without a gait belt in the past. LVN K stated she observed CNA O put Resident #7's hands on his shoulders then he lifted resident and put her into bed. LVN K stated she could not recall if CNA O lifted Resident #7 from under her arms or if he bear hugged resident. Interview on [DATE] at 3:20 PM with CNA N revealed she had observed CNA O transfer other residents and did not see CNA O use a gait belt. CNA N stated she observed CNA O pick up at least two (2) different residents, over the past two (2) months, who were two (2) person assists and were on the floor by bear hugging them and lifted residents into bed without a gait belt and without asking for assistance from herself and other staff. Interview on [DATE] at 3:24 PM with RN G revealed she did not perform a thorough physical assessment for Resident #49 after allegation of abuse and she thought Hospice RN did an assessment. RN G stated she only assessed Resident #325 for the cut on her leg. Interview on [DATE] at 2:57 PM with DON revealed [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the failed to implement their written abuse prevention policy and thoroughly investigate abuse allegations for three (Residents #7, #325 and #49) of nine residents reviewed for resident abuse. 1. The Administrator and DON failed to follow their abuse policy by reporting the allegations of physical abuse of Resident #325, by alleged perpetrator, CNA O, to HHSC within 2 hours after becoming aware of the incident on [DATE] and to thoroughly investigate the allegation for Resident #325. The facility failed to ensure that CNA O was suspended immediately pending investigation for the physical abuse allegation of Resident #325. 2. The Administrator failed to follow their abuse policy and thoroughly investigating the allegation of physical abuse for Resident #49. 3. The Administrator and DON failed to report an allegation of physical abuse ([DATE]) of Resident #7 by alleged perpetrator CNA O to HHSC within 2 hours of becoming aware of the incident on [DATE]. The Administrator failed to follow their policy to investigate the alleged abuse allegation for Resident #7 by CNA O. 4. The DON and RN G failed to perform a thorough physical assessment of Resident #325, Resident #49, and Resident #7 per facility's abuse policy for allegation of abuse. These failures resulted in the identification of Immediate Jeopardy (IJ) on [DATE] at 6:10 PM. The Corporate DON was notified and provided with the IJ template on [DATE]. While the IJ was removed on [DATE] at 7:00 PM, the facility remained out of compliance at potential for more than minimal harm with a scope identified as pattern. These failures could place residents at risk for not having allegations of abuse investigated thoroughly and for not having measures in place to protect them from serious harm, abuse, or death. Findings included: Review of facility's policy Abuse Policy dated [DATE] with a revised date of [DATE] reflected Resident has the right to be free from Abuse .Abuse is a willful infliction of injury or negligent, unreasonable confinement, imitation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse . Residents will not be subjected to abuse by anyone including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents . The administrator and/or designee are responsible for maintain ALL facility policies that prohibit abuse Investigating of allegations, reporting incidents, investigations, and facility response to results of investigation within mandated time frames . The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse .caused by another person to report the abuse . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation and in his/her absence . the abuse coordinator with the Director of Nursing/designee, will investigate all allegations and use the appropriate forms to document the investigation and turn it in to HHS within 5 calendar days. Upon completion of an investigation, the Director of Nursing and Administrator will analyze the occurrences and determine what changes, if any, are needed to prevent further occurrence . When there is no resolution to the suspected abuse, but there is indication that the abuse occurred, the facility will immediately conduct an in-service on abuse. Based on observations, interview and record review, the facility failed to 1.Record Review of Resident #325's Baseline Care Plan signed on [DATE] by DON revealed resident admitted on [DATE] for end-of-life care and was on hospice services with Hospice KK and required extensive assistance with ADLs. Record review of Hospice KK medical records for Resident #325 revealed a document titled Visit Report dated [DATE] which stated resident required maximum to total assistance, total assistance with ADLS, and was a two (2) person transfer. Record review of Resident #325's progress note dated [DATE] revealed resident expired on [DATE]. Review of grievance log for [DATE] revealed grievance dated [DATE] regarding CNA O being rough regarding Resident #325. There were blank spaces for categories of resolved, followed up with resident, or reported to state, or if follow up was needed. Record review of document titled Witness Interview dated [DATE] at 8:30 AM by Resident #325's family member and signed by DON revealed complaint alleging on the morning of [DATE] CNA O told Resident #325 was rough when he picked up Resident #325 from her wheelchair and threw her into the bed. Record review revealed grievance dated [DATE] for Resident #325 by family member and signed by Administrator revealed there was an established pattern with complaints of staff members while providing care and CNA O was suspended pending investigation. Record review of Resident #325 medical record revealed progress note dated [DATE] at 4:00 PM by RN G that Resident #325 was found with her leg in the blinds and resident was agitated and restless and had blood on her leg. Review of progress note revealed RN G called hospice and asked for a nurse to be sent with a comfort kit and family members arrived around 4:30 PM and then hospice arrived and provided medication to resident. Interview on [DATE] at 3:24 PM with RN G revealed she contacted DON on [DATE] after family member of Resident #325 complained about not receiving the care kits timely for Resident #325 and that CNA O was rough with his transfer of resident and tossed her into the bed. RN G stated she called the DON and was told CNA O tossing resident into the bed was a reportable incident and to contact Administrator. RN G stated she then called Administrator on [DATE] and the family spoke with Administrator over the phone and then was told by Administrator because the family did not use the word abuse it was not reportable incident to the state and CNA O continued to work and CNA O continued to work despite this allegation. RN G stated she assessed the cut on Resident #325 leg but did not complete a head-to-toe assessment. Interview on [DATE] at 11:59 AM with Resident #325's family member revealed she observed on the morning of [DATE] CNA O picked up Resident #325 from her wheelchair by himself and transferred resident into the bed. Family member stated she would describe the transfer as resident was plopped or tossed into the bed and the resident cried out. Family member stated she asked CNA O if he needed help before transferring resident and he said no. Family member stated she reported incident along with other concerns about care on the evening of [DATE] to RN G and then spoke with the Administrator. Family member stated Resident #325 was heavy and should have been a two person transfer which was why it appeared that resident was tossed into bed, and there was a lack of staff to assist. Family member stated she also arranged a meeting the following morning on [DATE] with the DON to go over her concerns further. Family member stated during her meeting with the DON and was told that they would look into the incident and did not recall filling out a witness statement or a grievance. Family member stated Resident #325 expired the following day and she had not been contacted by facility with an update. Interview on [DATE] at 2:57 PM with DON revealed Resident #325 was admitted to facility for end of life care and expired on [DATE]. DON stated Resident #325 required a significant amount of care and needed assistance to be turned. DON stated on the evening of [DATE] RN G called to report family of Resident #325 stated CNA O roughly picked up and tossed Resident #325 into the bed. DON stated she told RN G that the abuse allegation was reportable and instructed RN G to call the Administrator immediately. DON stated she came to the facility around 8:00 PM and asked Administrator what needed to be done for the investigation. DON stated Administrator told her everything had been done except for the in-services on abuse and neglect. DON stated Administrator printed the abuse and neglect policy and DON went to every CNA and clinical staff member and reviewed the policy with them and had them sign the in-service sheet. DON stated she met with the family member on [DATE], wrote a witness statement, and the Administrator refused to take the statement during the morning meeting in-service on abuse and neglect. Administrator told DON she did not want the statement because she did not think it was abuse, she was already investigating the allegation of abuse by CNA O to Resident #49, and CNA O was already suspended. DON stated Administrator expressed irritation at having to come back to facility the evening on [DATE]. DON stated she took the witness statement back to her office. DON stated the Corporate Nurse DD was onsite on [DATE] and saw the witness statement on her desk and instructed DON to give it to Administrator. DON stated she told Corporate Nurse DD that Administrator refused to take the statement and Corporate Nurse DD suggested she file a grievance for the family of Resident #325 because the Administrator was the abuse coordinator and would have to report and investigate the incident. DON stated she gave the information to SSD who wrote the grievance and put it back on DON's desk. DON stated Corporate Nurse DD gave grievance to Administrator. DON stated she was not aware the allegations regarding CNA O and Resident #325 were not reported to HHSC. DON stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. Interview on [DATE] at 3:42 PM with Administrator revealed she had concerns regarding CNA O handling of Resident #325 during transfer on [DATE] and spoke to family member on [DATE] over the phone but because family member did not use the words abuse she thought it was more of a training issue she did not believe CNA O would intentionally abuse any resident so she did not report the allegation with Resident #325. Administrator stated there were no witness statements for Resident #325. Administrator stated she did not suspend CNA O until a second similar allegation later in the evening on [DATE] about a rough transfer was made by Hospice RN stated she and RN G regarding Resident #49. Administrator commonly would receive conflicting reports from staff regarding different issues and took this report more seriously because Hospice RN was a neutral party. Administrator stated sometimes what may look like abuse was just a transfer and that sometimes staff had to just pick up a resident and it may appear to be rough. Interview on [DATE] at 9:48 AM with MDS Coordinator revealed she was present during the morning meeting on [DATE]. MDS Coordinator stated the Administrator was leading the meeting and reviewing the abuse and neglect policy with the department heads including the DON. MDS Coordinator stated that all allegations of abuse are to be reported to the Administrator who is the abuse coordinator. MDS Coordinator stated when Administrator read aloud examples of neglect the DON interjected and stated- see that is what I am talking about, it is abuse. MDS Coordinator stated Administrator became upset and stated it was not abuse, and ADON had observed CNA O provide care to residents and there were no concerns. MDS Coordinator stated Administrator stated she already recorded all the witness statements and did not want the witness statement from DON. MDS Coordinator stated Administrator and DON began to argue and MDS Coordinator and staff quickly left the room. MDS Coordinator stated she did not know which residents Administrator and DON were talking about. Interview on [DATE] at 2:56 PM with DON revealed she did not provide a thorough physical assessment for Resident #325 or Resident #49 and thought they had been done by the charge nurse and it should be documented in the resident's chart such as the progress notes. DON stated that RN G would have done an assessment and she did not follow up with RN G. DON stated she had asked Administrator the evening of [DATE] after the incident if the assessments had been done and what she could help with and Administrator stated only the in-services were left. Interview on [DATE] at 4:25 PM with Administrator revealed she did not report the family complaint about CNA O's treatment of Resident #325 because she did not think it was abuse at the time and did not think CAN O would intentionally abuse a resident. Administrator stated CNA O admitted to inappropriately transferring residents. Interview on [DATE] at 5:15 PM with Director of Therapy with Director of Therapy revealed Resident #325 was at facility for end of life care and would have concern with a CNA transferring Resident #325 by scooping resident out of bed by themselves and into shower chair because it could result in a resident being dropped or injured. Director of Therapy stated residents who required extensive assistance meant the person required a resident to be transferred with 2 people assisting and with gait belt at a minimum, possibly Hoyer lift. Interview on [DATE] at 11:02 AM with ADON revealed she worked the day of [DATE] until 6:00 PM. ADON stated Resident #325 had admitted to facility on [DATE] for hospice services, was on oxygen and was restless. ADON stated on [DATE] around 3:30 PM, she was in her office and heard RN G call for help and immediately went to assist RN G who was in Resident #325's room. ADON stated she observed RN G in Resident #325 room and Resident #325 was in bed next against the window and Resident #325 appeared confused of her surroundings, restless, agitated, and was flailing her arms around and kicking her legs. ADON stated she did not see any visible injuries on Resident #325 ADON stated she and RN G did not perform a head-to-toe assessment because the resident was restless and they stayed with resident to ensure safety while they waited for hospice services to arrive. ADON stated RN G asked CNA O to assist with moving the bed from the window to against a wall. ADON stated that family members of Resident #325 arrived before hospice services and were talking with RN G about their concerns and ADON left the room to give them privacy. ADON stated she was not aware that an allegation was made against CNA O until the following day at the morning meeting on [DATE]. ADON stated during the morning meeting the Administrator was reviewing the abuse and neglect policy and stated that there was an allegation of abuse of Resident #49 and Resident #325 by CNA O and that Administrator had done an investigation and felt that no abuse occurred. ADON stated DON interjected and said that she believed there was abuse. ADON stated Administrator replied that DON was showing favoritism to the nurse that reported the abuse, RN G. ADON stated DON stated it was the same favoritism the Administrator showed the Maintenance Director and began to leave the meeting and the Administrator told DON not to get in her feelings and that she had done this investigation and talked to family members of the residents and she didn't feel like it was abuse. ADON stated she spoke with the Administrator after the meeting and the Administrator told her that she did not believe abuse occurred and that if RN G witnessed abuse then why did she not intervene. ADON stated she was responsible for assessing competencies quarterly of MA's and CNA's and assessed for peri-care, hand washing, and use of Personal Protective Equipment (PPE). ADON stated she had only assessed CNA O for hand washing and PPE use because CNA O used to work full time then switched to only a couple days a week as needed and she had not gotten to him to assess the peri-care. ADON stated she was aware that Administrator spoke with CNA O in the past about not communicating with residents when providing care by not introducing himself and letting them know what care he was going to provide. 2. Record Review of Resident #49's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and diagnoses of dementia (loss of cognition), bi-polar disorder (mood disorder with periods of intense feelings), major depressive disorder (a mood disorder causing persistent feeling of sadness and loss of interest), and pseudobulbar affect (episodes of uncontrollable and inappropriate laughing or crying), unspecified pain, and a BIMS score of 0 (severely impaired cognition). Review revealed Resident #49 was dependent on assistance for ADL care including showers and transfers. Observation on [DATE] at 3:22 PM of Resident #49 revealed she was laying in geri chair wearing a long sleeve shirt, pants, with hair that appeared clean, with her legs curled up and arms in contracture, she was non-interviewable. Record review of medical record for Resident #49 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident experienced mood swings, visual and auditory hallucinations, had a history of agitation, aggressive behavior and was combative. Record review of physical therapy evaluation or Resident #49 revealed resident was known for grabbing hold of individuals nearby and hit and kicked. Record review of physical therapy evaluation revealed Resident #49 habitually coiled legs into extreme flexion at hip and knees which led to recurrent tightness and contractures and was non-weight bearing on her legs which caused additional challenges with assisted transfers. Review of physical therapy evaluation revealed Resident #49 did not ambulate on her own and used a geri chair. Record review of witness statement by Hospice RN, dated [DATE] at 8:05 PM, and signed by Administrator revealed Resident #49 had vomited multiple times on [DATE] and Hospice RN asked CNA O to shower resident. Hospice RN stated CNA O entered the room and did not say anything to Resident #49 before he rolled resident over and picked her up and roughly sat her in the chair. Hospice RN stated that Resident #49 was startled and was not covered all the way when transported through the hallway. Hospice RN stated she did not think he was abusive, but it was overly rough and aggressive. Record review of witness statement by RN G, dated [DATE] at 8:22 PM, and signed by Administrator revealed RN G witnessed CNA O roughly handled the shower chair as he transported Resident #49 out of shower room and she did not see his hands on physically on Resident #49 at any time. Interview on [DATE] at 3:24 PM with RN G revealed on the evening of [DATE] she was at the nurses station when she observed Hospice RN appeared upset. RN G stated Hospice RN told her CNA O picked up resident out of bed roughly and put Resident #49 into the shower chair. RN G was unable to explain why she did not intervene. RN G stated she felt startled when the shower door opened and CNA O jerked Resident #49 out of shower room and placed her at the nurses station. RN G stated she had training on Abuse, Neglect, and Exploitation during onboarding and in-services and was not sure if what she witnessed was abuse. RN G stated she called DON and Administrator and was told to have CNA O leave pending investigation. Interview on [DATE] at 3:19 PM with CNA N revealed Resident #49 required a two person transfer or hoyer lift with two people assisting because she is very strong and swings her limbs around and kicks during transfers. CNA N stated CNA O was a male and was stronger than the female CNA's and they would call CNA O when they needed assistance with heavy residents. Interview on [DATE] at 2:57 PM with DON revealed Resident #49 required at least two (2) staff and a Hoyer lift to be transferred. Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #49 was in PT therapy for contraction management and for balance training and had a tendency to grab things like ears, arms, anything within reaching distance and kicked. Director of Therapy stated Resident #49 was totally dependent with care and was a two (2) person assist or hoyer lift. Director of Therapy stated concern with a CNA who lifted Resident #49 by himself by scooping resident out of bed into shower chair would be CNA could have dropped or injured resident. Interview on [DATE] at 9:04 AM with Hospice LL Director revealed she received a phone call from Hospice RN on [DATE] regarding a concern with possible physical abuse of Resident #49 by CNA O and Hospice RN had reported incident to Administrator and RN G, the charge nurse, and CNA O had been removed from facility. Hospice LL Director stated that abuse should be reported to HHSC within 2 hours and did not report it herself because she was told the facility had reported incident. Hospice LL Director stated she received a phone call on [DATE] from Administrator who asked her how often hospice staff receive training on abuse and neglect. Hospice LL Director stated Administrator told her she did not feel that what CNA O did was abuse and that if a hospice nurse is present and believes they witnessed abuse then they should be the one to report the incident. Hospice LL Director stated Administrator told her that sometimes a transfer could look abusive if the observer is not trained to recognize abuse and sometimes staff just needed to pick up residents. Hospice LL Director stated Administrator sounded annoyed to have to conduct an investigation and told her CNA O had been suspended and the incident was self-reported. Hospice LL Director stated she documented her phone call with Administrator and submitted a report of abuse to CPS following her phone call with Administrator. Hospice LL Director stated that showers for Resident #49 would require two staff members because of Resident #49's functional status. Hospice LL Director stated risk to resident if not properly transferred or are showered with one staff member when they require two staff would be resident could be dropped, injured, or develop a skin tear due to friction or shearing. Interview on [DATE] at 9:49 AM with MDS Coordinator revealed Resident #49 required two people to transfer including a hoyer lift because resident has involuntary movements of her arms and legs and grabs on to anything within reach, kicks, and hits. MDS Coordinator stated the risk to residents when improperly transferred were injury from being dropped or pull on improperly. Interview on [DATE] at 3:33 PM with SSD revealed she was not in-serviced on the facility's abuse and neglect policy before she provided an in-service to staff on abuse and neglect on [DATE] and used the previous Abuse and Neglect policy dated 2020 by mistake instead of the most current policy dated [DATE]. Interview on [DATE] at 11:49 AM with CNA P revealed Resident #49 required two people and a Hoyer lift to transfer because she is a fall risk and commonly grabs anything within reach when being transferred. CNA P stated the risk to residents by not properly transferring would be injury from being dropped. Interview on [DATE] at 6:05 PM with MA Z revealed she had worked at facility since 2019 and typically worked on Hall 200 and 300. MA Z stated Resident #49 is a two (2) person assist and is not aware of her surroundings and would swing her limbs around, hit, and bite the elbows of staff during transfers. MA Z stated hospice usually gave Resident #49 showers with two (2) people assisting and she would always hear Resident #49 yelling during showers. MA Z stated she liked CNA O because he was strong and assisted with transfers of residents and could not recall ever seeing CNA O use a gait belt. MA Z stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. 3. Record Review of Resident #7 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of late onset Alzheimer's disease (loss of cognitive function), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), spondylolysis (crack or break in the bone of the spine), a BIMS score of 5 (severely impaired cognition). Record review of Resident #7 Care Plan dated [DATE] and revised [DATE] revealed resident required moderate assistance by one (1) staff to move between surfaces. Observation and interview on [DATE] at 2:07 PM of Resident #7 revealed resident was sitting in an electric wheelchair with her hair brushed wearing a long sleeve shirt, pants, and shoes. Resident #7 was non-interviewable due to cognitive impairment and could not recall incident with CNA O. Record review of medical record for Resident #7 revealed document titled Physical Therapy PT Evaluation and Plan of Treatment dated [DATE] revealed resident was confused regarding her surroundings, had difficulty communicating, was a fall risk, and required substantial to maximal assistance with ADL care. Interview on [DATE] at 5:17 PM with Director of Therapy revealed Resident #7 required moderate assistance with transfers, a one person assist with staff using a gait belt at the minimum. Director of Therapy stated a CNA who lifted Resident #7 under her arms to transfer from wheelchair to bed without gait belt placed the resident at risk of being dropped and injury. Director of Therapy stated improper transfers such as picking up a resident from under their arms when transferring increased risk of resident injury, fracture, and multiplied the fall risk for resident. Interview on [DATE] at 11:38 AM with LVN J revealed Resident #7 is care planned as a one person transfer assist which would mean always use a gait belt. LVN J stated she had seen Resident #7 be transferred from wheelchair to bed and usually the staff member would have Resident #7 put her hands on their shoulders and wrap around the resident and lift while wearing a gait belt. LVN J stated improper transfers of residents increased a resident risk of injury and harm. LVN J stated that if she observed abuse she would immediately inform the Administrator who is the abuse coordinator. Record review of Resident #48 Discharge MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to facility on [DATE] with diagnoses of chronic pulmonary disease (chronic lung disease obstructing airflow), Parkinson's disease (a chronic and progressive movement disorder), hypotension (low blood pressure), major depressive disorder (mood disorder with persistent feeling of sadness and loss of interest), was hospitalized on [DATE] and had a BIMS score of 14 (cognitively intact). Record review of resident safe surveys performed by SSD on [DATE] during abuse investigation for Resident #49 revealed Resident #48 reported she witnessed CNA O rip Resident #7's pants off roughly from her hip to her ankles and Resident # 7 was screaming. Observation of Resident #48 on [DATE] at 11:27 AM revealed resident was lying in bed asleep and wearing hospital gown. Surveyor attempted to interview resident #48 but was unable to due to illness. Interview on [DATE] at 3:24 PM with RN G revealed when she left work on [DATE], Resident #48 was smoking outside and talking with someone else about witnessing a CNA O treating Resident #7 roughly. RN G stated she asked Resident #48 about the incident. RN G stated that Resident #48 said she was in the hallway and able to see in Resident #7's room because the door and privacy curtain were not closed and she saw CNA O put Resident #7 in her bed and rip the pants off of Resident #7 when providing care. RN G stated she asked Resident #48 if she reported this incident and Resident #48 stated she told the social worker the previous day, [DATE]. RN G stated she called and let DON know of the conversation and was told it was being investigated. Interview on [DATE] at 5:05 PM with SSD revealed she conducted a safe survey on [DATE], in regard to Resident #49's allegation of abuse by CNA O, and Resident #48 reported she witnessed CNA O rip off the pants of Resident #7 while providing ADL care. SSD stated Resident #48's room is across the hall from Resident #7. SSD stated during safe surveys, Resident #44, who was the roommate of Resident #7, indicated a concern regarding treatment of Resident #7 by CNA O but Resident #44 declined to give further information. SSD stated she did not follow up with Resident #44. SSD stated she attempted to interview Resident #7 but resident was non-interviewable. SSD stated the Administrator was the abuse coordinator and was responsible for collecting evidence and investigating allegations of abuse. Record Review of Resident #44's Quarterly MDS dated [DATE] revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of cognition), hypertension (high blood pressure), anxiety disorder (feelings of worry and fear or unease), depression (persistent feelings of sadness) and BIMS score of 10 (moderately impaired cognition). Observation on [DATE] at 11:16 AM revealed Resident #44 was seated upright in wheelchair in 200 Hall wearing shirt, pants, and shoes and her hair was brushed. Interview on [DATE] at 11:18 AM with Resident #44 revealed she was roommates with Resident #7 and about a week ago she was in her room lying in bed and Resident #7 was sitting in an electric wheelchair next to her bed when CNA O entered the room and said he was going to change Resident #7. Resident #44 stated CNA O picked up Resident #7 by lifting from underneath both armpits and placed her roughly in bed. She recalled Resident #7 told CNA O to stop as soon as CNA O began to lift Resident #7 up from the armpits and CNA O continued to transfer resident. Resident #44 stated he roughly and quickly jerked Resident #7's pants off to perform ADL care and recalled Resident #7 screamed and said stop several times and that he was being rough with her and she was going to tell. Resident #44 stated she felt upset when she witnessed this and told CNA O to leave Resident #7 alone and CNA O finished providing ADL care to resident. Resident #44 stated that she told SSD about the incident during a safe survey ([DATE]) and that she was told CNA O was no longer at the facility. Resident #44 stated she currently felt safe at facility. Interview on [DATE] at 3:44 PM with Administrator revealed she did not report or investigate allegation of abuse for Resident #7. Administrator stated she did not interview Resident #48 about their allegation from safe survey or the roommate of Resident #7 (Resident #44) because she thought it was more of a dignity issue than abuse allegation. Administrator stated she should have investigated the incidents by including the additional residents because it was a similar allegation to Resident #49. Administrator stated Resident #7 should have been assessed by either the charge nurse or DON and was not aware if an assessment had been completed. Interview on [DATE] at 2:56 PM with DON revealed she was not aware of any abuse allegation for Resident #7 at the time of the safe survey and had only heard about it from other staff recently. DON stated she did not provide a physical assessment of Resident #7. DON stated she did not speak with Resident #44 about the incident. Interview on [DATE] at 2:32 PM with Regional VP[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of four (Residents #15, #174 and #71) residents reviewed for pressure ulcer care. 1. The Facility failed to notify Resident #15's Physician the Wound Care Consultant was no longer providing oversight for the resident's wounds from [DATE] through [DATE] which resulted in deterioration of her Left Ischium (hip) stage 4 pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone), sacrum stage 3 pressure ulcer (full thickness skin loss in which fat was visible and granulation tissues and rolled wound edges are often present), right gluteal fold (crease below the buttocks) stage 4 pressure ulcer, right lateral malleolus(outside ankle) stage 3 pressure ulcer, left medial malleolus (inside ankle) stage 3 pressure ulcer, left lateral malleolus (outside ankle) stage 3 pressure ulcer and new stage 3 pressure to her right foot. 2. The Facility failed to complete a skin and wound assessment upon Resident #15's re-admission to the facility on [DATE] until [DATE]. 3. The facility failed to obtain Physician orders for Resident #15's wound care after her re-admission on [DATE], instead re-started previous wound care on [DATE] without Physician authorization. 4. The Treatment Nurse failed to consult with Resident #15's Physician or the Wound care consultant prior to changing the resident wound care orders. 5. The facility staff failed to complete a Skin assessment, Wound Care assessment or notify the physician when a wound of unknown description was identified on [DATE] on Resident #174's coccyx, which resulted in the deterioration of the wound to an unstageable pressure ulcer (obscured full -thickness skin and tissue loss) with bone exposed and a stage 1 pressure injury(non-blanchable erythema of intact skin) to her right heel upon admission to hospice on [DATE]. Resident expired in the facility on [DATE]. 6. The facility failed to obtain physician orders for treatment of Resident #174's right heel when it progressed to a stage 2 pressure ulcer (partial-thickness loss with exposed dermis) that was indicated to have drainage on [DATE]. 7. The facility failed to complete a skin assessment, wound care assessment, or notify the physician, family, and Hospice on [DATE] when a Stage 2 pressure ulcer on Resident #71's coccyx and three small blisters on her right thigh were observed on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:40 PM. The IJ template was provided to the facility on [DATE] at 12:45 PM and signed by the Administrator. While the IJ was removed on [DATE] at 5:17 PM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: Record Review of Resident #15's Face Sheet dated [DATE], reflected a re-admission date of [DATE] to the facility. Record review of Resident #15's quarterly MDS, dated [DATE], reflected a [AGE] year-old female with an admission date of [DATE]. The resident had a BIMS of 13 which indicated she was cognitively intact and had not resisted care. She required extensive to dependent care with ADL. She had a foley catheter and was always incontinent of bowel. She had pressure ulcers and was at risk for pressure ulcers. Active diagnoses included diabetes, multiple sclerosis (disease in which the immune system eats away at protective coverings of nerves), paraplegia (paralysis that affects the legs) and seizure disorder. Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus, left medial malleolus, stage 4 pressure injury to her left ischial and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods . Record review of Resident #15's care plan dated [DATE] reflected, [Resident #15] has stage 3 pressure injury to sacrum, right lateral Malleolus (ankle), left medial malleolus (ankle), stage 4 pressure injury to her left ischial (hip) and right gluteal fold and is at risk since resident chooses to stay up in wheelchair up to 8-9 hours at times .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing daily. Measure length, width, and depth weekly. Assess and document stats of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .low air loss mattress .if the resident refuses treatment .try alternative methods to gain compliance. Document alternative methods . Record Review of Resident #15's Hospital summary from [DATE] to [DATE] revealed resident was admitted and treated for a gastrointestinal bleed. Progress notes revealed no wound care assessment was completed during the hospital stay. Record Review of Resident #15's Hospital Discharge orders dated [DATE], did not reflect any orders for wound care. Record Review of Resident #15's Physician order recap report with date range from [DATE] through [DATE], reflected, 1. Left Heel- apply skin prep twice daily to scabbed area, with a start date of [DATE] ( 7 days post admission) 2. Left Ischium (hip)- Cleanse wound with Dakin's (diluted bleach)solution. Apply Hydrofera Blue(antimicrobial dressing) foam to wound bed and cover with a dry dressing every day and as needed- with a start date of [DATE]. (3 days post admission) . Order was changed on [DATE] to Cleanse wound with Dakin's solution . Apply Santyl (removes dead tissue) to wound bed and calcium alginate (used for exuding wounds). Cover with a dry dressing daily, with a start date of [DATE]. 3. Left Lateral Malleolus (outside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE]. 4. Left Medial Malleolus (inside ankle)- Apply skin prep to scabbed area twice daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound Cleanser. Apply Santyl to wound bed and calcium alginate. Cover with a dry dressing daily with a start date of [DATE]. 5. Right Gluteal Fold (skin crease below the buttocks) - Cleanse with Normal Saline. Apply a thin layer of Santyl to wound bed. Lightly pace wound Kerlix roll moistened with Dakin's solution and cover with a super Absorbent dressing daily and as needed with a start date of [DATE]. 6. Right Lateral Malleolus(outside ankle)- Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Collagen and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. 7. Right Lateral (outside )side of foot- Cleanse with wound cleanser, apply a small amount of Santyl to wound bed, then apply Calcium Alginate, cover with dry dressing daily with a start date of [DATE]. 8. Right Medial Malleolus (inside ankle) Cleans with wound cleanser and pat dry. Apply collagen and Xeroform and a dry dressing daily and as needed every day with a start date of [DATE]- Order was changed on [DATE] to Cleanse wound with wound cleanser and pat dry. Apply Santyl and Calcium alginate to wound bed and cover with a dry dressing daily and as needed with a start date of [DATE]. 9. Sacral wound- Cleanse with wound cleanser. Apply Hydrofera Blue Foam to wound cand cover with a dry dressing daily with a start date of [DATE]. Order was changed on [DATE] to Cleanse with wound cleanser. Apply Collagen(protein used to make connective tissue), and calcium alginate to wound and cover with a dry dressing daily and as needed with a start date of [DATE]. Record Review of Resident #15's TAR for [DATE] reflected no wound care was documented for [DATE], [DATE], [DATE], [DATE]. Record review of Resident #15's Braden scales for predicting pressure sore risk, dated [DATE] reflected a score of 15 which indicated risk for pressure ulcers. Record Review of the facility's Pressure Skin/Wound Log, dated [DATE], (most current) reflected one resident with pressure ulcers. Resident #15 was listed with the following wound descriptions and treatments: admitted with- Stage 4 left Ischium- 11.0 x6.0 x 1.5 cm- treatment-hydofera blue and foam dressing. admitted with- Stage 3 sacrum- 2.0 x2.5 x1.3 cm treatment-hydofera blue and foam dressing. Facility acquired- Stage 4 right gluteal fold- 6.5 x7.0x 4.5 cm. treatment- Santyl, kerlix/dakin, foam dressing. Facility acquired- Stage 2 right Lateral Malleolus 2.0x 2.5 x 0.1 cm- treatment-Collagen foam dressing. Facility acquired- Deep tissue injury left heel- 2.0 x 1.0 x 0 cm- Treatment- skin prep. Facility acquired-Stage 3 left medial Malleolus 2.0 x 0 x 0 cm- treatment- Skin prep. Facility acquired- Stage 2 Left Lateral Malleolus- 1.5 x1.5 x 0 cm- Treatment- skin prep. Record Review of Wound Care Consultant Report dated [DATE] for Resident #15 reflected: 1. Left Ischium- 5x8x0.6 cm - stage 4 pressure- improving.- post debridement- 5x8x0.7 cm- Bone palpated. 2. Sacrum- 2x2.5x1 cm-stage 3 pressure-stable- post debridement- 2x2.5x1.1 cm 3. Right gluteal fold-5x8x5.3 cm-pressure- heavy exudate, slough, strong odor-post debridement- 5x8x5.4 cm. Bone palpated. 4. Right Lateral Malleolus- 2.4x2x0.2 cm- Stage 2 pressure 5. Left heel- 1.5x1.5x0.1 cm- deep tissue pressure injury- improving. 6. Left Medial Malleolus- 1.5x2x0.1 cm-Stage 3 pressure- improving. 7. Left Lateral Malleolus- 2x1.5x0.1 cm - improving. Record review of the electronic record for Resident #15 reflected no additional Wound Care Consultant reports. A visit was attempted by the Wound Care Consultant on [DATE]- Resident was involved in activities and declined assessment. Record review of Resident #15's admission assessment dated [DATE], completed by LVN J reflected, Skin integrity- was left blank- Under comment section- stated - See wound assessments. Record review of Resident #15's electronic record reflected no Wound Care assessment was completed until [DATE], which deferred to the Wound Care Consultants assessment completed on [DATE]. In an interview with the LVN Treatment Nurse on [DATE] at 02:00 PM, she stated she was the one doing the wound care assessments and measuring the wounds on Resident #15. She stated there had not been anyone from the Wound Care consultant company coming to the building for over a month. She stated even before that they were not coming consistently on a weekly basis. She stated the Wound care Nurse Practitioner had told her since Resident #15 was the only one in the building she thought they would just do Telehealth. She stated she told the NP due to the extensive nature of Resident #15's wounds she did not think that was going to be adequate, so the Nurse Practitioner stated she would get someone else to come. She stated another Nurse Practitioner from the wound care company came out, but she only came one time and they never sent anyone else. She stated at some point, Resident #15's wounds had started having more slough, so she added Santyl back to the wound care order. She stated the Nurse Practitioner had taken it off at one time. She stated she had not called the Primary care physician or his NP about any of the resident wounds. She stated Resident #15 was sent to the hospital a few weeks ago unrelated to her wounds, and stated she was told the hospital had not done wound care on her for the 3 days she was in the hospital. She stated she thought the wound on her coccyx had been improving. She stated once Resident #15 gets up she will refuse to lay back down until bedtime which makes healing very difficult. In an interview and observation with Resident #15 on [DATE] at 08:55 AM she stated she knew this Surveyor was going to watch her wound care this morning ([DATE]) and she was OK with that. She stated once she got up mid-morning she does not go back to be until around 8 or 9 PM. She stated she knew it was not good for the healing of her pressure injuries, but stated there was not enough staff to lay her down and get her back up throughout the day and she did not want to miss her smoke breaks. She stated part of the problem was the cushion in her wheelchair. She stated she had been asking the facility to get her a Roho cushion ( air filled cushion) but the facility had not provided one. Observation of the cushion in her wheelchair revealed a memory foam cushion that was concaved in the middle of the cushion. In an observation and interview with LVN J on [DATE] at 09:10 AM revealed her at the treatment cart preparing supplies for wound care for Resident #15. Observed CNA M and LVN J entered Resident #15's room to provide the residents wound care on [DATE] at 09:15 AM. Both staff washed their hands. LVN J cleaned the bedside table with a germicidal wipe and then placed the wound care supplies, plus a bottle of Dakin's solution and her computer on the table without placing the supplies on a barrier. CNA M put on gloves and uncovered the resident and found the resident with no brief lying on a cloth moisture resistant pad. CNA M rolled the resident on her right side revealing she had a bowel movement, which had contaminated the sacral wound dressing. CNA M provided incontinence care and changed her gloves but did not perform hand hygiene after she changed her gloves. LVN J noted the resident had 4 dressing on her right foot and stated she only had orders for her right Lateral ankle. She stated she was not sure what was going on with the resident's right foot. LVN J removed the dressing on the left outer ankle revealing a wound about the size of a golf ball with slough (yellowish white material in the wound bed consisting of dead cells) present, she stated this wound looked a little smaller since she saw it last week. LVN J cleaned the wound with normal saline, since she stated she was out of wound cleanser. LVN J removed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the wound bed and covered with a dressing. LVN J changed gloves without performing hand hygiene and removed the dressing from the resident's left interior ankle revealing a wound about the diameter of a double D battery. The wound had slough present. LVN J cleaned the wound with normal saline, changed gloves, with no hand hygiene, and applied Santyl and Calcium alginate and covered with a dressing. LVN J then applied skin prep to the resident's left heel, which had a scab approximately the diameter of a triple A battery. LVN J changed gloves, no hand hygiene and proceeded to remove all dressing on the outside the right ankle and revealed a wound approximately the diameter of a golf ball on the outer ankle with slough present and serous (yellow) drainage. Observed on the outer middle part of her foot a wound approximately the size of blue jean button. LVN J stated it appeared it had calcium alginate, but stated there was no order for a treatment of this wound. LVN J cleaned both wounds with normal saline, changed her gloves and re-gloved without performing hand hygiene and applied Santyl and calcium alginate to the ankle and calcium alginate to the wound on her right mid foot and covered both with a dressing. LVN J changed gloves without performing hand hygiene and proceeded to the wound on the resident's right gluteal fold. LVN J removed the dressing and revealed a wound with heavy greenish gray drainage and strong odor. Wound was approximately the diameter of a soup can and appeared to be to the bone. LVN J cleaned with normal saline, changed gloves with no hand hygiene and re-gloved and applied Santyl and packed with kerlix moistened with Dakin's solution and covered with a dry dressing. LVN J removed gloves- no hand hygiene and re-gloved and proceeded to the wound on the resident's sacrum. CNA M completed incontinence care, removing the remainder of the fecal matter after LVN J removed the soiled dressing. The sacral wound was crescent shaped and approximately the width of a tennis ball with slough present. LVN J cleaned with normal saline and applied collagen and calcium alginate and covered with a dressing. LVN J changed gloves- no hand hygiene and proceeded to the wound on the residents left Ischial. The wound was approximately the diameter of a orange with the top part of wound having some granulation (red and moist) present. The bottom of the wound had slough and necrotic tissue present with heavy drainage and an odor. LVN J cleaned with Daikin's solution, applied Santyl to the necrotic portion of the wound and calcium alginate to the remainder of the wound bed and covered with a dressing. LVN J changed her gloves and re-gloved without performing hand hygiene and provided catheter care and both she and CNA M placed a clean brief on the resident and dressed her for the day. Resident #15 was transferred with mechanical lift to her wheelchair. Wheelchair was noted to have a memory foam cushion that was concaved in the middle. Resident #15 again stated she had asked for a Roho (air filled pressure relief cushion) cushion. Both staff removed their gloves and performed hand hygiene. In an interview with LVN J on [DATE] at 10:15 AM she stated Resident #15's ankle wounds looked about the same since she saw them last week, but her wound on her gluteal fold was much worse as well as the sacrum and Ischium wound which appeared to be tunneling (opening under the skin). She stated she worked Monday through Friday on the 06:00 AM to 02:00 PM shift. She stated Resident #15 returned from the hospital on [DATE]. She stated there were no wound care orders from the hospital. She stated when she got report from the hospital, they stated they had done wound care on Saturday, but not Sunday stating the resident had refused. She stated she did not assess the wound when she returned to the facility on [DATE], since the Treatment Nurse did the Wound care assessments. She stated she did not find out until this week ([DATE]) the treatment nurse had stepped down from that position. She stated she thought the 2:00 PM to 10:00 PM nurse did her wound care on [DATE]. She stated she had asked the MDS Nurse if she could put in the wound care orders. She stated they were just using the previous wound care orders. She stated she had not contacted the MD to clarify the wound care orders. She stated she did the wound care on Tuesday [DATE] and the wounds were not draining like they were today ([DATE]) but stated they did have a lot more slough. She stated she had not contacted the primary care physician about the wounds, stating she assumed the treatment nurse wound be doing that. She stated she had not signed off on the wound care because the orders had still not been put in the system when she did the wound care on Tuesdays [DATE]. In an interview with Resident #15's NP DD on [DATE] at 11:40 AM who was in the building making rounds, she stated she had not been contacted about Resident #15's wounds since her return from the hospital. She stated she was on call last weekend. She stated the facilities usually had a wound care doctor that comes weekly. She stated she was not aware that no one was coming for wound care manage for Resident #15. She stated she did not re-call ordering any wound cultures on the resident, but stated if she were having signs and symptoms of infections, she would order them today ([DATE]). She stated anyone with the extensive nature of Resident #15's wounds needed to be seen weekly by a wound care specialist. She stated the risk of failing to manage Resident #15's wounds could lead to sepsis, further decline of the wound and loss of limbs. She stated they needed to contact the Primary Care physician or herself anytime there was a significant change. Attempted to contact Resident #15's Primary care physician on [DATE] at 11:51 AM and was told he was out of the office on vacation. In an interview with the DON on [DATE] at 12:45 PM stated she knew the Wound Care management company had not sent anyone out for several weeks. She stated they originally had wound care NP AA coming weekly, but her visits became less consistent. She stated NP AA had told the Treatment Nurse that she did not want to come for just one resident and wanted to do Telehealth, but the Treatment Nurse and herself felt Resident #15's wounds needed to be seen weekly, so NP AA arranged for someone else to come. She stated wound care NP EE came out about a month ago and had not been back. She stated she was planning on getting with the Treatment Nurse to see what was going on with Resident #15's wounds but stated due to the shortage of staff the Treatment Nurse had been working the floor covering shifts for the last 3 weeks. She stated due to this they had an in-service with the staff sometime in February 2024 letting them know the Treatment Nurse would no longer be doing the weekly skin assessments and the Nurses would be responsible for their assigned residents, but the Treatment Nurse would still be doing the wound care assessments weekly. She stated the staff were also told they would be responsible for doing the wound care if the Treatment Nurse was working the floor. She stated it was her expectation that anytime there was a new skin issues they were to complete a skin assessment, notify the physician and family and get orders. She stated the nurse who identified the issue needed to be the one who reached out to the physician. She stated she was not sure what they were going to do about a wound care physician at this time. She stated wound care orders could only be changed by the physician. She stated it was outside the scope of practice for the nurse to implement her own wound care orders. She stated the risk could be making the wound worse, risk of infection. She stated she had not considered who would complete the wound care assessments if the Treatment Nurse was unavailable, and stated after this week, the Treatment Nurse had stepped down from the position. In an interview with the MDS Coordinator on [DATE] at 12:50 PM she stated when Resident #15 returned to the facility on [DATE] she helped put in the hospital discharge medication orders but stated she had told the Treatment Nurse she needed to put in the wound care orders. She stated she was not aware of who the facility Wound care management company was or who to contact about wound care. In an interview with the Treatment Nurse on [DATE] at 10:05 PM she stated she was called in at 6:30 PM today to help on the floor as CNA. She stated she had told the nurse's back in January they were going to have to do the wound care when she was off or working the hall. She stated they were also supposed to be doing the skin assessment, but that was not happening, so they did an in-service on [DATE] on the requirement of for the weekly skin assessment. She stated the nurses were supposed to complete the skin assessment for any skin condition and if it was pressure or deep tissue injury, they were to report to her, and she would complete the Wound care assessment. She stated the nurse however was to contact the physician, family and obtain any treatment order needed. She stated she had been doing Resident #15's Skin assessment and wound assessment up until she went to the hospital on [DATE] and was trying to do the treatments when she could. She stated her wound assessments were scheduled for Thursdays and she was off on Thursday. She stated when Resident #15 came back to the facility on [DATE], the admitting nurse should have done a skin assessment and called the doctor for orders for the wound. She stated she was not surprised wounds were not getting documented as being done. She stated she was so frazzled by the time she leaves she was not sure what she did and did not do. She stated she did Resident #15's wound care on Wednesday[DATE] but did not do the wound care assessment. She stated she off on [DATE] the day the assessment was due. She stated there was a little bit of odor and drainage. She stated the wounds did not have an odor or drainage before she went to the hospital. She stated she probably could have reached out to the Wound care company, but stated she felt like the wounds had been stable prior to her going to the hospital. She stated when she started in [DATE], she received no training on wound care and was not aware of the facility's policy for wound care. She stated she had previous experience as a treatment nurse in another facility, but stated she was not wound care certified. In an interview with CNA L on [DATE] at 01:00 PM she stated she worked the day Resident #15 returned to the facility. She stated her wounds had a very foul smell. She stated the nurse was aware of the smell. She stated if she saw a new skin issue, she would put it in the electronic record and tell the nurse. In an interview with RN G on [DATE] at 02:45 PM stated when she arrived at work on [DATE] for her 2-10 PM shift, Resident #15 had been readmitted to the facility. She stated LVN J had re-admitted her but had not had a chance to do her wound care, so she stated she did the wound care that evening. She stated the wounds were terrible and smelled bad. She stated she assumed the Treatment Nurse was taking care of the wound care orders. She stated the wounds on the residents' ankles looked worse to her and she had a new place on the middle of her right foot. She stated she thought she contacted the physician about the new place on the resident right foot but stated she had deleted all her old calls and was not sure what day she called him. She stated she should have written the order and signed the TAR when she did the wounds on [DATE], [DATE] and [DATE]. She stated it was so crazy last week she was doing good just to get the care done. She stated she did not feel like she had enough experience to complete the wound care assessments and would need more training before she felt comfortable staging or measuring a wound. 2. Record Review of Resident #174's Significant Change MDS assessment dated on [DATE] reflected a [AGE] year-old female with an admission date of [DATE]. Resident had a BIMS of 2 which indicated she was severely cognitively impaired. She required extensive assistance with all ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident had a one unstageable pressure injury listed and was receiving Hospice services. Active diagnoses included heart failure and dementia. Record Review of Resident #174's care plan initiated on [DATE] reflected, [Resident #174] is at increased risk for pressure sores due to immobility .Interventions Administer treatments as ordered .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident /family/caregivers of any new area of skin breakdown . Record review of Resident #174's Braden assessment completed on [DATE] by MDS Coordinator indicated the resident had a score of 14 which placed her at moderate risk of pressure ulcers. Record Review of Resident #174's progress note dated [DATE] at 07:35 PM by RN EE reflected, resident found with medium sized wound to buttocks. Resident denies pain at this time. barrier cream applied and brief changed. [Treatment Nurse], notified of wound and stated she would look into it tomorrow morning. Record Review of Resident #174's progress note dated [DATE] at 07:58 PM by RN EE, reflected, resident assessed coughing up green, thick, productive sputum and lung sounds are wet and wheezy. Vitals are stable at this time. resident remains afebrile. [NP CC] notified of cough and sputum . Further review of the progress noted reviewed there was no documentation the NP was notified of the wound to the residents' buttocks. Record review of Resident #174's progress noted dated [DATE] at 10:22 AM by RN E reflected, pressure area to coccyx wound nurse is performing dressing changes to area day 4 for zpack (Azithromycin)) and prednisone will continue to monitor, air mattress present on bed with controls available as well as call light and water pitcher. Denies needs or pains at present time will continue to monitor and update md, family and admin(sic) prn status changes. Record review of Resident #174's progress note dated [DATE] at 08:15 PM by LVN Treatment nurse, reflected, Unstageable pressure ulcer to sacrum d/t slough present. 5cm x 3cm x 2cm. New order received from Hospice Cleanse with wound cleanser, Apply Santyl to wound bed then apply Hydrofera Blue foam and a dry dressing daily and as needed. Family and MD notified. Resident admitted [company name] Hospice today. Record review of Resident #174's Physician order Summary report date [DATE] reflected, Sacrum- Cleanse wound with wound cleanser. Apply Santyl to wound bed. Then lightly pack with Hydrofera Blue and apply Supers absorbent Dressing daily and as needed every day shift with a start date of [DATE]. Order was changed to Cleanse wound with wound cleanser. Apply Silver Alginate to wound bed and cover with a super absorbent dressing daily and as needed, with a start date of [DATE]. There were no orders for the Pressure ulcer to the Resident's right heel. There were no orders for [DATE] for wound care to the resident's sacrum. Record review of Resident #174's TAR for [DATE] reflected no documentation of wound care to the residents' sacral wound. Record review of Resident #174's TAR for February 2024, reflected no documentation of wound care from [DATE] through [DATE], [DATE] through [DATE], and [DATE] for the Resident sacral wound. Further review revealed there was no documentation for wound care to the resident right heel from [DATE] through [DATE]. Record review of Hospice GG's admission assessment dated [DATE] reflected Resident #174 had an unstageable 4x4 cm to her coccyx with bone exposed and bleeding. In addition, she had a Stage 1 pressure injury to her right heel that was red, mushy with a black center. Will follow up for wound care orders. Record review of Hospice GG's assessment dated [DATE] reflected, Wound #1 Sacral is a [TRUNCATED]