Every finding on record at Alfredo Gonzalez Texas State Veterans Home

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) residents reviewed for infection control.The facility failed to ensure CNA A wore proper PPE while feeding Resident #1 in bed on 07/08/26. This failure could place residents at risk for infection.Findings included:Record review of Resident #1's admission record, dated 07/08/26, reflected a [AGE] year-old male admitted [DATE]. His relevant diagnoses included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lunch).Record review of Resident #1's significant change MDS assessment, dated 03/30/26, reflected a BIMS score of 00, which indicated his cognition was severely impaired. Resident #1 had an indwelling catheter .Record review of Resident #1's quarterly care plan assessment, dated 03/30/26, reflected:Focus: [Resident #1] requires a catheter: at risk for infection and catheter related injury/issues. Revised on 03/30/26. Interventions.Infection risk: EBP. Date initiated 03/26/26.Record review of Resident #1's physician's order summary, dated 07/08/26, reflected an order for EBP : Practice EBP as indicated. Every shift, effective dated 04/21/26.During an observation on 07/08/26 at 9:15 a.m., an EBP signage and supplies by Resident #1's door.During an observation on 07/08/26 at 9:17 a.m., CNA A was observed sitting on Resident #1's bed while feeding him. LVN A was not wearing the required PPE (gown and gloves).1.During an interview on 07/08/26 at 9:25 a.m., CNA A said Resident #1 required assistance with feeding and preferred eating in his room. CNA A said Resident #1 was under EBP because he had an indwelling catheter. She said EBP meant whoever walked in his room to provide direct care was required to wear a gown and gloves. CNA A said she was supposed to have worn a gown and gloves while she fed Resident #1 because he was under EBP and was not supposed to have been sitting on his bed because of the possibility of coming in contact with his gown or linen. She said a negative outcome of her not wearing the appropriate PPE and sitting on Resident #1's bed while she fed him was she could spread germs. CNA A said she was in-serviced on the topic of infection control and EBP when she was hired 2 months ago.During an interview on 07/08/26 at 9:38 a.m., LVN B said Resident #1 required EBP due to having an indwelling catheter. She said anyone that went into Resident #1's room to provide direct care was required to gown up and wear gloves. LVN B said Resident #1 had the EBP signage and supplies by his door to alert staff. LVN B said CNA A was supposed to have worn a gown and gloves while she fed Resident #1. LVN A said CNA A was not supposed to sit on Resident #1's bed due to infection control. LVN A said a negative outcome for CNA A not wearing the appropriate PPE and sitting on Resident #1's bed was the spreading of infection and her scrubs coming into contact with the resident's linen.During an interview on 07/08/26 at 9:59 a.m., ADON C said Resident #1 was under EBP due to having an indwelling catheter. She said, All staff going into his room to provide direct contact care should practice appropriate PPE. She said Resident #1 had EBP signage and supplies by his door to alert staff. ADON C said due to the fact that Resident #2 was under EBP, CNA A should have worn a gown, gloves and should not have sat on his bed due to the possibility of coming into contact with his linen. ADON C said the facility's protocol when a resident needed assistance in feeding was for the person assisting them to sit on a chair next to the resident. ADON C said a negative outcome of CNA A not wearing the appropriate PPE and sitting on Resident #1's bed could be cross-contamination.During an interview on 07/08/26 at 11:00 a.m., ADON E said she was the acting DON. She said a resident required to be under EBP when they had anything invasive like indwelling catheters. She said, Anytime there was hands on care, staff needed to gown up and wear gloves. She said if a resident was under EBP and required assistance with feeding staff needed to wear the appropriate PPE and not sitting on the resident's bed.Record review of the facility's Infection and Prevention Control policy, revised April 2024, reflected: Compliance Guideline:the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance program.The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.In addition to isolation practices, Enhanced Barrier Precautions (EBP) may be implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when contact precautions do not otherwise apply) for residents with the following.wounds or indwelling medical devices.

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (500 hall cart) of 5 medication carts reviewed for storage. The facility failed to ensure LVN D locked his medication cart on 07/09/26 when he walked away to care for a resident. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.Findings included: During an observation on 07/09/26 at 10:15 a.m., revealed the 500 Hall nurse's medication cart was left unlocked and unattended in the hallway. The length of time it had been left unlocked prior to this observation is unknown. During the observation, no residents, visitors, or staff were in the hallway. Approximately three minutes after this observation started, LVN D was observed coming down the hallway towards the medication cart. During an interview on 07/09/26 at 10:20 a.m., LVN D stated he was the charge nurse for Hall 500, and the medication cart was assigned to him. He said he was called by a CNA to assist her in repositioning a resident and he had forgotten to lock the medication cart. LVN D said he knew medication carts needed to be locked each time they were not in front of them, he said I know, but I got distracted. LVN D said the facility's protocol was to lock the medication cart each time the medication cart was left unattended. LVN D said Nursing staff are constantly reminded to lock the medication carts. LVN D said a negative outcome for leaving a medication cart unlocked would be a resident could open the cart and did not elaborate. During an interview on 07/08/26 at 10:22 am, ADON E said she was the acting DON. She said the facility's protocol for medication carts was they should be locked whenever the nurse is not in front of it. She said the nursing staff were regularly in-serviced lock their medication carts and in-serviced annually on keeping their medication carts secured. She said a negative outcome of leaving a medication cart unsecured would be anybody could go in. Record review of the facility's policy titled, Medication Cart Use and Storage revised January 2023, reflected:Compliance Guidelines: The nursing Team Members (Nurses and CMA's) use the medication cart to systematically distribute physician ordered medications to residents. Responsible Disciplines: Licensed nurses, C.M.A.s Guidelines: Security The medication cart and its storage bins should be kept closed, secured.

Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents (Resident #1) reviewed for urinary catheters.The facility failed to ensure Resident #1's indwelling catheter was appropriately placed while lying in bed. This failure could place residents at risk for a decline in their health status.Findings included:Record review of Resident #1's admission record, dated 07/08/26, reflected a [AGE] year-old male admitted [DATE]. His relevant diagnoses included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lunch).Record review of Resident #1's significant change MDS assessment, dated 03/30/26, reflected a BIMS score of 00, which indicated his cognition was severely impaired. Resident #1 had an indwelling catheter .Record review of Resident #1's quarterly care plan assessment, dated 03/30/26, reflected:Focus: [Resident #1] requires a catheter: at risk for infection and catheter related injury/issues. Revised on 03/30/26. Interventions.Infection risk: EBP. Date initiated 03/26/26.Record review of Resident #1's admission record, dated 07/08/26, reflected a [AGE] year-old male admitted [DATE]. His relevant diagnoses included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lunch).Record review of Resident #1's significant change MDS assessment, dated 03/30/26, reflected a BIMS score of 00, which indicated his cognition was severely impaired. Resident #1 had an indwelling catheter .Record review of Resident #1's quarterly care plan assessment, dated 03/30/26, reflected:During an observation and interview on 07/08/26 at 9:35 a.m., Resident #1 was observed lying in bed awake. He had no facial grimacing. Resident #1's had an indwelling catheter collection bag was secured to his lower right leg while lying in bed. Dark yellow urine noted in the drainage bag. Resident #1 was not interviewable.During an interview and observation on 07/08/26 at 9:40 a.m., LVN B was observed as she assessed Resident #1's indwelling catheter collection bag was strapped on his lower right leg while lying in bed. She said she was not sure how long Resident #1's indwelling catheter collection bag had been strapped to his lower right leg. She said, Resident #1's indwelling catheter collection bag was secured to his lower right leg because it's probably because he gets up several times a day. She said when a resident with an indwelling catheter was lying down, the collection bag should be hanging on the side of their bed hanging below his bladder to prevent leakage, backflow which could cause an infection. She said it was her responsibility to ensure Resident #1's indwelling catheter collection bag was appropriately placed when lying in bed. LVN B said she had been in-serviced on the topic of indwelling catheters.During an interview on 07/08/26 at 9:59 a.m., ADON C said Resident #1 was under EBP due to him having an indwelling catheter. She said all staff going into his room to provide direct contact care should practice appropriate PPE. She said Resident #1 had the proper EBP signage and supplies by his door to alert staff. ADON B said Resident #1's collection bag should not have been strapped to his lower right leg when lying down. She said when a resident with an indwelling catheter was lying in bed, the collection bag should be on his hanging on the side of their bed, off the floor, and below their bladder. ADON B said a negative outcome for Resident #1 having his indwelling catheter collection bag strapped on his lower right leg would be the possibility of an infection and not enough room for the urine output.During an interview on 07/08/26 at 11:00 a.m., ADON E said she was the acting DON. ADON E said when a resident with an indwelling catheter was lying down, their collection bag was supposed to be hanging on the side of his bed, lower than the resident. She said a negative outcome to Resident #1 having his indwelling catheter collection bag strapped to his leg while lying down in bed would an infection if there is any urine in the bag.Record review of the facility's Infection and Prevention Control policy, revised April 2024, reflected: Compliance Guideline:the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance program.The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.In addition to isolation practices, Enhanced Barrier Precautions (EBP) may be implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when contact precautions do not otherwise apply) for residents with the following.wounds or indwelling medical devices.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected oral care issues.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #1's face sheet, dated 05/20/26, reflected an [AGE] year-old male, admitted on [DATE], diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), acute embolism and thrombosis of deep veins (formation of a blood clot in blood vessels), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), and dysphagia (trouble swallowing). Record review of Resident #1's MDS assessment, dated 02/11/26, reflected a BIMS score of 00, indicating severe cognitive impairment. The MDS reflected Resident #1 required substantial/maximal assistance for oral hygiene (ability to use suitable items to clean teeth) and for personal hygiene (ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands, excludes baths, showers, and oral hygiene). The MDS assessment reflected Resident #1's oral/dental status as: obvious or likely cavity or broken natural teeth. Record review of Resident #1's care plan, dated 05/20/26, reflected [Resident #1] had a self-care deficit related to Alzheimer's disease. Date initiated: 09/19/25. Care plan did not reflect oral care issues. During an interview and observation, on 05/19/26 at 3:15 PM, Resident #1 was asked basic questions and he did not respond coherently. Resident #1 was not interviewable. Resident #1 had no visible bruising, skin tears or open wounds noted to his skin. Resident #1 was observed to have some natural teeth that appeared stained/discolored. During an interview, on 05/20/26 at 1:00 PM, the MDS Nurse stated residents had oral care issues care planned to address diagnoses that may cause oral issues. The MDS Nurse stated she was responsible for updating care plans, but it was also an interdisciplinary team effort. The MDS Nurse stated Resident #1's oral care issues were care planned back in 2023 as he had some of his own teeth and cavities. The MDS Nurse stated Resident #1 had Alzheimer's which could have caused Resident #1 to forget to brush his teeth or not allow staff to provide the care. The MDS Nurse stated she was unsure of when or who resolved the oral care issues, but when it was resolved, it caused it to be removed off the care plan. The MDS Nurse stated the oral care issues should have been reflected on the care plan and it would be added back on his care plan. The MDS Nurse stated Resident #1 had no negative outcome from his oral care issues not being on his care plan as the staff provided oral care and took care of his oral needs by following the Kardex and tasks. The MDS Nurse stated it was important for the care plan to reflect accurately to ensure the interventions were being done. During an interview, on 05/20/26 at 1:50 PM, the DON stated Resident #1 had the problem area for oral care as he had some loss of teeth and the diagnosis of Alzheimer's, so interventions should have been implemented to try to prevent oral issues from getting worse. The DON stated Resident #1's oral care issues should have been in the care plan. The DON stated she reviewed Resident #1's care plan and verified the oral care issues were added today, 05/20/26, by the MDS Nurse. The DON stated there was no negative outcome or change for Resident #1's oral issues and no risk of harm because staff were aware of providing oral care as it was part of their Kardex and tasks. The DON stated it was important to develop care plans accurately, so everyone knew how to care for the residents and meet their needs. Record review of the facility's Care Plans policy, dated January 2023, reflected - Guidelines: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate interventions in relation to the identified problem or risk.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2) reviewed for reporting alleged allegations of abuse.The facility did not report to HHSC within two hours, when Resident #1 hit Resident #2's hand with an empty water bottle on 03/13/26.This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being.Findings included:1. Record review of Resident #1's face sheet dated 04/01/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included Alzheimer's disease (causing severe memory loss, cognitive decline, and behavioral changes), Schizoaffective disorder (combination of hallucinations, delusions, and mood disorder), anxiety disorder (chronic, excessive, and uncontrollable worry), depression (persistent feeling of sadness and loss of interest), and muscle weakness. Record review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 02, indicating severe cognitive impairment. Resident#1 had 1 to 3 days with behaviors of physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing). Record review of Resident #1's care plan, dated 04/01/26 reflected [Resident #1] was at risk of psychosocial concerns such as emotional distress related to diagnosis of Alzheimer's, depression, and anxiety. Resident to resident physical aggression on 03/13/26. Interventions included: Resident was redirected during incident, placed on a 1:1 monitoring, and sent to the behavioral hospital as per section 28 request. Date initiated: 03/13/26. Record review of Resident #1's progress note, dated 03/13/26 at 11:14 AM, reflected head to toe assessment done. No new skin abnormalities noted. No sign and symptoms of emotional distress or pain noted. Resident on one to one. 2. Record review of Resident #2's face sheet, dated 04/01/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included unspecified dementia (decline in cognitive function with memory loss affecting language, problem-solving and other cognitive abilities), anxiety disorder (chronic, excessive, and uncontrollable worry), restlessness and agitation, and muscle wasting and atrophy (decrease in muscle mass and strength). Record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #2 did not exhibit physical or verbal behavioral symptoms directed towards others. Record review of Resident #2's care plan, dated 04/01/26, reflected [Resident #2] was at risk of psychosocial concerns such as related to diagnosis of unspecified dementia, anxiety, and restlessness/agitation. Interventions included: Redirect resident, calm and reassure resident is safe, monitor for behaviors. Date initiated: 06/27/25. Record review of Resident #2's progress note, dated 03/13/26 at 11:14 AM, reflected head to toe assessment done. No new skin injuries or abnormalities noted. No signs or symptoms of emotional distress or pain noted or verbalized by resident. During an interview and observation, on 03/31/26 at 12:00 PM, Resident #1 was not interviewable as he did not answer basic questions. Resident #1 had no visible injury and was not in distress. During an interview and observation, on 03/31/26 at 12:10 PM, Resident #2 was not interviewable as he did not answer basic questions. Resident #2 had no visible injury and was not in distress. During an interview, on 04/01/26 at 11:40 AM, the Administrator stated she was the abuse coordinator and was responsible for reporting any incidents of abuse to HHSC within a two-hour timeframe. The Administrator stated Resident #1 hit Resident #2's hand with an empty water bottle on 03/13/26 at around 10:00-10:10 AM. The Administrator stated she was notified of the incident between Residents #1 and #2 on 03/13/26 at around 10:45 AM. The Administrator stated the incident between Residents #1 and #2 should have been reported within two hours, but she reported the incident to HHSC on 03/13/26 at 2:26 PM. The Administrator stated she reported late because she was conducting interviews and gathering information. The Administrator stated the facility policy indicated the facility had to report any allegations or incidents of abuse within two hours. The Administrator stated failing to report an incident within two hours did not result in a negative outcome to Resident #1 and #2 as the facility staff ensured their safety. The Administrator stated reporting incidents of abuse within two hours was important because HHSC could have had follow-up questions to assess the urgency of the situation. Record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy, date implemented of February 2017, revised date of January 2024, reflected - Report alleged or suspicions of abuse to HHSC by email reporting or via online portal reporting within the designated time frame Are reported immediatelyBut not later than two hours after allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish and, emotional distress. The findings included: 1. Record review of Resident #1's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseased classified elsewhere, severe, with agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), major depressive disorder (persistent, intense feelings of sadness, worthlessness, and a lack of interest in life lasting at least two weeks), single episode, severe without psychotic features and insomnia (persistent difficulty falling asleep, staying asleep or waking too early) due to other mental disorder. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. Resident #1 had 1 to 3 days with behaviors of verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #1's closed Care Plan initiated on 09/02/25 revealed the focus Psycho-social / Behavioral Risk: GENRERALIZED ANXIETY and MDD. currently on treatment for these diagnosis. 11/20/25:Resident refused peri care and raised his voice at staff to leave his room. 12/2/25:Resident to resident verbal aggression. 12/11/25: Resident to staff verbalaggression. 12/21/25:Resident to staff Verbal aggression. 12/29/25:Resident to resident verbal aggression. 2/7/26:Resident to resident verbal aggression. 2/8/26: Residnet [SIC] to resident physical and verbal aggression. Record review of Resident #1's nursing notes documented by LVN B and dated 02/07/26 at 7:37am stated, Resident noted by CNAs attempting to remove his roommate from his room. Resident began to is [SIC] his roommate and attempt to close the door with him in the doorway. At this point nurse was there and able to help hold the door open and remove the roommate from the doorway. Roommate brought to the front common area. no injuries noted on either resident. RN Supervisor notified, DON and Administrator notified. resident redirectable at this time. scheduled anxiety medication given as prescribed. Resident asked if about incident and did not remember what occurred; could not tell nurse if someone was here with him and denies being upset. No emotional distress noted no injuries noted. no signs of pain or discomfort. Record review of Resident #1's IDT: Star - VA ABC tool completed by LVN B and dated 02/07/26 stated, there was a resident to resident verbal and physical aggression on the morning of 02/07/26 with his roommate (Resident #2) at the entrance of their room. Record review of Resident #1's IDT: Star - VA ABC tool completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was standing over roommate with table, per CNA. Resident was upset saying that he would hit roommate again. Record review of Resident #1's transfer form completed by LVN D and dated 02/08/26 reflected Resident #1 was being transferred to the hospital due to behavioral symptoms and stated, Resident got physically aggressive with roommate. Record review of Resident #1's nursing noted completed by LVN D and dated 02/08/26 at 6:25am stated he had been picked up by EMS at 6:25pm. Record review of Resident #1's social service note completed by Social Worker I and dated 02/08/26 at 12:47pm stated family was in agreement for a referral to another facility. Record review of Resident #1's nursing note completed by RN J and dated 02/08/26 at 10:20pm stated he arrived back to facility and was placed on a one to one. Record Review of the observation sheet reflected Resident #1 had observations documented every 15 minutes intervals started on 02/08/26 at 10:45pm and ending on 02/10/26 at 2:00pm. Record review of notification of room change form completed by Social Worker I for Resident #1 reflected he was moved rooms on 02/09/26 due to not being compatible with current roommate. Record review of the application for emergency apprehension and detention completed by Social Worker I and dated 02/09/26 reflected emergency commitment was sought for Resident #1 and stated [Resident #1] has been in 2 physically aggressive episodes in the past 48 hours. [Resident #1] pushed his roommate out of his chair and caused him to get skin tears. He stood over his roommate threatening to hit him. Record review of Resident #1's social services note completed by Social Worker I dated 02/10/26 at 10:12am stated Signed Section 28 signed by [Judge] d/t physical aggressive behaviors demonstrated in facility. Record Review of Resident #1's nursing note completed by LVN K and dated 02/10/26 2:34pm stated, Resident #1 was transferred out of facility to hospital. Record review of Resident #1's nursing note dated 02/10/26 at 4:24pm by MD Z stated, I was informed this patient had to be referred to a behavioral unit due to uncontrollable aggressive behavior towards staff and other residents. He poses a threat to other residents in our community, and I recommend he gets discharged . Record Review of nursing note completed by ADON L dated 02/16/26 at 9:41am stated, Resident sent out to behavioral center; as per BOM resident RP discontinued bed hold on 2/15 at 0951a; [SIC] resident belonging packed and placed in storage for pick up; 2. Record review of Resident #2's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified (causing severe memory loss, cognitive decline, and behavioral changes), chronic kidney disease (kidneys do not filter waste effectively), stage 3 (moderate kidney damage) unspecified, acute on [SIC] chronic diastolic (congestive) heart failure (left ventricle becomes stiff and can't relax properly and prevents it from filling with enough blood)and bradycardia (slow resting heart beat under 60 beats per minute), unspecified. Record review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #2 had 1 to 3 days with behaviors of physical and verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #2's care plan initiated on 01/10/26 revealed the focus Psycho-social / Behavioral Risk: ALZHEIMER's. As per family he used to have some form of anger issues with them at home but nonphysical. 2/7/26 resident has a res-to-res physicalAltercation 2/8/26 resident has a res-to-res physical altercation Record review of Resident #2's nursing note completed by LVN B and dated 02/07/26 at 7:40am stated, Resident on receiving end of resident to resident physical aggression. Resident attempted to enter his room where roommate would not let him in, he began to push him out of the room (CNA reports seeing resident get hit in the face by roommate). Then roommate attempted to close the door on resident, by that time nurse was there and able to separate residents. Resident remembers incident, denies being hit in the face and denies any pain. No signs of emotional distress, no injuries noted no redness; resident states his roommate only his [SIC] his wheelchair. RN supervisor aware, ADON, DON and Administrator aware. Record review of Resident #2's IDT: Star - VA ABC tool Completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was in [SIC] floor asking for help. Record review of nursing note completed by RN J with effective date of 02/08/26 at 4:30am stated, Late Entry: RN supervisor did head to toe assessment on resident, skin tear to right arm, left arm and right knee noted, a red discoloration noted on bridge of nose, no other injuries noted. Resident is A&Ox 2, lungs clear, on room air, VS WNL, able to move all extremities with ease, he is continent of bowel and bladder, says he has pain from his arm, pain meds offered but resident refused. Resident denies any emotional distress. Record review of Resident #2's nursing note completed by LVN D and dated 02/08/26 stated [Resident #2] was calling for help, CNA entered room and found resident on the floor. He had skin tear on BIL arms and R knee. Statedroommate had pushed him. No emotional distress. No pain to body. Going out as a precaution. Record review of Resident #2's skin: abrasion/bruise/edema/mole/rash document completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital (shallow, triangular depression located on the anterior surface of the elbow) and to front of right knee. Record review of change in condition for Resident #2 completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital.' Record review of Resident #2's nursing note completed by RN J and dated 02/08/26 at 5:28am stated Resident #2 was transferred to hospital by EMS at 5:20am. Record review of Resident #2's hospital records from 02/08/26 did not identify any fractures. Record review of Resident #2's nursing note completed by LVN M and dated 02/08/26 at 8:18am stated, spoke with [staff] from [hospital], resident is being discharged with no critical findings. no fractures and coming back withimaging results. During an interview with Resident #2 on 02/24/26 at 2:24pm he would only answer that yes he had an incident with Resident #1 and that yes he did get hurt. Resident #2 would not answer any other questions related to the incidents and would respond with, Its none of your business when asked. During an interview with the DON on 02/25/26 at 4:40pm she stated on 02/07/26 CNA A had reported to the nurse that Resident #2 was hit by Resident #1 on the chest but LVN B had assessed Resident #2 and he had no injuries. During an interview with CNA A on 02/25/26 at 4:57pm she stated on 02/07/26 she was doing her rounds with her partner CNA E when she heard a resident yelling in the hall at around 7:00am. CNA A stated when she went to go check she saw Resident #1 standing at the entrance of his room door holding the door open and Resident #2 on his wheelchair trying to get out of the room. CNA A stated Residents #1 and #2 were facing each other and Resident #1 had a hold of Resident #2's shirt when she witnessed Resident #1 hit Resident #2 with a closed fist hand, once on the jaw and once on the chest. CNA A stated she yelled for them to stop and for help separating them. CNA A stated LVN B went to assist in separating residents, and took Resident #2 to the common area. CNA A stated she informed LVN B that she saw Resident #1 hit Resident #2 once in the face and once in the chest and to check Resident #2. CNA A also stated she told LVN B that Residents #1 and #2 could not be together because of the incident and that Resident #1 was aggressive and if they were to put them back together that Resident #1 could attack Resident #2. CNA A stated LVN B asked Resident #2 about being hit and he denied it. CNA A stated she did not know why staff did not listen to her about what she had witnessed and reported. CNA A stated throughout the rest of that morning staff was alternating who was in the room between Resident #1 and #2 until about 10:00 or 11:00am when LVN B took Resident #1 to the room while Resident #2 was already in there. CNA A stated she informed LVN B that they could not be together because Resident #1 could kill Resident #2. CNA A stated Resident #1 had been aggressive before but had never hit Resident #2. CNA A mentioned Resident #1 had aggressive episodes with his wife previously when she would visit him at the facility but did not mention any incident with other residents. During an interview with the DON on 02/25/26 at 6:11pm she stated LVN B had reported to her an incident between Resident #1 and #2 where Resident #1 didn't let Resident #2 into the room and stated LVN B questioned Resident #2 about the incident and he stated Resident #1 hit his wheelchair and not him. The DON stated because of this they did monitoring and had an aide out there and RN F stayed outside the room. The DON stated there was no other indication of any behaviors and stated Resident #2 had documentation completed every hour. The DON stated they did not do a room change because they were doing close monitoring and Resident #2 had hourly checks on his chart. The DON stated there was no other behaviors and no indication something else was going to happen. The DON was unable to answer if the 2nd incident on 02/08/26 was preventable. During an interview with RN F on 02/25/26 at 7:40pm she stated she was made aware of the incident between Resident #1 and #2 and went to assess and interview Resident #2 who denied being hit and had no injury. RN F stated in response to incident she was doing monitoring and had an aide posted outside the door. RN F stated Resident #1 had no indications of continued behaviors. During an interview with LVN D on 02/26/26 at 9:56am she stated she did not witness the incident on 02/08/26 between Resident #1 and #2 and was called by the aide and when she arrived to their room she saw Resident #1 standing up and Resident #2 on the floor. LVN D stated she assessed both residents and Resident #2 had skin tears around bilateral elbows that were not greater than 3.5 inches and superficial, a skin tear to his knee about .5 inches and some redness to his nose bridge. LVN D stated Resident #2 stated Resident #1 hit him on his arms and LVN B could not recall if Resident #2 told her how he ended up on the floor. LVN D stated both residents were sent out for further evaluation and stated Resident #1 was eventually discharged or transferred but was no longer at the facility. LVN D stated she entered work on 02/07/26 at 10:00pm and was made aware of an argument the residents had the prior but nothing about hitting and stated she did not know about other behaviors before. LVN D stated she was told to keep a close eye on them and monitor them but stated there was not any form or documentation for them to document and stated there weren't any behaviors to document either. During an interview with CNA C on 02/26/26 at 10:28am she stated on 02/08/26 she heard someone calling for help and when she went to Resident #1 and Resident #2's room she saw Resident #2 on the floor and Resident #1 carrying his bedside table at his waist. CNA C stated Resident #1 put the table down and got close to her and she called for help at that same time and Resident #1 went to the door and was taken to the common area. CNA C stated once the nurse got there she left to another room. CNA C stated Resident #2 had some skin areas with blood on 1 side and stated Resident #2 did not tell her how he got on the floor and neither resident spoke to her about the incident. CNA C stated she did not know of any previous behaviors and had not been told to monitor either resident when she entered her shift on 02/07/26 at 10:00pm. During an interview on 02/26/26 at 11:27am CNA A stated when she saw Resident #1 and #2 on 02/07/26 she did not see any injury on Residents #1 or #2. CNA A stated in response to the incident they had her sit outside the resident's room for about 10 minutes and stated she did not see anyone else sitting outside their room that day on 02/07/26. CNA A stated she does not know what else the facility did in response to the incident but stated they could have prevented the second incident that occurred between Resident #1 and #2 on 02/08/26 but stated she was not able to do anything and that it was up to the nurses and leadership. CNA A stated she was told by staff leadership that her statement was false and stated the facility wrote her up for it. CNA A stated Resident #1 had been aggressive before but had never hit Resident #2. CNA A stated she did not report what she saw to the Administrator because she reported to her supervisor LVN B who she assumed would report to the Administrator. During an interview with the DON on 02/26/26 at 6:32pm she stated on 02/07/26 LVN B notified her of an incident with Resident #1 and #2 when Resident #1 would not allow Resident #2 in the room. The DON stated LVN B did not mention any hit. The DON stated it as RN F who notified her that CNA A reported that she saw Resident #1 punch Resident #2 but there was no redness or anything. The DON stated both LVN B and RN F reported right after the incident occurred. The DON stated in in response they had close monitoring and had an aide posted outside the door for about an hour and then when CNA A had to get back on the floor RN F was on the floor and had the door open to Resident #1 and #2's room with RN F checking them and stated staff tried to alternate them in the common area. The DON stated the only monitoring they had was what was in the chart. The DON stated in general residents had been verbally aggressive but had no previous incidents with each other. The DON stated neither resident expressed fear and stated Resident #2 stated he was not hit and only his wheelchair was. The DON stated on 02/08/26 an aide heard someone yelling for help and found Resident #2 on the floor with Resident #1 standing next to him, the DON stated Resident #2 was moved and the aide called for help and the nurses arrived to assess and evaluate. The DON stated on 02/08/26 Resident #2 stated that Resident #1 grabbed him by the arms and pushed him to the floor when he was sitting at edge of bed. The DON stated Resident #2 had paper thin skin and that why the skin to his bilateral arms occurred. The DON stated Resident #1 was sent out to the emergency room for admission to behavioral and Resident #2 was sent out for to get evaluated. The DON stated both residents returned to the facility and stated Resident #1 was placed on a one to one with room change and they implemented a monitoring tool, orders for counseling and psychiatric services and stated Resident #1 got sectioned and transferred out of the facility. During an interview with LVN B on 02/26/26 at 7:21pm she stated on 02/07/26 she was made aware by CNA A of Resident #1 hitting Resident #2 in the face or the head but when she arrived to the incident the residents were already being separated and she did not witness any hit. LVN B stated she took Resident #2 to the common area and assessed him and found no injuries and no pain and stated Resident #2 denied being hit. LVN B stated she then went to assess Resident #1 who had no injuries and did not recall the incident. LVN B stated neither resident expressed fear. LVN B stated in response to the incident they removed Resident #2 from the room, provided Resident t#1 his schedule anxiety medication and educated the residents on their shared room and stated she would escort Resident #2 back to his room when he wanted to go to his room and would educate Resident #1 that Resident #2 was roommate and not to be alarmed. LVN B stated neither resident had any other incidents during her shift. LVN B stated she believed Resident #1 had a history of similar behaviors but was not sure about Resident #2. LVN B stated within 20 minutes she reported to and made the ADON, DON and administrator aware of everything that CNA A had reported. LVN B stated when she reported to her supervisors they did not mention who would be a good room change and LVN B stated she did not think there were any rooms at that time and stated changing rooms could increase agitation. LVN B stated she asked the aides to stay close outside of the door while charting and stated she tried to park her cart outside the room as well. During an interview with the Administrator on 02/26/26 at 8:06pm she stated on 02/07/26 CNA A was the responding and reporting aide that stated Resident #1 had hit Resident #2. The Administrator stated she was notified about this report by LVN B. The Administrator stated she asked LVN B if they needed to do a one to one of a urinary analysis and stated that LVN B stated there was no injury or redness and that Resident #2 had denied being hit and had stated that it was his wheelchair that got hit. The Administrator stated the DON then called LVN B and told her to monitor. The Administrator then the following morning at 5:00am she was called about a resident to resident where Resident #2 was on the floor and wasn't injured but had some really thin skin that kind of peeled a little bit. The Administrator stated no one witnessed anything but an aide reported she heard Resident #1 say I'm going to hit him again so they sent both residents out to the hospital. The Administrator stated Resident #1 had some verbal aggressive incidents before but nothing that caused injury. The Administrator stated when Resident #1 returned they did a room change for Resident #2 and put Resident #1 on one to one, got a section and transfer. During an interview on 02/27/26 at 6:37am LVN G stated he was notified of an incident going on in the 600 hall and stated when he arrived Resident #2 was on the floor and Resident #1 was standing but they had already been separated. LVN G stated Resident #2 told him that Resident #1 pulled him by his arms from his wheelchair to the floor. LVN G stated he assessed Resident #2 and noted superficial skin tears to arms and a skin tear to his knee and some redness to bridge of his nose. LVN G stated he notified the administrator and his RN supervisor of the incident and both residents were sent out. LVN G stated from what he understood this was the residents first altercation with each other. During an interview with the DON on 02/27/26 at 10:37am she stated as per their abuse policy during an abuse investigation they protect the resident by doing a one to one or room change or continuous monitoring to see for any indications of behaviors. The DON stated who ever identified the abuse reports it to the Administrator who will start the investigation and stated all staff were responsible for the protection of the resident. The DON stated in response to the incidents on 02/07/26 with Resident #1 and #2 they implemented monitoring which she stated it was only what was reflected in the chart and stated she was aware that there was no documentation for monitoring during the night shift and stated she did not know why there was not any. The DON stated because Resident #2 denied being hit they did not do an abuse investigation and only did the monitoring because of what CNA A reported. The DON stated the second incident on 02/08/26 could have been prevented had they continued the monitoring. The DON stated the facility followed their abuse policy and stated staff had been trained both before and after the incident by the administrator. The DON stated not implementing their abuse policy for the protection of the residents could negatively impact the resident because it could cause injury and stated the only negative impact Resident #2 had due to it not being implemented was superficial skin tears. The DON stated moving forward residents would be protected during abuse investigation by either doing one to one of room changes with any incident that occurs. During an interview with the Administrator on 02/27/26 at 1:13pm stated during an abuse investigation they would keep residents safe by separating them and closely monitoring them. The Administrator stated they did not initiate an abuse investigation into the incident on 02/07/26 because they did not identify abuse because Resident #2 denied being hit. The Administrator stated CNA A's report was taken into consideration but Resident #2 denied being hit. The Administrator stated Resident #2 was a fair historian. The Administrator stated she thought the incident was investigation by the nurse. The Administrator stated CNA A was not a good historian and was not very reliable based on previous history. The Administrator stated the facility should have done additional monitoring with better documentation. The Administrator stated, I think we were doing a lot when asked if they followed their abuse policy. The Administrator stated she had been trained over their abuse policy both before and after the incident and stated not implementing their abuse policy for the protection of the residents could impact a resident by not preventing another incident. The Administrator stated she felt the part of the policy that was not implemented was that CNA A did not call her.Record review facility policy titled, Abuse Guidance: Preventing, Identifying and Reporting with a implemented date of February 2017 and revised date of January 2024 stated, Protection - Our community will protect residents from harm during the investigation of abuse allegations. And The community should prevent occurrences of abuse, will monitor for triggers that may results in abusive behavior and monitor prevention measures on a regular basis through the community's QAPI process.The noncompliance was identified as PNC. The IJ began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began.The facility had corrected the noncompliance before the survey began as followed: Record review of room change consent form reflected Resident #1 had a room change on 02/09/26.Record Review of observation sheet reflected Resident #1 had observations documented every 15 minutes intervals starting on 02/08/26 at 10:45pm and ending on 02/10/26 at 2:00pm.Record Review of Residents #1's nursing notes reflected Resident #1 was sent out of the facility on 02/10/26 and his responsible party cancelled the bed hold on 02/15/26.Observations on 02/24/26 at 2:15pm and record review of nursing notes for Resident #1 reflected Resident #1 was no longer a resident at the facility.Record review of a monitoring tool form used to identify any residents with resident to resident behaviors was implemented on 02/09/26 and identified residents with incidents of behaviors and what action was taken to correct the behavior.Record review of ADHOC Quality Assurance and Performance Improvement meeting dated 02/12/26 covered the report of a resident to resident incident.Record review of Resident #1's care plan reflected it had been updated on 02/11/26 regarding his resident to resident aggression on 02/07/26 and 02/08/26. Record review of Resident #2's care plan reflected it had been updated on 02/10/26 regarding his resident to resident altercations on 02/07/26 and 02/08/26. Record review and interview on 02/26/26 at around 1:15pm the DON provided care plans with a print date of 02/26/26 for additional residents #4, #5, #6, #7, #8. #9, #12 which were reviewed and reflected residents behaviors and interventions to address them. On 02/27/26 at around 9:00am the DON provided care plans with a print date of 02/27/26 for Resident #10 and #11 which were reviewed and reflected residents behaviors and interventions to address them. The DON stated the care plans provided were for the resident's they had identified with behaviors. Record review of an email communication between the DON and the psychiatric nurse practitioner dated 02/10/26 at 9:53am reflected residents (#2,#4, #8, #9, #10, #11) and the behaviors they had and continued email communication from 02/23/26 at 10:08am and 2:09pm reflected residents (#2, #6, #7, #8 #9, #12) and behaviors they had.Record review of psychiatry notes reflected:Resident #2 was seen on 02/10/26 and 02/23/26Resident #4, #5, #10 and #11 were seen on 02/12/26Resident #8 was seen on 02/23/26Resident #6, #7 were seen on 02/26/26.Record review of staff development/in-services attendance sheet dated 02/08/26 with an audience documented as All team members covered reporting any incidents of abuse, injury of unknown origin neglect and exploitation immediately to the Administrator and included her phone number. It also covered reporting any resident to resident aggression or Inappropriate touching to the administrator and to redirect resident and keep residents safe. Also covered was that all residents needed to be put on a one to one and be kept separated.Interviews with CNA A on 02/26/26 at 11:27am, LVN B on 02/26/26 at 7:21pm, CNA C 02/26/26 at 10:28am, LVN D on 02/2626 at 9:56am,, LVN G on 02/27/26 at 6:37am, LVN H on 02/25/26 at 1:20pm, the DON on 02/26/26 at 6:29pm and Administrator on 02/26/26 at 8:06pm reflected they had been trained to report any abuse to the Administrator immediately and were aware to separate and implement one to one monitoring with any resident to resident altercation.Record review of training over abuse guidance: preventing, identifying and reporting dated 02/09/26 reflected the DON and Administrator received the training.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to put interventions in place to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish and, emotional distress. The findings included: 1. Record review of Resident #1's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseased classified elsewhere, severe, with agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), major depressive disorder (persistent, intense feelings of sadness, worthlessness, and a lack of interest in life lasting at least two weeks), single episode, severe without psychotic features and insomnia (persistent difficulty falling asleep, staying asleep or waking too early) due to other mental disorder. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. Resident #1 had 1 to 3 days with behaviors of verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #1's closed Care Plan initiated on 09/02/25 revealed the focus Psycho-social / Behavioral Risk: GENRERALIZED ANXIETY and MDD. currently on treatment for these diagnosis. 11/20/25:Resident refused peri care and raised his voice at staff to leave his room. 12/2/25:Resident to resident verbal aggression. 12/11/25: Resident to staff verbal aggression. 12/21/25:Resident to staff Verbal aggression. 12/29/25:Resident to resident verbal aggression. 2/7/26:Resident to resident verbal aggression. 2/8/26: Residnet [SIC] to resident physical and verbal aggression. Record review of Resident #1's nursing notes documented by LVN B and dated 02/07/26 at 7:37am stated, Resident noted by CNAs attempting to remove his roommate from his room. Resident began to is [SIC] his roommate and attempt to close the door with him in the doorway. At this point nurse was there and able to help hold the door open and remove the roommate from the doorway. Roommate brought to the front common area. no injuries noted on either resident. RN Supervisor notified, DON and Administrator notified. resident redirectable at this time. scheduled anxiety medication given as prescribed. Resident asked if about incident and did not remember what occurred; could not tell nurse if someone was here with him and denies being upset. No emotional distress noted no injuries noted. no signs of pain or discomfort. Record review of Resident #1's IDT: Star - VA ABC tool completed by LVN B and dated 02/07/26 stated, there was a resident to resident verbal and physical aggression on the morning of 02/07/26 with his roommate (Resident #2) at the entrance of their room. Record review of Resident #1's IDT: Star - VA ABC tool completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was standing over roommate with table, per CNA. Resident was upset saying that he would hit roommate again. Record review of Resident #1's transfer form completed by LVN D and dated 02/08/26 reflected Resident #1 was being transferred to the hospital due to behavioral symptoms and stated, Resident got physically aggressive with roommate. Record review of Resident #1's nursing noted completed by LVN D and dated 02/08/26 at 6:25am stated he had been picked up by EMS at 6:25pm. Record review of Resident #1's social service note completed by Social Worker I and dated 02/08/26 at 12:47pm stated family was in agreement for a referral to another facility. Record review of Resident #1's nursing note completed by RN J and dated 02/08/26 at 10:20pm stated he arrived back to facility and was placed on a one to one. Record Review of the observation sheet reflected Resident #1 had observations documented every 15 minutes intervals started on 02/08/26 at 10:45pm and ending on 02/10/26 at 2:00pm. Record review of notification of room change form completed by Social Worker I for Resident #1 reflected he was moved rooms on 02/09/26 due to not being compatible with current roommate. Record review of the application for emergency apprehension and detention completed by Social Worker I and dated 02/09/26 reflected emergency commitment was sought for Resident #1 and stated [Resident #1] has been in 2 physically aggressive episodes in the past 48 hours. [Resident #1] pushed his roommate out of his chair and caused him to get skin tears. He stood over his roommate threatening to hit him. Record review of Resident #1's social services note completed by Social Worker I dated 02/10/26 at 10:12am stated Signed Section 28 signed by [Judge] d/t physical aggressive behaviors demonstrated in facility. Record Review of Resident #1's nursing note completed by LVN K and dated 02/10/26 2:34pm stated, Resident #1 was transferred out of facility to hospital. Record review of Resident #1's nursing note dated 02/10/26 at 4:24pm by MD Z stated, I was informed this patient had to be referred to a behavioral unit due to uncontrollable aggressive behavior towards staff and other residents. He poses a threat to other residents in our community, and I recommend he gets discharged . Record Review of nursing note completed by ADON L dated 02/16/26 at 9:41am stated, Resident sent out to behavioral center; as per BOM resident RP discontinued bed hold on 2/15 at 0951a; [SIC] resident belonging packed and placed in storage for pick up; 2. Record review of Resident #2's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified (causing severe memory loss, cognitive decline, and behavioral changes), chronic kidney disease (kidneys do not filter waste effectively), stage 3 (moderate kidney damage) unspecified, acute on [SIC] chronic diastolic (congestive) heart failure (left ventricle becomes stiff and can't relax properly and prevents it from filling with enough blood)and bradycardia (slow resting heart beat under 60 beats per minute), unspecified. Record review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #2 had 1 to 3 days with behaviors of physical and verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #2's care plan initiated on 01/10/26 revealed the focus Psycho-social / Behavioral Risk: ALZHEIMER's. As per family he used to have some form of anger issues with them at home but nonphysical. 2/7/26 resident has a res-to-res physical Altercation 2/8/26 resident has a res-to-res physical altercation Record review of Resident #2's nursing note completed by LVN B and dated 02/07/26 at 7:40am stated, Resident on receiving end of resident to resident physical aggression. Resident attempted to enter his room where roommate would not let him in, he began to push him out of the room (CNA reports seeing resident get hit in the face by roommate). Then roommate attempted to close the door on resident, by that time nurse was there and able to separate residents. Resident remembers incident, denies being hit in the face and denies any pain. No signs of emotional distress, no injuries noted no redness; resident states his roommate only his [SIC] his wheelchair. RN supervisor aware, ADON, DON and Administrator aware. Record review of Resident #2's IDT: Star - VA ABC tool Completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was in [SIC] floor asking for help. Record review of nursing note completed by RN J with effective date of 02/08/26 at 4:30am stated, Late Entry: RN supervisor did head to toe assessment on resident, skin tear to right arm, left arm and right knee noted, a red discoloration noted on bridge of nose, no other injuries noted. Resident is A&Ox 2, lungs clear, on room air, VS WNL, able to move all extremities with ease, he is continent of bowel and bladder, says he has pain from his arm, pain meds offered but resident refused. Resident denies any emotional distress. Record review of Resident #2's nursing note completed by LVN D and dated 02/08/26 stated [Resident #2] was calling for help, CNA entered room and found resident on the floor. He had skin tear on BIL arms and R knee. Statedroommate had pushed him. No emotional distress. No pain to body. Going out as a precaution. Record review of Resident #2's skin: abrasion/bruise/edema/mole/rash document completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital (shallow, triangular depression located on the anterior surface of the elbow) and to front of right knee. Record review of change in condition for Resident #2 completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital.' Record review of Resident #2's nursing note completed by RN J and dated 02/08/26 at 5:28am stated Resident #2 was transferred to hospital by EMS at 5:20am. Record review of Resident #2's hospital records from 02/08/26 did not identify any fractures. Record review of Resident #2's nursing note completed by LVN M and dated 02/08/26 at 8:18am stated, spoke with [staff] from [hospital], resident is being discharged with no critical findings. no fractures and coming back withimaging results. During an interview with Resident #2 on 02/24/26 at 2:24pm he would only answer that yes he had an incident with Resident #1 and that yes he did get hurt. Resident #2 would not answer any other questions related to the incidents and would respond with, Its none of your business when asked. During an interview with the DON on 02/25/26 at 4:40pm she stated on 02/07/26 CNA A had reported to the nurse that Resident #2 was hit by Resident #1 on the chest but LVN B had assessed Resident #2 and he had no injuries. During an interview with CNA A on 02/25/26 at 4:57pm she stated on 02/07/26 she was doing her rounds with her partner CNA E when she heard a resident yelling in the hall at around 7:00am. CNA A stated when she went to go check she saw Resident #1 standing at the entrance of his room door holding the door open and Resident #2 on his wheelchair trying to get out of the room. CNA A stated Residents #1 and #2 were facing each other and Resident #1 had a hold of Resident #2's shirt when she witnessed Resident #1 hit Resident #2 with a closed fist hand, once on the jaw and once on the chest. CNA A stated she yelled for them to stop and for help separating them. CNA A stated LVN B went to assist in separating residents, and took Resident #2 to the common area. CNA A stated she informed LVN B that she saw Resident #1 hit Resident #2 once in the face and once in the chest and to check Resident #2. CNA A also stated she told LVN B that Residents #1 and #2 could not be together because of the incident and that Resident #1 was aggressive and if they were to put them back together that Resident #1 could attack Resident #2. CNA A stated LVN B asked Resident #2 about being hit and he denied it. CNA A stated she did not know why staff did not listen to her about what she had witnessed and reported. CNA A stated throughout the rest of that morning staff was alternating who was in the room between Resident #1 and #2 until about 10:00 or 11:00am when LVN B took Resident #1 to the room while Resident #2 was already in there. CNA A stated she informed LVN B that they could not be together because Resident #1 could kill Resident #2. CNA A stated Resident #1 had been aggressive before but had never hit Resident #2. CNA A mentioned Resident #1 had aggressive episodes with his wife previously when she would visit him at the facility but did not mention any incident with other residents. During an interview with the DON on 02/25/26 at 6:11pm she stated LVN B had reported to her an incident between Resident #1 and #2 where Resident #1 didn't let Resident #2 into the room and stated LVN B questioned Resident #2 about the incident and he stated Resident #1 hit his wheelchair and not him. The DON stated because of this they did monitoring and had an aide out there and RN F stayed outside the room. The DON stated there was no other indication of any behaviors and stated Resident #2 had documentation completed every hour. The DON stated they did not do a room change because they were doing close monitoring and Resident #2 had hourly checks on his chart. The DON stated there was no other behaviors and no indication something else was going to happen. The DON was unable to answer if the 2nd incident on 02/08/26 was preventable. During an interview with RN F on 02/25/26 at 7:40pm she stated she was made aware of the incident between Resident #1 and #2 and went to assess and interview Resident #2 who denied being hit and had no injury. RN F stated in response to incident she was doing monitoring and had an aide posted outside the door. RN F stated Resident #1 had no indications of continued behaviors. During an interview with LVN D on 02/26/26 at 9:56am she stated she did not witness the incident on 02/08/26 between Resident #1 and #2 and was called by the aide and when she arrived to their room she saw Resident #1 standing up and Resident #2 on the floor. LVN D stated she assessed both residents and Resident #2 had skin tears around bilateral elbows that were not greater than 3.5 inches and superficial, a skin tear to his knee about .5 inches and some redness to his nose bridge. LVN D stated Resident #2 stated Resident #1 hit him on his arms and LVN B could not recall if Resident #2 told her how he ended up on the floor. LVN D stated both residents were sent out for further evaluation and stated Resident #1 was eventually discharged or transferred but was no longer at the facility. LVN D stated she entered work on 02/07/26 at 10:00pm and was made aware of an argument the residents had the prior but nothing about hitting and stated she did not know about other behaviors before. LVN D stated she was told to keep a close eye on them and monitor them but stated there was not any form or documentation for them to document and stated there weren't any behaviors to document either. During an interview with CNA C on 02/26/26 at 10:28am she stated on 02/08/26 she heard someone calling for help and when she went to Resident #1 and Resident #2's room she saw Resident #2 on the floor and Resident #1 carrying his bedside table at his waist. CNA C stated Resident #1 put the table down and got close to her and she called for help at that same time and Resident #1 went to the door and was taken to the common area. CNA C stated once the nurse got there she left to another room. CNA C stated Resident #2 had some skin areas with blood on 1 side and stated Resident #2 did not tell her how he got on the floor and neither resident spoke to her about the incident. CNA C stated she did not know of any previous behaviors and had not been told to monitor either resident when she entered her shift on 02/07/26 at 10:00pm. During an interview on 02/26/26 at 11:27am CNA A stated when she saw Resident #1 and #2 on 02/07/26 she did not see any injury on Residents #1 or #2. CNA A stated in response to the incident they had her sit outside the resident's room for about 10 minutes and stated she did not see anyone else sitting outside their room that day on 02/07/26. CNA A stated she does not know what else the facility did in response to the incident but stated they could have prevented the second incident that occurred between Resident #1 and #2 on 02/08/26 but stated she was not able to do anything and that it was up to the nurses and leadership. CNA A stated she was told by staff leadership that her statement was false and stated the facility wrote her up for it. CNA A stated Resident #1 had been aggressive before but had never hit Resident #2. CNA A stated she did not report what she saw to the Administrator because she reported to her supervisor LVN B who she assumed would report to the Administrator. During an interview with the DON on 02/26/26 at 6:32pm she stated on 02/07/26 LVN B notified her of an incident with Resident #1 and #2 when Resident #1 would not allow Resident #2 in the room. The DON stated LVN B did not mention any hit. The DON stated it as RN F who notified her that CNA A reported that she saw Resident #1 punch Resident #2 but there was no redness or anything. The DON stated both LVN B and RN F reported right after the incident occurred. The DON stated in in response they had close monitoring and had an aide posted outside the door for about an hour and then when CNA A had to get back on the floor RN F was on the floor and had the door open to Resident #1 and #2's room with RN F checking them and stated staff tried to alternate them in the common area. The DON stated the only monitoring they had was what was in the chart. The DON stated in general residents had been verbally aggressive but had no previous incidents with each other. The DON stated neither resident expressed fear and stated Resident #2 stated he was not hit and only his wheelchair was. The DON stated on 02/08/26 an aide heard someone yelling for help and found Resident #2 on the floor with Resident #1 standing next to him, the DON stated Resident #2 was moved and the aide called for help and the nurses arrived to assess and evaluate. The DON stated on 02/08/26 Resident #2 stated that Resident #1 grabbed him by the arms and pushed him to the floor when he was sitting at edge of bed. The DON stated Resident #2 had paper thin skin and that why the skin to his bilateral arms occurred. The DON stated Resident #1 was sent out to the emergency room for admission to behavioral and Resident #2 was sent out for to get evaluated. The DON stated both residents returned to the facility and stated Resident #1 was placed on a one to one with room change and they implemented a monitoring tool, orders for counseling and psychiatric services and stated Resident #1 got sectioned and transferred out of the facility. During an interview with LVN B on 02/26/26 at 7:21pm she stated on 02/07/26 she was made aware by CNA A of Resident #1 hitting Resident #2 in the face or the head but when she arrived to the incident the residents were already being separated and she did not witness any hit. LVN B stated she took Resident #2 to the common area and assessed him and found no injuries and no pain and stated Resident #2 denied being hit. LVN B stated she then went to assess Resident #1 who had no injuries and did not recall the incident. LVN B stated neither resident expressed fear. LVN B stated in response to the incident they removed Resident #2 from the room, provided Resident t#1 his schedule anxiety medication and educated the residents on their shared room and stated she would escort Resident #2 back to his room when he wanted to go to his room and would educate Resident #1 that Resident #2 was roommate and not to be alarmed. LVN B stated neither resident had any other incidents during her shift. LVN B stated she believed Resident #1 had a history of similar behaviors but was not sure about Resident #2. LVN B stated within 20 minutes she reported to and made the ADON, DON and administrator aware of everything that CNA A had reported. LVN B stated when she reported to her supervisors they did not mention who would be a good room change and LVN B stated she did not think there were any rooms at that time and stated changing rooms could increase agitation. LVN B stated she asked the aides to stay close outside of the door while charting and stated she tried to park her cart outside the room as well. During an interview with the Administrator on 02/26/26 at 8:06pm she stated on 02/07/26 CNA A was the responding and reporting aide that stated Resident #1 had hit Resident #2. The Administrator stated she was notified about this report by LVN B. The Administrator stated she asked LVN B if they needed to do a one to one of a urinary analysis and stated that LVN B stated there was no injury or redness and that Resident #2 had denied being hit and had stated that it was his wheelchair that got hit. The Administrator stated the DON then called LVN B and told her to monitor. The Administrator then the following morning at 5:00am she was called about a resident to resident where Resident #2 was on the floor and wasn't injured but had some really thin skin that kind of peeled a little bit. The Administrator stated no one witnessed anything but an aide reported she heard Resident #1 say I'm going to hit him again so they sent both residents out to the hospital. The Administrator stated Resident #1 had some verbal aggressive incidents before but nothing that caused injury. The Administrator stated when Resident #1 returned they did a room change for Resident #2 and put Resident #1 on one to one, got a section and transfer. During an interview on 02/27/26 at 6:37am LVN G stated he was notified of an incident going on in the 600 hall and stated when he arrived Resident #2 was on the floor and Resident #1 was standing but they had already been separated. LVN G stated Resident #2 told him that Resident #1 pulled him by his arms from his wheelchair to the floor. LVN G stated he assessed Resident #2 and noted superficial skin tears to arms and a skin tear to his knee and some redness to bridge of his nose. LVN G stated he notified the administrator and his RN supervisor of the incident and both residents were sent out. LVN G stated from what he understood this was the residents first altercation with each other. During an interview with the DON on 02/27/26 at 10:37am she stated as per their abuse policy during an abuse investigation they protect the resident by doing a one to one or room change or continuous monitoring to see for any indications of behaviors. The DON stated who ever identified the abuse reports it to the Administrator who will start the investigation and stated all staff were responsible for the protection of the resident. The DON stated in response to the incidents on 02/07/26 with Resident #1 and #2 they implemented monitoring which she stated it was only what was reflected in the chart and stated she was aware that there was no documentation for monitoring during the night shift and stated she did not know why there was not any. The DON stated because Resident #2 denied being hit they did not do an abuse investigation and only did the monitoring because of what CNA A reported. The DON stated the second incident on 02/08/26 could have been prevented had they continued the monitoring. The DON stated the facility followed their abuse policy and stated staff had been trained both before and after the incident by the administrator. The DON stated not implementing their abuse policy for the protection of the residents could negatively impact the resident because it could cause injury and stated the only negative impact Resident #2 had due to it not being implemented was superficial skin tears. The DON stated moving forward residents would be protected during abuse investigation by either doing one to one of room changes with any incident that occurs. During an interview with the Administrator on 02/27/26 at 1:13pm stated during an abuse investigation they would keep residents safe by separating them and closely monitoring them. The Administrator stated they did not initiate an abuse investigation into the incident on 02/07/26 because they did not identify abuse because Resident #2 denied being hit. The Administrator stated CNA A's report was taken into consideration but Resident #2 denied being hit. The Administrator stated Resident #2 was a fair historian. The Administrator stated she thought the incident was investigation by the nurse. The Administrator stated CNA A was not a good historian and was not very reliable based on previous history. The Administrator stated the facility should have done additional monitoring with better documentation. The Administrator stated, I think we were doing a lot when asked if they followed their abuse policy. The Administrator stated she had been trained over their abuse policy both before and after the incident and stated not implementing their abuse policy for the protection of the residents could impact a resident by not preventing another incident. The Administrator stated she felt the part of the policy that was not implemented was that CNA A did not call her.Record review facility policy titled, Abuse Guidance: Preventing, Identifying and Reporting with a implemented date of February 2017 and revised date of January 2024 stated, Protection - Our community will protect residents from harm during the investigation of abuse allegations. And The community should prevent occurrences of abuse, will monitor for triggers that may results in abusive behavior and monitor prevention measures on a regular basis through the community's QAPI process.The noncompliance was identified as PNC. The IJ began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began.The facility had corrected the noncompliance before the survey began as followed: Record review of room change consent form reflected Resident #1 had a room change on 02/09/26.Record Review of observation sheet reflected Resident #1 had observations documented every 15 minutes intervals starting on 02/08/26 at 10:45pm and ending on 02/10/26 at 2:00pm.Record Review of Residents #1's nursing notes reflected Resident #1 was sent out of the facility on 02/10/26 and his responsible party cancelled the bed hold on 02/15/26.Observations on 02/24/26 at 2:15pm and record review of nursing notes for Resident #1 reflected Resident #1 was no longer a resident at the facility.Record review of a monitoring tool form used to identify any residents with resident to resident behaviors was implemented on 02/09/26 and identified residents with incidents of behaviors and what action was taken to correct the behavior.Record review of ADHOC Quality Assurance and Performance Improvement meeting dated 02/12/26 covered the report of a resident to resident incident.Record review of Resident #1's care plan reflected it had been updated on 02/11/26 regarding his resident to resident aggression on 02/07/26 and 02/08/26. Record review of Resident #2's care plan reflected it had been updated on 02/10/26 regarding his resident to resident altercations on 02/07/26 and 02/08/26. Record review and interview on 02/26/26 at around 1:15pm the DON provided care plans with a print date of 02/26/26 for additional residents #4, #5, #6, #7, #8. #9, #12 which were reviewed and reflected residents behaviors and interventions to address them. On 02/27/26 at around 9:00am the DON provided care plans with a print date of 02/27/26 for Resident #10 and #11 which were reviewed and reflected residents behaviors and interventions to address them. The DON stated the care plans provided were for the resident's they had identified with behaviors. Record review of an email communication between the DON and the psychiatric nurse practitioner dated 02/10/26 at 9:53am reflected residents (#2,#4, #8, #9, #10, #11) and the behaviors they had and continued email communication from 02/23/26 at 10:08am and 2:09pm reflected residents (#2, #6, #7, #8 #9, #12) and behaviors they had.Record review of psychiatry notes reflected:Resident #2 was seen on 02/10/26 and 02/23/26Resident #4, #5, #10 and #11 were seen on 02/12/26Resident #8 was seen on 02/23/26Resident #6, #7 were seen on 02/26/26.Record review of staff development/in-services attendance sheet dated 02/08/26 with an audience documented as All team members covered reporting any incidents of abuse, injury of unknown origin neglect and exploitation immediately to the Administrator and included her phone number. It also covered reporting any resident to resident aggression or Inappropriate touching to the administrator and to redirect resident and keep residents safe. Also covered was that all residents needed to be put on a one to one and be kept separated.Interviews with CNA A on 02/26/26 at 11:27am, LVN B on 02/26/26 at 7:21pm, CNA C 02/26/26 at 10:28am, LVN D on 02/2626 at 9:56am,, LVN G on 02/27/26 at 6:37am, LVN H on 02/25/26 at 1:20pm, the DON on 02/26/26 at 6:29pm and Administrator on 02/26/26 at 8:06pm reflected they had been trained to report any abuse to the Administrator immediately and were aware to separate and implement one to one monitoring with any resident to resident altercation.Record review of training over abuse guidance: preventing, identifying and reporting dated 02/09/26 reflected the DON and Administrator received the training.

Based on interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1.The facility failed to follow their skin and wound prevention and management policy and did not have a licensed nurse complete and document a skin assessment at least weekly for Resident #3. This failure could put residents at risk of having skin breakdowns that could go unidentified and untreated. The findings included: 1. Record review of Resident #3's face sheet dated 02/24/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS (seizures that continue despite adequate trials of at least two appropriate anti-seizure medications ), DYSPHAGIA (difficulty swallowing) FOLLOWING NONTRAUMATIC INTRACEREBRAL HEMORRHAGE (stroke), AGE-RELATED PHYSICAL DEBILITY (state of severe, generalized weakness, fatigue, and reduced functional stamina ), COGNITIVE COMMUNICATION DEFICIT (difficulties with verbal and non-verbal communication caused by underlying, disrupted cognitive process). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #3's skin section reflected she had no unhealed pressure ulcers/injuries, no venous or arterial ulcers and no other wounds or skin problems. Record review of Resident #3's care plan initiated on 06/27/25 revealed the focus Actual or At Risk for Skin Impairment R/T incontinence, I depend on staff for toileting and mobility, I have eczema to bilateral hands, I have rash to neck with an intervention of Skin Risk: Follow community's practice for assessing skin, reporting skin concerns to charge nurse, doctor, resident or representative and follow skin protocol in place as indicated with an initiated date of 09/30/25. Record review of Resident #3's Order Summary reflected an order for Weekly Skin Check 0 - for No Skin issues 1 - for No new Skin issues 2 - New skin issue identified every day shift every Thu for Skin Integrity with a discontinue date on 09/11/25. No other order for weekly skin checks were added until 02/25/26. Record review of Resident #3's nursing note documented by the DON on 02/24/26 stated, Head to toe assessment done no abnormalities noted Record review of Resident #3's assessments reviewed from 02/25/26 till 9/30/25 revealed her last skin and wound evaluation form was completed on 09/30/25 and reflected a healed surgical incision. During an interview and record review with the DON on 02/26/26 at 6:21pm she stated residents should have orders in place for weekly skin assessments that should be completed by the nurses. The DON stated Resident #3's orders for weekly skin assessments were discontinued on 09/11/25 and were reordered on 02/24/26 after she was notified by surveyor X of orders not identified in chart. The DON stated she went to do a skin assessment on her on 02/24/26 and found no skin abnormalities. The DON stated staff had not been doing skin assessments on Resident #3 and stated her last skin assessment was sometime in September 2025. The DON stated Resident #3 had not had any skin issues or deterioration since the time her skin assessments were discontinued on 09/11/25.The DON stated staff do provide Resident #3 with zinc, bathing and changes multiple times a day with no abnormalities report identified during care. The DON did not know why it was not identified that Resident #3 did not have orders in place for skin assessments or why they were not being completed. The DON stated it was important to ensure residents had skin assessments orders in place and were being completed so that if something was identified they can work on resolving it. The DON stated nursing staff had been trained over ensuring orders for skin assessments were in place and completed and documented. The DON stated the RN supervisor and herself were responsible for ensuring orders and documentation were in place. The DON stated not having skin assessment orders in place and not completing skin assessments could negatively impact the residents because it could leave issues not treated on time.Record review of staff training reflected an Inservice on 11/24/25 for charge nurses that covered nurses obtaining and entering wound care orders at time of admission and when identified, and completing head to toe skin assessments upon admission and RN supervisors assisting to verify orders are entered at time of admission. Record review of facility policy titled Skin and wound Prevention and Management with an implemented date of 03/14/19 and a revised date of January 2023. Under the section titled, Guideline It included stated, A licensed nurse should at least weekly conduct a routine skin assessment/evaluation in order to identify new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks in the resident's medical record.

Based on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 3 residents reviewed for unnecessary medications. 1.The facility failed to have an adequate indication for the use of the medication Seroquel (an antipsychotic) for Resident #1 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: 1. Record review of Resident #1's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 02/15/26 with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseased classified elsewhere, severe, with agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), major depressive disorder (persistent, intense feelings of sadness, worthlessness, and a lack of interest in life lasting at least two weeks), single episode, severe without psychotic features and insomnia (persistent difficulty falling asleep, staying asleep or waking too early) due to other mental disorder. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. There were no potential indicators of psychosis and 1 to 3 days with behaviors of verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Resident #1's MDS reflected her was taking and had an indication noted for antipsychotics medication. Record review of Resident #1's Care Plan initiated on 09/02/25 revealed the focus I require Anti-psychotic medication r/t: MDD and to help me with my INSOMNIA DUE TO OTHER MENTAL disorder with an initiated date of 09/02/25 and a cancelled date of 02/11/26. Record review of Resident #1's consent for Seroquel 200mg every day at bed time was signed by Resident #'1's responsible party on 01/07/26 and completed by MD Z. Section that read, I believe the individual has the following psychiatric condition and/or maladaptive behavior; had the following diagnoses listed, DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE WITH AGITATION; MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, SEVERE WITHOUT PSYCHOTIC FEATURES; ALZHEIMER'S DISEASE WITH LATE ONSET; ANXIETY DISORDER, UNSPECIFIED; Record review of Resident #1's Order Summary reflected an order for SEROquel Oral Tablet (Quetiapine Fumarate) Give 200 mg by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH AGITATION.ANXIETYDISORDER, UNSPECIFIED with a start date of 01/07/26 and a discontinue date of 01/20/26. Record review of Resident #1's Order Summary reflected an order for, Antipsychotic Side Effect Monitoring. If S/E identified call physician. Side Effects: Sedation/Drowsiness, Dizziness/Gait Disturbance/Falls, Tremors/Sweating/Rashes. Increased Confusion orAgitation, Appetite Change, Insomnia, Constipation/Urinary Retention, Dry Mouth/SoreThroat, Swallowing Difficulty, BP and Cardiac Changes, Abnormal Body movements, Blurred Vision, Weakness, Headache every shift with a start date of 10/28/25 and a discontinue date of 02/11/26 Record review of Resident #1's January 2026 MAR reflected Resident #1's order SEROquel Oral Tablet (Quetiapine Fumarate) Give 200 mg by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH AGITATION.ANXIETYDISORDER, UNSPECIFIED was held on 01/07/25 and administered at bed time from 01/08/26 until 01/20/26. During an interview with the DON on 02/26/26 at 6:29pm she stated Resident #1 had an order for seroquel200 mg from 01/07/26 - 01/20/26 for dementia, severe with agitation and anxiety disorder. The DON stated antipsychotics such as Seroquel were not indicated for dementia. The DON did not know why they were not indicated for dementia or what negative impact it could have and stated on 01/20/26 they changed the diagnosis Resident #1 had Seroquel ordered for to insomnia. The DON stated Resident #1 was receiving the Seroquel because he had insomnia, anxiety and major depressive disorder. The DON stated it was important to ensure there was a proper indication for use of antipsychotics to make sure they were being used with the right diagnoses. The DON stated she felt the Seroquel was appropriate prescribed for Resident #1 and stated he did not have any negative impact from being given the mediation. During an interview with PA Y on 02/26/26 at 10:31am she stated she would see Resident #1 but stated he was also under the care of a mental health provider. PA Y stated whenever antipsychotics were used they usually request mental health providers to follow the resident and stated in her personal opinion antipsychotics should be used carefully with the elderly which was why they consulted with providers with specialties in those areas. PA Y stated antipsychotics could help control aggression and be helpful but stated overall there could be negative impact with use. Record review of facility's policy titled, Psychotropic Medication & Gradual Dose Reduction with an implementation date of January 2022 and a revised date of January 2023 included a guideline statement that read, Physicians and mid-level providers will use psychotropic medication appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 3 residents (Residents #1 and #2) reviewed for reporting alleged allegation of abuse. The facility did not report to HHSC within 2 hours, when Resident #2 was found on the floor with bilateral skin tears to arms and stated Resident #1 had pulled him down to the floor on 02/08/26. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included:1. Record review of Resident #1's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseased classified elsewhere, severe, with agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), major depressive disorder (persistent, intense feelings of sadness, worthlessness, and a lack of interest in life lasting at least two weeks), single episode, severe without psychotic features and insomnia (persistent difficulty falling asleep, staying asleep or waking too early) due to other mental disorder. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. Resident#1 had 1 to 3 days with behaviors of verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #1's closed Care Plan initiated on 09/02/25 revealed the focus Psycho-social / Behavioral Risk: GENRERALIZED ANXIETY and MDD. currently on treatment for these diagnosis. 11/20/25:Resident refused peri care and raised his voice at staff to leave his room. 12/2/25:Resident to resident verbal aggression. 12/11/25: Resident to staff verbalaggression. 12/21/25:Resident to staff Verbal aggression. 12/29/25:Resident to resident verbal aggression. 2/7/26:Resident to resident verbal aggression. 2/8/26: Residnet [SIC] to resident physical and verbal aggression. Record review of Resident #1's IDT: Star - VA ABC tool completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was standing over roommate with table, per CNA. Resident was upset saying that he would hit roommate again. 2. Record review of Resident #2's face sheet dated 02/25/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified (causing severe memory loss, cognitive decline, and behavioral changes), chronic kidney disease (kidneys do not filter waste effectively), stage 3 (moderate kidney damage) unspecified, acute on [SIC] chronic diastolic (congestive) heart failure (left ventricle becomes stiff and can't relax properly and prevents it from filling with enough blood)and bradycardia (slow resting heart beat under 60 beats per minute), unspecified Record review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident#2 had 1 to 3 days with behaviors of physical and verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Record review of Resident #2's care plan initiated on 01/10/26 revealed the focus Psycho-social / Behavioral Risk: ALZHEIMER's. As per family he used to have some form of anger issues with them at home but nonphysical. 2/7/26 resident has a res-to-res physicalAltercation 2/8/26 resident has a res-to-res physical altercation Record review of Resident #2's IDT: Star - VA ABC tool Completed by LVN D and dated 02/08/26 stated, at 4:00am Resident was in [SIC] floor asking for help. Record review of nursing note completed by RN J with effective date of 02/08/26 at 4:30am stated, Late Entry: RN supervisor did head to toe assessment on resident, skin tear to right arm, left arm and right knee noted, a red discoloration noted on bridge of nose, no other injuries noted. Resident is A&Ox 2, lungs clear, on room air, VS WNL, able to move all extremities with ease, he is continent of bowel and bladder, says he has pain from his arm, pain meds offered but resident refused. Resident denies any emotional distress. Record review of Resident #2's nursing note completed by LVN D and dated 02/08/26 stated [Resident #2] was calling for help, CNA entered room and found resident on the floor. He had skin tear on BIL arms and R knee. Statedroommate had pushed him. No emotional distress. No pain to body. Going out as a precaution. Record review of Resident #2's skin: abrasion/bruise/edema/mole/rash document completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital (shallow, triangular depression located on the anterior surface of the elbow) and to front of right knee. Record review of change in condition for Resident #2 completed by LVN D and dated 02/08/26 reflected a skin tear to bilateral antecubital.' Record review of Resident #2's nursing note completed by RN J and dated 02/08/26 at 5:28am stated Resident #2 was transferred to hospital by EMS at 5:20am. Record review of Resident #2's hospital records from 02/08/26 did not identify any fractures. Record review of Resident #2's nursing note completed by LVN M and dated 02/08/26 at 8:18am stated, spoke with [staff] from [hospital], resident is being discharged with no critical findings. no fractures and coming back withimaging results. During an interview with Resident #2 on 02/24/26 at 2:24pm he would only answer that yes he had an incident with Resident #1 and that yes he did get hurt. Resident #2 would not answer any other questions related to the incidents and would respond with, Its none of your business when asked. During an interview with the Administrator on 02/26/26 at 8:35pm she stated she was the abuse coordinator and was responsible for reporting any incidents of abuse to HHSC within a 2 hour timeframe. The Administrator stated she was notified by LVN D at 5:00am on 02/08/26 of the altercation between Residents #1 and #2 and the skin tears sustained by Resident #2 earlier that morning at around 4:15am. The Administrator stated the altercation between Residents #1 and #2 should have been reported within 2 hours. The Administrator stated she did not report to HHSC until 5:00pm on 02/08/26. She stated she reported late because she was busy doing her interviews. The Administrator stated the facility policy reflected reporting any abuse within 2 hours. The Administrator did not give clear answer when asked if she had followed the facility policy in this situation. The Administrator stated reporting incidents of abuse within 2 hours was important because depending on the allegation a surveyor may need to arrive to the facility faster. The Administration stated the negative impact on resident for not reporting within 2 hours would be questionable. Record review facility policy titled, Abuse Guidance: Preventing, Identifying and Reporting with a implemented date of February 2017 and revised date of January 2024 stated, Report alleged or suspicions of abuse to HHSC by email reporting via TULIP reporting within the designated time frame in accordance with HHSC PL19-17 (Replaces PL 17-19).Are reported immediatelyBut not later than 2 hours after allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #96) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #96's contact precautions. These failures could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.The findings included: Record review of Resident #96's face sheet dated 01/05/2026 reflected the resident was an 83 -year-old male admitted to the facility on [DATE] with an original admission date of 06/10/2021. Resident #96 had diagnosis of ESBL to arterial ulcer. Record review of Resident #96's Quarterly MDS assessment, dated 10/10/2026, reflected that he scored a 4 on her BIMS which reflected severely cognitively impaired. Record review of Resident #96 most recent Care Plan reflected Resident #96 did not have contact precautions developed on his care plan or interventions. Record review of Resident #96 Physician's Order Summary dated 01/05/2026 reflected Meropenem Intravenous Solution Reconstituted 1 GM for Escherichia coli ESBL to arterial ulcer until 01/06/2026. There was no contact precaution order. During an interview on 01/05/2026 at 5:03 p.m. the MDS nurse stated she was responsible for developing care plan for Resident #96. The MDS stated that contact precautions should have been care planned but does not know why it was not completed. She stated that the orders were checked daily in their morning meetings, except on the weekends. The MDS nurse stated that a negative outcome was the lack of communication between staff/resident and the spread of infection to others. During an interview on 01/07/2026 at 9:53 a.m., ADON H stated that the nurses, herself, and MDS nurses were responsible for developing the care plan. They discuss it together in their morning meetings. ADON H stated that the care plan should be completed as soon as possible. She stated that contact precautions should have been care planned and she did not know how it was missed. ADON H stated that the care plan was important because they have to know what the residents were being treated for and how to treat the residents. During an interview on 01/07/2026 at 11:00 a.m. with the DON, stated the nurse that received the order was the one responsible for completing the care plan for Resident #96. She stated that contact precautions should have been care planned and was to be completed as soon as they got the order. The DON stated that it was important for it to be completed to let staff know about the care that needs to be provided to the residents. Record review of the facility's Care Plan policy, date revised January 2023 revealed: Guidelines: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a residents' medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the residents' highest practicable physical, mental, and psychosocial wellbeing. . The care plan should be updated and reviewed at lease quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. 2.Record review of Resident #103's admission sheet dated 01/06/26 reflected a [AGE] year-old male with an admit date of 06/26/25. His relevant diagnoses included cauda equina syndrome ( where nerve roots at the bottom of the spine (the cauda equina meaning horse tail get severely compressed, causing intense low back pain, numbness in the saddle area (buttocks, inner thighs, genitals), leg weakness, and problems with bowel/bladder control), paraplegia (paralysis affecting the lower half of the body including the legs, trunk, and pelvic organs), bed confinement status ( a patient is medical unable to get out of bed or ambulate), and adult failure to thrive ( a syndrome affecting primarily older adults, marked by a decline in physical and cognitive functions). Record review of Resident 103's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated his cognition was intact. Record review of Resident #103's quarterly care plan dated 10/01/25 reflected: Focus. [Resident #103] likes reading, watching tv, he's Catholic wants pray/blessing in room, reminiscing with staff, music-[NAME] (Tex-Mex music). Staff will be monitoring for any new activities interested and for any changes. He needs daily in room visits, activity package for mental stimulation. Date initiated/revised 07/01/25. Interventions.included Ask me and assist me with turning on my TV, radio, opening blinds, providing reading material and reaching phone, provide me with an activity calendar, and respect my wishes for not attending activities (date Initiated/revised 07/01/25) Record review of Resident #103's One to One Activity Monthly Sheets for the months of October 2025 to December 2025, reflected he had been visited at least three times a week and the following activities were done: exercise, prayer, sensory music, watching western tv, Christmas carolers, reminiscing, and aroma therapy, An observation on 01/05/26 at 10:30 am, Resident #103 was observed lying in bed watching television. A current activity calendar was taped on the wall within Resident #103's reading distance. Resident #103 did not have a radio or reading materials in his room. In an interview on 01/05/26 at 10:32 am, Resident #103 said he enjoyed watching television, reading, and listening to Tex-Mex music. He said he would often get bored because the only thing he could do is watch television and sleep. He said he was bed bound due to both legs being contracted and it was painful for him to sit in a wheelchair. He said he had never received any reading materials or had a radio. Resident #103 did say an activity lady visited him several times a week. An interview on 01/06/25 at 1:59 pm, Activity Director said part of her responsibility as an Activity Director was to ensure all residents participated in activities outlined in their care plan. She said when Resident #103 was first admitted , he was very fragile and did not like to get up that was on 06/26/25. She said that was why he had been placed on a 1 to 1 for activities. She said that meant an activity aide would visit him three times a week and provided activities in his room. She said she was not aware Resident #103 had not been provided with a radio or reading materials. The Activity Director said what her aide does when she would visit Resident #103 was to reminisce and massage his hands. She said reminiscing meant they give the resident time to talk about this past. The Activity Director said a negative outcome for Resident #103 not being mentally stimulated could be boredom and/or depression. In an interview on 01/07/15 at 1:15 pm, Activity Aide it was her responsibilities was to assist the facility's Activity Director with day-to-day activities. She said she had been assigned to Resident #103. She said resident #103 was a 1 on 1 for activities which meant she would visit his room three times a week. She said the only two activities she would do with Resident #103 was allow him to reminisce while she would massage his hands. She said she had not been told Resident #103 liked listening to the radio or reading. She was not able to say what the negative outcome to Resident #103 was for not being provided with reading materials or a radio. In an interview on 01/07/25 at 3:15 pm, the Administrator said the facility's Activity Director was responsible to ensure all residents participated in activities of their choice. She said she was not aware the Activity Director was not following Resident #103's interventions as outlined on his care plan. She said she would have to talk to the Activity Director and was not able to say what the negative outcome was for Resident #103 not having reading materials or a radio. Record review of the facility's Activities Program policy revised on January 2023 reflected: Compliance Guidelines: The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interest and to maintain the physical, mental and psychosocial well-being of each resident.The activities program is an essential component of the community's fulfillment of its obligation to care for its residents in a manner and environment that maintain or enhance each resident's quality of like. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual resident's need. Individualized activities plan.Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 1 (Resident #42) of 42 residents reviewed for call lights.The facility failed to ensure Resident #42 had the call light within reach while in bed in their room.This failure could place residents at risk of being unable to obtain assistance when needed and in the event of an emergency.The findings were:Record review of Resident #42's admission record dated 1/07/2025 reflected an [AGE] year-old male with diagnoses of Parkinson's Disease (a brain disorder that slowly damages nerve cells, leading to symptoms like tremors (shaking), stiffness, and balance problems), Diabetes Mellitus Type 2 (a chronic condition where the body has high blood sugar levels), Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills).Record review of Resident #42's Quarterly MDS dated [DATE] reflected a BIMS score of 3, which indicated severe cognitive impairment.Record review of Resident #42's Quarterly MDS dated [DATE] indicated in Section GG 0130- 01-Dependent for: A-Eating, B-Oral Hygiene, C-Toileting hygiene, E-Shower/bathe self, F-Upper body dressing, G-Lower body dressing, H-Putting on/taking off footwear, I-Personal hygieneObservation on 1/05/2026 at 10:36 AM revealed Resident #42's call light device was hanging low on the bedside rail and Resident #42 was unable to reach it.In an interview on 1/05/2026 at 10:45 AM, CNA A said Resident #42 cannot reach over to grab his call light and that he does use it when he needs assistance. She said the resident's call light was supposed to be within his reach because he needs total assistance with his care. CNA said that not having the call light within reach could place the resident at risk for a fall or assistance with ADLs not given. She said she had an in-service on call lights in December 2025.In an interview on 1/05/2026 at 10:56 AM, LVN B said if the resident needed something, he would not be able to notify the staff. She said she performs her rounds three to four times during her shift to check that call lights are within reach, the resident's beds were at the lowest position and checked resident to make sure they were okay. LVN B said she provided reminders to the CNAs on keeping the call lights within reach of the residents.In an interview on 1/05/2026 at 5:37 PM Resident #42 said if the call light is not within reach, then he would just have to do without. Resident #42 said they could do a lot better if the call light was clipped to my gown. Resident #24 said they had difficulty pressing the call bell because his hands were too shaky.On 1/07/2026 at 2:51 PM the DON stated there was no policy in place for call lights.Record review of the facility's policy titled Statement of Resident Rights date revised June 2025, indicated Resident/Patient Rights include: 1. To call care necessary for them to have the highest possible level of health; 2. To safe, decent, and clean conditions .

Based on interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 8 residents (Resident #96) reviewed for resident records. The facility failed to ensure a physician order was written for isolation precautions for Resident #96 on 12/23/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Findings Included: Record review of Resident #96's face sheet dated 01/05/2026 reflected the resident was an 83 -year-old male admitted to the facility on [DATE] with an original admission date of 06/10/2021. Resident #96 had diagnosis of ESBL to arterial ulcer. Record review of Resident #96's Quarterly MDS assessment, dated 10/10/2026, reflected that he scored a 4 on her BIMS which reflected severely cognitively impaired. Record review of the most recent Care Plan for Resident #96, reflected the resident had ESBL to wound date 12/18/2026, antibiotics for 14 days. Interventions reflected: Report changes in condition to MD as clinically indicated, administer medication and/or antibiotic as per MD orders, and monitor vital signs as indicated. There was no care plan implemented to place resident on isolation precautions. Record review of Resident #96 Physician's Order Summary dated 01/05/2026 reflected Meropenem Intravenous Solution Reconstituted 1 GM for Escherichia coli ESBL to arterial ulcer until 01/06/2026. There was no isolation precaution order. During an interview on 01/07/2026 at 9:05 a.m. with LVN D, stated that the person who was responsible for entering the isolation precaution order was the ADON H but that she and the wound care nurse can enter the order if it has not been done. She did not know that there was no isolation precaution for Resident #96. LVN D stated it was important to have a physician order in place to make sure that the order was followed through for safety and to understand why he was placed on isolation precautions. During an interview on 01/07/2026 at 9:37 a.m. LVN G, stated the nurses were responsible for entering the physician orders for isolation precaution. They enter them as soon as they get the order from the doctor. LVN G stated it was important for them to have a physician order for isolation precautions for safety to the residents and staff. During an interview on 01/07/2026 at 10:30 a.m. with WCN, stated that he was responsible for entering wound care physician orders. He stated that the nurses enter the other orders to include isolation precaution orders. WCN stated that he was available that afternoon in that area on Monday, 01/05/2026, reached out to the doctor and entered the order that afternoon. During an interview on 01/07/2026 at 9:53 a.m., ADON H, stated that he and the nurse were responsible for entering physician orders. He stated the nursing staff who receive the order should be the ones who enter it. ADON H stated the physician order needs to be placed in the record as soon as the nurse gets the order. He stated that he was not aware that Resident #96 did not have a physician order for isolation precautions. ADON H stated that a physician order needs to be in place to implement necessary precautions for staff and residents. During an interview on 01/07/2026 at 11:00 a.m. with the DON, stated the person responsible for entering the physician order was the nurse who gets the order. She stated the order should be entered as soon as they get the orders. The DON stated it was important for the order to be in place so they can know how to care for the residents in isolation for the proper PPE that was required. Record review of policy titled, Professional Standard of Care revised January 2024, reflected Compliance Guidelines: The community provides services that meet professional standards of quality and are provided by appropriate qualified persons.Compliance with Professional Standard of Care Nursing (d) When a licensed nurse takes a verbal or telephone order form a medical provider (MD/NP/PA), podiatrist, or dentist, the nurse should sign the order. The community should obtain the medical provider (MD/NP/PA), podiatrists, or dentist's signature on the order and return it to the clinical record in a timely manner.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 5 medication carts (400 Hall medication cart) reviewed for storage of drugs. The facility failed to ensure that there were no expired medications inside the 400-hall medication nurse cart for Resident #152 on 01/06/2026. This failure could place the residents at risk of not receiving the medication's full therapeutic benefits and possible side effects.Findings included: Record review of Resident #152's face sheet, dated 01/06/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #152's was diagnosed with Essential Hypertension (high blood pressure), Cerebral Infraction (stroke), Chronic Kidney Disease, Parkinson's Disease, Unspecified Dementia (a condition characterized by loss of memory and ability to reason), and Anxiety. Record review of Resident #152's Quarterly MDS assessment, dated 10/21/2025, reflected that he scored a 12 on her BIMS which reflected moderately cognitively impaired. Record review of Resident #152's Comprehensive Care Plan, dated 11/24/2025, reflected the resident had Essential Hypertension. Goals: Resident #152will not experience chest pain and/or acute cardiac complications through the next review date. Interventions: Administer my medications as ordered by my physician. Record review of Resident #152 Physician's Order Summary dated 01/06/2026 reflected Metoprolol Tartrate 100mg give 2 tablets by mouth three times a day related to essential hypertension start date 02/07/2025 and Amlodipine Besylate 10mg give 1 tablet by mouth every 12 hours as needed for SBP over 130 start date 08/11/2025. Observation on 01/06/2026 at 3:56 p.m. revealed during inspection of the medication nurse cart in the 400 hall, 2 medication blister packs that were expired for Resident #152. Metoprolol Tartrate 100mg expiration date 12/31/2025 and Amlodipine Besylate 10mg expiration date 12/31/2025. During an interview on 01/06/2026 at 3:56 a.m. LVN E confirmed Metoprolol Tartrate and Amlodipine Besylate were expired and should not be inside the medication nurse cart. She stated that the Metoprolol Tartrate was administered by the nurse at night from this medication nurse cart. She stated the medication aide has a separate medication cart, and she administers the other 2 doses of Metoprolol Tartrate, in the morning and the afternoon. The Amlodipine Besylate was administered as needed when Resident #152's SBP was above 130. LVN E stated that all the nurses were responsible for checking the medication nurse cart. She stated she has not checked because she has not administered the medications. She stated that they have a pharmacy nurse who audits the medication carts monthly. LVN E stated that the negative outcome of administering expired medications would not be effective and could cause an adverse reaction. During an interview on 01/06/2025 at 4:25 p.m., RN F stated that he was the pharmacy nurse and was responsible for checking all the medication carts and the medication storage rooms once a month. He stated that the nurses should check the medication carts as well. RN F stated that he has not checked the medication carts this month because it was early in the month. RN F stated that the negative outcome would be the efficacy of the medication would not be as potent. Resident #152's blood pressure could be not as controlled. He stated during in-services they discussed that the nurses and med aides were to check expiration dates at every medication pass/administration. RN F stated that this was also part of the onboarding medication administration training. During an interview on 01/07/2026 at 10:14 a.m., ADON J stated that the nurses were responsible for checking the expiration date on the medications. She stated that the pharmacy nurse checks the medication carts, not sure when, maybe once every month. ADON J stated that the negative outcome of having an expired medication would be that the efficacy of the medication would not meet its strength. During an interview on 01/07/2026 at 11:00 a.m., the DON stated that the pharmacy nurse, nurses, and medication aids were responsible for checking the expired dates on the medications. She stated that they were to check the expired dates every time they pull out that medication to be administered. She stated there should be no expired medications in the medication carts. The DON stated negative outcome of expired medications could be that the resident does not get their full dose due to the medication strength not as strong. She stated that in service training for medication administration was done upon hire, annually, and as needed. Record review of the facility policy, Pharmacy Services: Provision of Medications and Biologicals revised November 2024, revealed Compliance Guidelines:Labeling of medications and biologicals Medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug labeling regulations. Even though the pharmacy is responsible for labeling medication and biologicals, the community is responsible for ensuring that the labeling requirements are being met. The critical elements of the drug label include:.expiration dates,.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 (Resident #96) residents reviewed for infection control, in that: The facility failed to ensure that Resident #96 had a Contact precaution sign on the door or PPE. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.Findings include: Record review of Resident #96's face sheet dated 01/05/2026 reflected the resident was an 83 -year-old male admitted to the facility on [DATE] with an original admission date of 06/10/2021. Resident #96 had diagnoses which included the following: ESBL to arterial ulcer, Dementia (a condition characterized by loss of memory and ability to reason), Muscle Weakness, Type 2 Diabetes Mellitus (high blood sugar levels), Acute Kidney Failure (rapid loss of the kidneys ability to remove waste and help balance fluids and electrolytes in the body). Record review of Resident #96's Quarterly MDS assessment, dated 10/10/2025, reflected that he scored a 4 on her BIMS which reflected severely cognitively impaired. Record review of Resident #96 Physician's Order Summary dated 01/05/2026 reflected Meropenem Intravenous Solution Reconstituted 1 GM for Escherichia coli ESBL to arterial ulcer until 01/06/2026. There was no isolation precaution order. Record review of the most recent Care Plan for Resident #96, reflected the resident had ESBL to wound date 12/18/2026, antibiotics for 14 days. Interventions reflected: Report changes in condition to MD as clinically indicated, administer medication and/or antibiotic as per MD orders, and monitor vital signs as indicated. There was no care plan implemented to place resident on isolation precautions. Observation on 01/05/2026 at 11:10 a.m. revealed there was no sign posted on Resident #96's door and no PPE near the door. During an interview on 01/05/2025 at 11:58 a.m. LVN D stated she was Resident #96's nurse. LVN D stated that Resident#96 was on antibiotics for ESBL to the wound and should be on contact precautions. She stated the resident's privacy curtains had been changed this morning and the sign probably fell off. LVN D stated she did not notice the sign was not there. She stated that she was using the PPE that was across the hall. She stated that she or ADON H were responsible for putting up the sign. She stated that PPE for contact precautions were gloves, gowns, and goggles if wound were to be irrigated. She stated PPE was to be donned prior to going into Resident #96's room. LVN D stated that the negative outcome of not wearing proper PPE would be further contamination to someone else. Infection control in-services were done three times a month. During an interview on 01/06/2025 at 4:25 p.m. RN F stated that he was the pharmacy nurse and the Infection Preventionist (IP). He stated the nurses were responsible for placing the isolation precaution signage and PPE. He stated that the required PPE for contact precautions was gloves, gown, and shield was optional before going into the room. RN F stated that the negative outcome for not having the sign posted would be transmission of organism to staff and residents. He stated infection control in-services were ongoing throughout the year. During an interview on 01/07/2026 at 9:37 a.m. LVN G stated that she was made aware of a resident who was on contact precautions by communication from report and the signage on the resident's door. She stated that the nurses were responsible for placing the sign on the door and PPE. We will do this as soon as we get the order. She stated the PPE required for contact precautions were gloves, gown, and mask. LVN G stated that the negative outcome of not having sign on the door would be the spread of infection to staff, residents, and visitors. During an interview on 01/07/2026 at 9:53 a.m., ADON H, stated Resident #96 should have had a sign on door. She stated that the sign at the door was a reminder to visitors and staff about the infection. ADON H stated that the nursing staff who received the order should enter it as soon as possible. She stated that the proper PPE for contact precautions was gloves and a gown anytime they go in the room. ADON H stated the negative outcome of not having the signage would be that the infection would be transported to another resident. During an interview on 01/07/2025 at 11:00 a.m. with the DON stated the person responsible for placing the contact precaution sign on the door would be the nurse who gets the order or ADON H. She stated that the sign at the door and the PPE bin alerts visitors and staff of infection. The DON stated that the negative outcome of not having sign on door was that the bacteria can get on the staff uniform and pass it to other residents. Record review of the facility policy, titled Infection Prevention and Control, revised April 2024, revealed The infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment.

Based on observation, interviews, and record reviews, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Resident # 105) of 6 residents reviewed for resident call system.The facility failed to ensure Resident #105 had a call light that was functional. Resident #105's call light did not turn on when the button was pressed.This failure could place residents at risk for a delay in assistance and decreased quality of life.The findings included:Record review of Resident #105's face sheet dated 1/07/2025 indicated Resident #105 was a 77-years-old male admitted to the facility on [DATE]. Resident #105 had diagnoses including Cerebral Infarction (a type of stroke, meaning part of the brain is starved of oxygen and nutrients because a blood vessel is blocked), Hemiplegia and Hemiparesis (paralysis or weakness to one side of the body), Speech and Language Deficits (having trouble with speech, affecting communication), Hypertension (high blood pressure).Record review of Resident #105's Quarterly MDS assessment dated [DATE] indicated Resident #105 had a BIMS score of 5 which indicated severe cognitive impairment. Resident #105 was dependent for personal hygiene, upper and lower body dressing, shower, and toileting. Resident #105 was frequently incontinent of urine and always incontinent of bowel.Record review of Resient #105's Care Plan dated 12/01/2025 indicaleted a FOCUS: Risk for Seizure Activity, FOCUS: I have chronic health conditions and co-morbid conditions that have affected my physical function and may further affect my quality of life. FOCUS: I have Bowel and Bladder incontinence r/t Dx. Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right dominant side. During an observation on 1/05/2026 at 4:34 PM Resident #105 was sitting in his wheelchair in the hallway. He called this surveyor into his room and demonstrated that his call light was not working. He pushed the button but the light in the room did not turn on nor did the outside light turn on. Resident #105 said his call light was working earlier in the day but did not know why it wasn't working now.During an observation and interview on 1/05/2026 at 4:38 PM with CNA C arrived in Resident # 105's room and pressed the call light but the light did not turn on inside the room nor did the light turn outside the room. CNA C turned on Resident #105's roommate and both the inside and outside lights turned on. The CNA checked the call lights in two other rooms in the same hallway, and they were functioning. She said various situations can occur by not having a functional call light such as falls or a delay in changing his brief. She said the resident may think his call light is on and will be waiting and waiting for someone to come into his room. She said she performs rounds every two hours and checks call light placement, assists with ADLs, or any other thing the resident may need. She said frequent reminders are given to her regarding call lights.During an interview on 1/05/2026 at 5:02 PM LVN E said she performs two to three rounds during her 2pm-10pm shift and checks the call lights. She said random checks and rounds are also done by administration and supervisors throughout the 2pm-10pm shift to make sure the residents are okay. LVN E said that Resident #105 does use his call light and by not having a function call light, the risk of fall can increase as he may try and get up on his own. She said she provides reminders on call lights to the CNAs daily.During an interview on 1/07/2026 at 8:10 AM the Maintenance Supervisor said he was notified on 1/05/26 by the DON that the call light was not working in Resident #105's room. He said he immediately checked it and replaced the cord. The Maintenance Supervisor said he checked the Nurse Call Lights throughout the facility on 1/06/2026. He said call light audits were performed weekly and random checks were performed monthly. The Maintenance Supervisor said he had spare call lights available for the staff if they were needed during the night. He said call lights were frequently repaired or replaced due to wear and tear. The Maintenance Supervisor said the staff were good at notifying him whenever there was a problem with the call lights and he was quick to address it.In an interview on 1/07/2026 at 5:30 PM with the Administrator, she said the facility has a sophisticated call light system which was installed by a regional vendor. She said screens were located at each nurse's station and were designed to notify staff of any problems with the call light system. The Administrator said she was going to notify the regional vendor to check the system.Record review of Logbook Documentation dated 12/08/2025 provided by the Maintenance Supervisor indicated Nurse Call Checks Results for Rooms: 203, 207, 301-302, 313-314, 315-316, 401-402, 413-314, 415-416, 501-502, 513-514, 515-516, 613-614, 614-616, 707-708, 709-710,711-712, 802-803a, 803b-804. 806-807, and Lobby Rest Rooms-PASS. Comments: Check Nurse Call System, masters, monitors, main server, and modules, replace 3 cords at room [ROOM NUMBER]A, 607 B, 718 A, NO other issues found done on 11/26/2025.Resident #105's room was tested on [DATE] as indicated in Logbook Documentation.Record review of Logbook Documentation dated 12/24/2025 provided by the Maintenance Supervisor indicated Nurse Call Checks for 303-304, 305-306, 307-308, 403-404, 405-406, 407-408, 503-504, 505-506, 507-508, 601-602, 603-604, 605-606, 713-714, 715-716, 717-718, 808-809-, 810-811, 812-813, 814-815, and Rehab 128-PASS. Comments: Check Nurse Call System, masters, monitors, main servers, and modules, replace 3 cords at room [ROOM NUMBER]A, 408 B, 715 A, NO other issues found.Record review of Completed Work Oder #6607 dated 1/06/2026 provided by the Maintenance Supervisor indicated Nurse Call Lights Notes: All Nurse Call Lights cords must be checked through the facility, Due Date: 1/6/2026, Priority: High. Comments: Check Nurse Call Lights through the facility, check cords, dome lights and monitors, replace cord in room [ROOM NUMBER] b, also replace some missing clips, also check main master computer, modules, no issues were found.On 1/07/2026 at 2:51 PM the DON stated there was no policy in place for call lights.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #2) reviewed for infection control practices, in that: The facility failed to ensure CNA A performed proper hand hygiene and proper incontinent care for Resident #2.This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices.The findings were: Record review of Resident #2's electronic face sheet dated 8/14/25 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (a chronic disease in which glucose levels in the blood were higher than normal because the body does not make enough insulin or use it the way it should), muscle weakness, unsteadiness on feet, dementia (loss of cognitive functioning, such as thinking, remembering and reasoning to such an extent that it interferes with a person's daily life and activities), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and chronic kidney disease. Record review of Resident #2's comprehensive person-centered care plan, dated 5/23/25, reflected Resident #2 had a self-care deficit R/T Parkinson's, weakness, and dementia.Date Initiated: 04/25/2025. Interventions included toileting/incontinent care [with] 1 person assistance. Care plan also reflected Resident #2 had incontinence r/t impaired mobility, weakness.Date Initiated: 04/25/2025. Interventions included to ask and assist resident to toilet during waking hours as indicated, check and change on rounds and as needed, incontinent care assistance every shift and as needed, and initiate, collect and review documentation to establish toileting and/or incontinent patterns as indicated. Record review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 required partial/moderate assistance for self-care in toileting hygiene and was frequently incontinent for urine and bowel. During an incontinent care observation for Resident #2, on 8/14/25 at 1:30 PM., CNA A and CNA B performed incontinent care on Resident #2. CNA A grabbed two wipes and wiped the front genital area from the top to bottom towards the scrotum and back up again then outwards towards the left thigh using the same wipes, then disposed of the wipes. CNA A then grabbed two more wipes and wiped the front genital area from the top down towards the scrotum and back up again then outwards towards the right thigh using the same wipes, then disposed of the wipes. CNA A did not first clean the penis starting at the tip of the penis and working outward in a circular motion, then cleanse the remainder of the area including the penis, scrotum and outward to the thighs without returning to the urethral area. CNA A did not use one wipe per swipe. After CNA A completed cleaning the front genital area, CNA A grabbed two wipes and wiped up from the bottom of the left buttock to the top and back down the center of the buttocks to the scrotum, then back up again towards the lower back using the same wipes and disposed of the wipes. CNA A then grabbed two more wipes and wiped up from the bottom of the left buttock to the top and back down the center of the buttocks to the scrotum, then back up again towards the lower back using the same wipes and disposed of the wipes. CNA A did not clean the rectum and buttocks without returning towards the direction of the front genital area. CNA A did not sanitize hands between glove changes throughout the whole procedure. In an interview on 8/14/25 at 1:50 pm., CNA A said she must wash her hands before and after provided care for a resident and must wash hands for 30 seconds. CNA A said every time she reached for new wipes, she should change gloves and sanitize her hands between glove changes. CNA A said she did not sanitize her hands between glove changes this time because there was no hand sanitizer available in the resident's room, and she had none in her pockets at the time. CNA A said she knew she must sanitize between glove changes. CNA A said she should only use a wipe once and dispose of it. CNA A said she thought she did that and did not realize she wiped in the wrong direction using the same wipes. CNA A said she gets training on incontinent care and infection control at least monthly and as needed and the facility goes over hand hygiene, types of precautions, and proper use of PPE. CNA A said if she did not follow proper infection control, hand hygiene and incontinent care procedures, the residents could get an infection. In an interview on 8/14/25 at 2:00 pm CNA B stated the facility does frequent trainings for hand hygiene, PPE, and infection control. CNA B said when provided incontinent care, she must wash hands prior for at least 30 seconds. She said she must apply clean gloves before providing care to the front area. She said when she completed care to the front side, she changed gloves before started incontinent care on the back side. She said she sanitized her hands between glove changes. She said when cleaned the front side for a male resident, she must clean the penis by going around the tip, disposing of the wipe and wiping around again and disposing the wipe. CNA B said she must dispose of wipes after each wipe. CNA B said when she cleans the rest of the front area, and she wiped from top to the back towards the buttocks. CNA B said when she cleaned the back side, she wiped from bottom of buttocks to top towards the back. CNA B said if incontinent care were not performed correctly, the resident could get a urine infection. In an interview on 8/14/25 at 2:19 pm CNA C said she received training for infection control, PPE, and hand hygiene upon hire and annually. CNA C said she gets reminded about infection control all the time. CNA C said during incontinent care, she must perform proper hand hygiene prior to providing any care to a resident and after providing care to a resident. CNA C said she must sanitize between glove changes and wash her hands for at least 30 seconds if they became soiled. CNA C said that for a male resident, she first cleaned the penis from the tip of the penis to the base of the shaft. CNA C said she wiped the rest of the front area from the top towards the scrotum and outwards to the thighs. CNA C said she must dispose of the wipe immediately after. CNA C said she could not fold over or use the wipe again. CNA C said she removed gloves immediately after, sanitized hands, then placed clean gloves before moving to the back side. CNA C said when she wiped the back side, she wiped the center of the buttocks from the bottom up towards the lower back, then continued from the bottom of each buttock up towards the lower back. She said she must never reuse a wipe or fold over and use the wipe again. CNA C said she removed gloves and sanitized hands immediately after. CNA C said if incontinent care was performed improperly or if they did not change gloves or perform proper hand hygiene, the resident could get a urine infection. In an interview on 8/14/25 at 2:20 pm ADON she said they provide education, training and skills check offs to the CNAs for incontinent care at least annually. She said if there was an outbreak or any issues, they will provide the training again as needed. The ADON said she also did spot checks to ensure the CNAs were providing appropriate care. The ADON said it was an ongoing reminder and training for infection control. The ADON said the CNAs must perform hand hygiene before entering a resident's room and when completing any care. The ADON said if a resident was on precautions, such as EBP staff must remove PPE and place in appropriate disposal receptacle located inside of the resident's room, then complete hand hygiene. The ADON said when the CNAs provide incontinent care, they must change gloves when the gloves were soiled and must sanitize hands between removing soiled gloves and placing clean gloves. The ADON said the CNAs must sanitize hands anytime gloves were changed. The ADON said for a circumcised male, the CNA must clean the top of the penis by holding the shaft and cleaning in a circular motion, then clean the shaft from top to bottom towards the scrotum. She said the remainder of the front area must be cleaned from top to back. The ADON said the buttocks must be wiped from the bottom of buttocks up towards the lower back. The ADON said the CNAs must use the wipe once, then dispose of the wipe. The ADON said they must use a new wipe after each time they swipe. The ADON said if the CNAs did not use proper hand hygiene and incontinent care procedures or follow infection control protocols, the CNAs run the risk of cross contamination, and the resident could obtain a UTI. In an interview on 8/18/25 at 11:45 am the DON stated the Director of Clinical Education was usually in charge of annual competency check of the CNA's skills. The DON said the CNAs were the only staff that get checked off on incontinent care skills. The DON said the ADONs, and the DON did spot checks to help ensure proper care was being provided to the residents. The DON said when a CNA provided incontinent care, they must perform hand hygiene before starting care, when dirty gloves were removed and clean gloves applied and before they exit the room. She said CNAs must perform hand hygiene or hand sanitize between glove changes. The DON said wipes were used then disposed. She said CNAs must use one wipe per swipe. The DON said if a resident was circumcised, the CNA must hold the shaft of the penis, clean the tip of a penis in a circular motion, then dispose of the wipe. The CNA wiped the shaft of the penis from top to bottom. The DON said they must wipe down towards the scrotum. The DON said the CNAs must wipe the buttocks from the back of the back of the scrotal area up towards the lower back. She said they must wipe in the same direction regardless of if the resident was male or female. The DON said they must still use one wipe per swipe and must hand sanitize between glove changes. The DON said if incontinent care and hand hygiene were not done properly, residents can get an infection or UTI. Record review of CNA/Caregiver Competency Checklist dated 6/9/25 indicated CNA A was checked off as met on the following: Infection Control for hand hygiene and hand washing and PPE donning & doffing. Personal Care for Pericare/Incontinent Male and Pericare/Incontinent Female. Record review of Name of Skill: Hand-Hygiene form used as guidance for skills indicated,Purpose: To prevent cross contamination and the spread of infection. Guidelines and Precautions:1. Handwashing is the single most important method in the prevention and control of infection.2. Handwashing should be done at the following times: a. When coming on and going off duty. b. Before and after caring for each resident.c. Before applying gloves and after removing gloves. Record review of Name of Skill: PPE (Personal Protective Equipment) used as guidance for skills indicated, Purpose: Protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission as well as to protect the health care worker from occupational exposure to pathogens.Steps of ProcedureA. Donning Guidance: Disposable Isolation Mask, Gown and/or Gloves:1. Perform hand washing / hand hygiene before donning mask, gown and/or gloves.B. Doffing Disposable Isolation Gloves, Gown and/or Mask: .6. Lastly, perform hand hygiene. Record review of facility's Infection Prevention and Control policy revised April 2024, reflected,Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.1. Coordination/Oversight/Education.e. Staff will receive training on the community's infection prevention and control program to include but not limited to preventative measures, standard precautions, isolation precautions and enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions and isolation practices. 2. Policies and Procedures.b.The annual review will include: (2) Assessment of staff compliance with existing policies and regulations; .9. Prevention of Infection.a. Important facets of infection prevention include: .(3) educating staff and ensuring that they adhere to proper techniques and procedures; .(6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his /her role responsibilities and situation.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 Residents (Resident #1) that were reviewed for infection control and transmission-based precautions policies and practices, in that: LVN I failed to don (put on) the appropriate PPE before she entered Resident #1's room and provided medication on 03/10/25 at 7:27 PM. CNA M failed to don the appropriate PPE before she entered Resident #1's room to provide care on 05/11/25 at 08:02 PM. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: Record review of Resident #1's face sheet dated 05/08/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (chronic brain disorder that caused gradual decline in motor and non-motor functions) with dyskinesia (involuntary muscle movements), without mention of fluctuations, type 2 diabetes mellitus without complications (high levels of sugar in blood), encounter for attention to gastrostomy (feeding tube insertion), and dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident #1's 02/13/25 Quarterly MDS reflected a BIMS of 04 (severe cognitive impairment) and the use of a feeding tube. Record review of Resident #1's care plan dated 03/03/25 and initiated on 11/09/23 reflected Resident #1 had a focus of: Resident #1 required a feeding tube related to diagnosis: Adult failure to thrive; encounter for attention to gastrostomy; and dysphagia, oropharyngeal phase. Interventions included: EBP related to PEG tube. Observation of video footage on 05/13/25 at 11:45 AM from Resident #1's electronic monitoring device obtained from the Texas Unified Licensure Information Portal (TULIP) system revealed: -On 03/10/25 at about 07:27 pm, LVN I entered Resident #1's room not not donning a gown or gloves, instilling eyedrops to Resident #1's eye without proper PPE. -On 05/11/25 at about 7:47 PM, CNA M entered Resident #1's room without donning a gown when providing incontinent care. Observation of Resident #1's room on 05/08/25 10:15 AM, revealed the resident was not in room. Plastic drawers with PPE were outside of Resident #1's room with gowns. A box of gloves and hand sanitizer were stationed inside the room at the entrance with signage posted on the outside. There was a sign on Resident #1's door that reflected enhanced barrier precautions. Instructions indicated everyone must complete hand hygiene before entering and when leaving room and instructed providers and staff must also wear gloves and a gown for high contact resident care activities which included device care. Observation of Resident #1 on 05/08/25 at 10:28 AM revealed the resident was sitting by the nurse's station television area. The resident gave no response when surveyor attempted to talk with him. He looked straight ahead. In an interview on 05/13/25 at 01:38 PM, CNA B stated when a resident was on EBP, they were supposed to wear PPE. She said the PPE they were supposed to wear was gloves and gowns. She said she would not go into a room that had EBP sign on the door and not wear PPE because then there would be a risk of infection. In an interview on 05/13/25 at 01:40 PM, CNA C stated both gown and gloves were worn for EBP rooms. She said it was important to wear PPE to decrease the risk of infection. She said if there was a sign (EBP), she would wear both gown and gloves. In an interview on 05/15/25 at 04:17 PM, CNA K stated when she went into a room with EBP, she sanitized her hands, puts on a gown, and put on gloves before going into the room. She said it could cause cross-contamination if she entered the room without gown and gloves. She said she always wears gown and gloves with Resident #1 because he was EBP. In an interview on 05/15/25 at 04:57 PM, LVN F stated whenever medications were given, gloves were worn. She stated, if gloves were not worn, it would be an infection control issue or cross-contamination could happen. LVN F stated if going into a resident's room with EBP, a gown and gloves were worn. In an interview on 05/16/25 at 10:00 AM, the DON stated the nurse who instilled the drops was LVN I who no longer worked at the facility. The DON stated staff were in-serviced on infection control and EBP was ongoing and frequent. The DON was shown the video footage of LVN I and agreed that LVN I failed to follow the policy regarding PPE. The DON said LVN I failed to wear proper PPE on 03/10/25 at 07:27:15 PM when she had not donned gown or gloves before administering a medication. The DON was shown the video footage of CNA M and agreed CNA M failed to follow the policy regarding PPE. The DON stated CNA M failed to wear proper PPE on 05/11/25 at 08:02 PM when she did not don a gown for incontinent care. In an interview on 05/16/25 at 12:12 PM, ADON E stated she completed in-services with her CNAs and LVNs frequently. ADON E stated she performed spot check-offs on incontinent care, PPE, etc. ADON E stated not wearing a gown and gloves when performing care on a resident who was on EBP, would increase the risk of infection and/or cross-contamination. In an interview on 05/16/25 at 01:46 PM, ADON G stated CNAs were in-serviced usually once a month on infection control and incontinent care every couple days and annually. ADON G stated the ADONs observed random check-offs periodically. ADON G stated EBP training was on-going. ADON G stated Resident #1 was on EBP which meant a gown and gloves were to be donned before going into the room for infection control. ADON G said LVNs and MAs were spot checked for medication administration every time the pharmacy went in to destruct medications (varying times). Attempted telephone interview on 05/16/25 at 03:42 PM with CNA M the CNA who had not worn a gown into Resident #1's room to provide care. Call went directly to voicemail. Voicemail left. In an interview on 05/16/25 at 03:55 PM, LVN I stated when she worked at the facility, they were in-serviced on infection control and PPE like every other day. She said she would always gown and glove up before going into a resident's room to give medications. She said if she did not, she could pass along infections or even cross-contaminate and that would not be good. Record review of the facility's Infection Prevention and Control Program policy revised on April 2024 reflected Enhanced Barrier Precautions maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. EBP requires the use of gown and gloves during high-contact resident care activities. The policy indicated high contact activities included: Device care or use (central line, urinary catheter, feeding tube).

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 Residents (Resident #1) that were reviewed for infection control and transmission-based precautions policies and practices, in that: LVN A failed to don (put on) the appropriate PPE before she entered Resident #1's room and provided care to Resident #1's PEG tube on 02/04/25 at 3:15 PM, on 02/06/25 at 7:47 PM, and on 02/18/25 at 7:25 PM and 10:13 PM. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: Record review of Resident #1's face sheet dated 02/10/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (chronic brain disorder that caused gradual decline in motor and non-motor functions) with dyskinesia (involuntary muscle movements), without mention of fluctuations, type 2 diabetes mellitus without complications (high levels of sugar in blood), encounter for attention to gastrostomy (feeding tube insertion), and dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS also reflected the use of a feeding tube while a resident. Record review of Resident #1's care plan dated 02/10/25 and initiated on 11/09/23 reflected Resident #1 had a focus of: Resident #1 required a feeding tube related to diagnosis: Adult failure to thrive; encounter for attention to gastrostomy; and dysphagia, oropharyngeal phase. Interventions included: EBP related to PEG tube. Record review of Resident #1's order summary report dated 02/10/25 reflected Resident #1 had an order for, EBP (Enhanced Barrier Precautions): Practice EBP as indicated. every shift. Order had an order status of active and an order start date of 11/08/24. Observation of video footage from Resident #1's electronic monitoring device obtained from the Texas Unified Licensure Information Portal (TULIP) system revealed: -On 02/04/25 at about 3:15 PM, LVN A entered Resident #1's room with only gloves and did not don a gown. LVN A applied a gauze on Resident #1's PEG tube without proper PPE. -On 02/06/25 at about 7:47 PM, LVN A entered Resident #1's room without donning gown or gloves. LVN A applied a gauze on Resident #1's PEG tube without proper PPE. -On 02/18/25 at about 7:25 PM, LVN A entered Resident #1's room without donning gown or gloves. LVN A applied a gauze on Resident #1's PEG tube without proper PPE. -On 02/18/25 at about 10:13 PM, LVN A entered Resident #1's room without donning gown or gloves. LVN A applied a gauze on Resident #1's PEG tube without proper PPE. Observation and attempted interview of Resident #1 on 02/12/25 at 3:20 PM revealed resident did not answer questions. Observation revealed a container of gowns outside of Resident #1's room and a box of gloves and hand sanitizer stationed inside the room at the entrance with signage posted on the outside of. There was a sign on Resident #1's door stating enhanced barrier precautions. Instructions indicated everyone must complete hand hygiene before entering and when leaving room and instructed providers and staff must also wear gloves and a gown for high contact resident care activities which included device care. Interview with LVN A on 02/20/25 at 1:35 PM revealed LVN A said Resident #1 was on EBP because of the PEG tube. LVN A said she was aware she needed to wear gown and gloves to provide care. LVN A said this included anything dealing with the PEG tube such as administering the feedings, medications, or handling the PEG tube in any manner. LVN A said she always ensured to wear the appropriate PPE with Resident #1 which was gown and gloves. LVN A said she wore the appropriate PPE to change or apply the gauze for the PEG tube. LVN A said she did not recall any days that she did not follow the PPE and EBP guidelines. LVN A said she was trained and in-serviced on infection control, PPE, and the different precautions including EBP. LVN A said she received training during orientation upon being hired and as refreshers but did not recall the dates. LVN A said there were plenty of gowns and gloves available to the staff. LVN A said it was important for staff to wear the proper PPE when working with residents on EBP for the safety of the residents and to prevent spreading of infections or decline in health. LVN A was not shown video footage as LVN A was not at the facility as it was her day off. Interview with the ADON on 02/21/25 at 10:25 AM revealed the ADON assisted and provided in-services on infection control and placed the signs and bins with PPE supplies outside the rooms of the residents that required certain precautions. The ADON said Resident #1 was on EBP because of the PEG tube Resident #1 required for feedings and medication administration. The ADON said the staff that provided direct care needed to wear gown and gloves at all times. The ADON said if the nurse handled the feeding tube in any way, such as to administer feedings, medications, or change/apply the gauze, the nurse had to wear the proper PPE which was gown and gloves. The ADON was shown the video footage of LVN A and agreed that LVN A failed to wear proper PPE on 02/04/25 at 3:15 PM, on 02/06/25 at 7:47 PM, and on 02/18/25 at 7:25 PM and 10:13 PM, when LVN A applied a gauze on Resident #1's PEG tube without donning gown and gloves. The ADON said LVN A was trained on infection control, PPE, and EBP guidelines. The ADON said failure to wear the proper PPE could place the residents at risk of not being protected from the spread of MDROs. Interview with the DON on 02/21/25 at 12:35 PM revealed the DON said Resident #1 was on EBP because Resident #1 had a feeding tube. The DON said staff were aware that they had to wear gown and gloves to provide direct care (high contact activities) for residents with EBP which included residents that had wounds, foleys, and PEG tubes. The DON said high contact activities included tasks such as transferring, changing, giving medications, administering feedings, emptying the foley, and dressing. The DON said staff were in-serviced on infection control, including EBP, during orientation upon hire, annually, and as needed. The DON said the staff had gowns, gloves, and necessary supplies available. The DON said the facility policy stated gowns and gloves should be used during high contact activities with residents on EBP. The DON said she ensured staff wore the appropriate PPE by doing rounds and seeing staff go in and out of the rooms and providing them with in-services as needed. The DON was shown the video footage of LVN A and agreed that LVN A failed to follow the policy regarding PPE. The DON said LVN failed to wear proper PPE on 02/04/25 at 3:15 PM, on 02/06/25 at 7:47 PM, and on 02/18/25 at 7:25 PM and 10:13 PM, when LVN A applied the gauze for Resident #1's PEG tube without donning gown and gloves. The DON said LVN A was trained on infection control, PPE, and EBP guidelines. The DON said failure to wear the proper PPE could place the residents at risk of not being protected from the spread of MDROs or other infections. The DON said LVN A would be re-educated. Record review of the facility's Licensed Nurse Competencies Checklist document reflected LVN A completed infection control competencies, including isolation techniques (masing, gowning, gloving, resident equipment) and proper signage - EBP. Document was signed by: LVN A and the ADON on 01/09/25. Record review of the facility's In-service attendance sheet dated 01/27/25 reflected LVN A's signature. The in-service covered the topic of PPE. Record review of the facility's Infection Prevention and Control Program policy revised on April 2024 reflected Enhanced Barrier Precautions maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. EBP requires the use of gown and gloves during high-contact resident care activities. The policy indicated high contact activities included: Device care or use (central line, urinary catheter, feeding tube).

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 5 rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to ensure the facility was sanitary when the facility did not effectively clean room [ROOM NUMBER]'s shower as there was a white dirty towel with brown colorations. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment. The findings included: Observation on 02/14/25 at 12:15 PM revealed room [ROOM NUMBER] had a white dirty towel with brown colorations in the private shower area. Interview with HK J on 02/21/25 at 9:15 AM revealed HK J said the rooms were cleaned every day which included cleaning the room, restroom, shower area for those with showers, and floors. HK J said she cleaned hall 300 and had no concerns brought up for room [ROOM NUMBER]. Observation on 02/21/25 at 9:30 AM revealed room [ROOM NUMBER] had a white dirty towel with brown colorations in the same exact area of the private shower. Interview with HK S on 02/21/25 at 9:50 AM revealed HK S said the rooms were cleaned every day which included dusting, sweeping, mopping, cleaning the restroom, sink, toilet, and shower. HK S said for the residents with private showers, the housekeeping staff cleaned the shower and then also cleaned the main shower area in the hallway. HK S said there were no concerns or issues brought up for room [ROOM NUMBER]. HK S said it was important to keep a clean environment for the residents. HK S said staff kept the facility safe and sanitary, but it was a team effort and housekeeping as well as other staff could assist in keeping the rooms clean. HK S said if there was a dirty towel or other used linen in the shower, the housekeeper could have picked it up or told the CNAs. HK S was shown a photo of the dirty towel in the shower of room [ROOM NUMBER]. HK S said maybe when they were showering the resident, the towel fell and nobody saw it. HK S said anyone that saw the towel, should have removed it, put it in the dirty laundry or should have made the CNAs aware to get it. HK S said he was not aware of the dirty towel being in the shower for a week or more but he would ensure to address this issue with his department. Interview with the DON on 02/21/25 at 12:35 PM revealed the DON was shown a photo of the dirty towel in the shower of room [ROOM NUMBER]. The DON said the dirty towel should not have been there for a week or more. The DON said if someone, like housekeeping or CNAs saw the towel, they should have removed it. The DON said there was no negative outcome to the residents from the dirty towel but she would ensure to in-service staff. Interview with the ADM on 02/21/25 at 1:50 PM revealed the ADM was shown a photo of the dirty towel in the shower of room [ROOM NUMBER]. The ADM said this issue had been brought to her attention today. The ADM said although there was no negative outcome to the residents, it was important to keep a sanitary, clean, and comfortable environment. Record review of the facility's Physical Environment policy revised on January 2023 reflected Other environment conditions: The community environment is safe, functional, sanitary, and comfortable for residents, team members, and the public.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for four Residents (Resident #76, Resident #93 ) of eight residents whose records were reviewed for elopement and supervision. 1.The facility failed to ensure Resident #76, and Resident #93 received adequate supervision. Resident #76 eloped from the facility memory unit on 10/22/2022 & 12/19/22. Resident #93 eloped on 1/30/23. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 12/18/22 and ended on 2/13/23. The facility corrected the non-compliance before the survey began. These failures could place the residents with exit seeking behaviors at risk for injury or death and could place residents at risk for smoking-related injuries. Findings were: 1. Record review of R#76's Order Summary Report dated 7/14/23 revealed an [AGE] year-old male with diagnoses of ST Elevation Myocardial Infraction Involving (STEMI) other coronary artery of inferior wall (most severe type of heart attack), Essential (Primary) Hypertension (pressure in blood vessels is too high), Unspecified dementia (loss of thinking, remembering, reasoning) Unspecified severity with other behavioral disturbance, and Peripheral vascular disease (slow circulation disorder). Record review of R#76's MDS Section C dated 4/27/23 revealed resident had a BIMS Score of 00 (Severely Impaired Cognition). Resident is able to ambulate with no assistive devices. Record review of R#76's Care Plan dated 11/14/22 revealed: Focus: I am exit seeking impaired safety awareness. Interventions: - arrange furniture placement such as tables positioned in the dining room area to distract from exit doors in that area. -Increased and /or frequent monitoring to validate safety -Sleep pattern on resident to be established -Promote activity and exercise during day so that I can rest at night. Record review of the facility's incident report dated 10/22/22 at approximately 6:41am revealed R#76 eloped from facility through the library window in the Memory Care Unit. An open window to the Memory Care Unit library was observed by CNA T. Resident #76 was found by police almost two miles from the facility. Speed limit at 30 mph (miles per hour). Resident #76 was taken to ER by police then returned to facility. Physical injuries sustained to face were skin laceration to right eyebrow and laceration to nose bridge, skin abrasion to right shoulder, skin discoloration noted to right elbow, skin abrasion to right knee. Record review of the facility's incident report dated 12/19/22 revealed Resident #76 eloped again on 12/18/22 at approximately 11:48 p.m. He was seen on camera eloping from facility through the dining room door in the Memory Care Unit. LVN P heard the door alarm, went to look, saw nothing, the door alarm turned off, and the nurse went back to her station. At approximately 12:00 am, Police called to notify facility they had taken Resident #76 to ER for evaluation. Resident #76 returned to facility from ER with no skin discolorations, skin tears, cuts, abrasions or any injuries. Record review of Police Department Incident Report dated 12/18/22 stated the temperature outside at the time was at 53 degrees. -In an interview with LVN P on 7/13/23 at 3:30 pm revealed that on 12/18/22 at 11:48 pm an alarm went off, LVN P said she heard the alarm from the dining area but as she approached the area, the alarm turned off. She said she looked outside but did not go check outside. She said she knew she was supposed to check outside and knew the procedure for elopement but did not follow it. She stated she received in services and trainings on resident elopements after the incident and also have monthly in services after incident with Resident #76. -In an interview on 7/13/23 at 9:52 p.m. CNA P said stated he received in services and trainings on resident elopements after the incident with Resident #76 and also have monthly in services. - In an interview on 7/13/23 at 10:35 am LVN X stated he received in services and trainings on resident elopements after the incident with Resident #76 and also have monthly in services. Record review of R#93's Admission Record dated 7/17/23 revealed an [AGE] year-old male with an initial admitted [DATE]. His diagnoses included Type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), Essential (Primary) Hypertension (pressure in blood vessels is too high), Unspecified dementia (loss of thinking, remembering, reasoning) Unspecified severity without behavioral disturbance, Muscle wasting & atrophy not elsewhere classified Unspecified site. Record review of R#93's Care plan revealed; Focus: I am exit seeking, I am at risk for elopement and/or wandering with unsafe boundaries r/t: Dementia Interventions/Tasks: - Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of the facility's incident report dated 1/30/23 revealed Resident #93 eloped through exit door on 01/30/2023 at approximately 7:35 am, alarm sounded in 400 hall. Two employees went towards exit door where alarm had been set off. They looked outside through the window but did not see Resident #93 outside. RN L proceeded to disengage the alarm. Resident #93 was found by another staff member outside the facility near the facility sidewalk. Resident #93 was unharmed. -On 7/11/23 at 11:25 am observation of resident sitting in wheelchair in living room area of secure unit. Resident residing in room [ROOM NUMBER] - A in secure unit as a result of elopement incident. In an interview on 7/14/23 at 8:24 am the DON stated that the employees who responded to the elopement of Resident #93 were both terminated due to not following elopement procedures. According to DON, RN L and Floor Tech D responded to an alarm on 1/30/23, they walked towards the exit doors but did not go outside to check for residents. As per DON, RN L then proceeded to turn off the alarm. DON also stated that both Floor Tech D and RN L were terminated as the result of the investigation on Resident #93's elopement. DON also stated, the facility placed a white affixed box with a keypad outside the DON's office. The box contains keys to turn off alarms when alarms are activated. The DON and Administrator were the only ones who had the code to open the box. The staff must follow elopement protocol before they can request the keys from DON/Administrator to turn off alarm. -Record review of in-services dated 12/19/22 revealed; All staff were in-serviced for Door Alarms/Missing person protocol, how to identify residents at risk for elopement, how to supervise, monitor, and redirect residents, at risk for elopement. Additionally, staff were in-serviced post elopement policy and the facility elopement book and elopement drills are being conducted monthly. - On 7/14/23 at 11:35 am a white box with keypad was observed outside the office of DON's office. -Resident #93 was reassessed for placement in the memory care support unit, pending IDT evaluation of status and continued need for placement. Record review of the Missing Resident/Elopement Facility Policy dated 5/23/22 stated; When an elopement occurs; All team members will be alerted to search in the community or grounds as soon as there is an awareness of the resident missing If the resident is not quickly located in the community or on the grounds a point person is designated to make the notifications to staff. Observation of the locked box in a med cart in the nurse's station on the memory care unit and interview with RN-A on 07/14/23 at 11:08 am, RN-A stated the process for residents to smoke was for them to collect their smoking materials at the nurse's station and a staff or family member would take the lighter and light the residents' cigarettes. RN-A stated he was unsure of the smoking times, and only one or two residents in the memory care unit smoked. A review of an undated list of residents who smoke provided by the facility on 07/12/23 revealed five residents in the facility that smoked cigarettes. Record review of the facility Smoking Guidelines-Residents revised 05/11/12 documented .A smoking assessment shall be completed on admission and updated quarterly and more frequently as deemed necessary .Resident smoking materials shall be turned in to the charge nurse. No resident shall be allowed to keep cigarette lighters, matches, or smoking materials in any other area than the nursing station . 44748

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for three of ten residents (Resident#127, Resident #128, and Resident #112) reviewed for accidents and supervision, 1)NA B provided incontinent care to Resident #127 alone. Resident #127 was a two person assist and fell from the bed while care was being provided by NA B and he sustained a laceration to the forehead which required 10 sutures and a three day hospitalization . 2)CNA C provided Resident#128 incontinent care alone. Resident #128 was a two person assist during incontinent care. 3)NA D provided Resident#112 incontinent care alone. Resident #112 required a two person assist during incontinent care. These failures could place residents who require supervision at risk of accidents or injury. The findings included: The findings were: 1)Record review of Resident #127's Order Summary Record, dated 05/28/21, revealed Resident #127 was a [AGE] year-old male and was admitted to the facility on [DATE]. Resident #127 was readmitted on [DATE]. Resident #127's diagnoses included: Dementia, Lack of Coordination, Alzheimer's Disease, and Cognitive Communication Deficit. Record review of Resident #127's quarterly MDS, dated [DATE], revealed Resident#127: -had severely impaired cognitive status, with a Brief Interview of Mental Status score of 3, -required total assistance with two-person physical assist for bed mobility, transfers, and dressing -activity did not occur for toilet use. -was always incontinent for bladder and bowel, and -had no falls since re-admission or last assessment. Record review of Resident #127 Care Plan date initiated 05/10/19 revealed: I have an ADL self-care performance deficit due to Dementia: Toilet use: the resident requires (total assistance) by (2) staff toileting. Record review of Incident Report for Resident #127 revealed: 05/15/2021: [LVN A]; CNA notified me that resident had fallen off his bed. I went to resident's room and upon entering I noticed resident laying face down on his right side to the right side of his bed. Bed was to the highest position. I walked around to the left side of resident's bed and noticed blood underneath resident's head. Resident was alert and talking. I asked him if he was okay and resident stated yes. -Description; EMS came in at 16:05 [4:05 p.m.]. EMS left facility with resident awake, alert and speaking at 16:21 [4:21 p.m.]. Record review of Progress notes for Resident #127 revealed: 05/18/2021: Resident arrived to facility via stretcher accompanied by EMS staff x 2. Resident AAx1 to person, vital signs within normal range. Head to toe assessment done fading discoloration to mid forehead with laceration 0.5 x 4.5 cm 10 sutures in place. Noted with purple discoloration under bilateral eyes. healing abrasion to right shoulder 0.3x0.3 cm. Purple discoloration right posterior forearm 2.5x1.5 cm [centimeters] [length X width], red discoloration 1.5x0.5 to left posterior forearm. Record review of Resident #127's Care Plan, date initiated 05/18/21, revealed: The resident has a laceration of the right forehead r/t s/p fall: Identify potential causative factors and eliminate/resolve when possible. Record review of Resident #127's Activities of Daily Living [from Kardex] revealed: 05/28/21: Toileting; Toilet use: the resident requires (total assistance) by (2) staff for toileting. Observation of Resident #127's bedroom on 05/25/21 at 10:45 a.m., revealed resident in his room in bed, awake. Further observation revealed dark laceration on his forehead was visible. Resident #127 cognitive status was severely impaired and he did not respond to greeting. In an interview on 05/28/21 at 9:25 a.m., the DON revealed that, when NA B had provided care for Resident #127, the resident fell to the floor and was sent to the hospital. The DON confirmed Resident #127 was a two person assist for incontinent care, but NA B provided incontinent care by himself. The DON said, while NA B provided assistance, the resident jerked and fell to the floor. The DON said, as per NA B, the other CNA on the floor was assisting another resident, and he (NA B) proceeded to assist Resident #127. In an interview on 05/28/21 at 10:08 a.m., CNA C said Resident #127 required total care with a two person assist. CNA C said Resident #127 did not participate in his care, and everything had to be done for him. CNA C said Resident #127 did not move in bed or reposition himself. CNA C said after the incident, they were in-serviced about the two person assist for Resident #127 at all times. In an interview on 05/28/21 at 1:00 p.m., NA B said he provided incontinent care to Resident #127 when the resident shook and fell to the floor. NA B said he attempted to hold onto Resident #127, but could not. NA B said he was not aware that Resident #127 was a two person assist because he was not very knowledgeable of how to find the information in the computer. NA B said none of his co-workers had mentioned to him that Resident #127 was a two person assist. NA B said he had assisted Resident #127 before with no issues. In an interview on 05/28/21 at 01:51 p.m., LVN A said Resident #127 was occasionally alert x 1 and required total assistance x 2-person assist. She said, on the day of the incident, she was called by NA B who said Resident #127 had a fall while he had provided incontinent care. She said she had two CNAs on the floor, but she was not aware why NA B had not asked for assistance when he went to provide incontinent care for Resident #127. In an interview on 05/28/21 at 02:14 p.m., the DON said CNA B was not aware that Resident #127 required a two person assist for incontinent care. She said after the incident facility made a change to assign two CNAs to train new CNAs, to make sure that new staff was aware of the level of assistance that residents required. In an interview on 06/11/21 at 1:40 p.m., the DON said ADONs (Assistant Director of Nurses) and Mentor CNAs trained new staff on the use of the Kiosk computer. In an interview on 06/11/2021 at 3:46 p.m., NA B said after Resident #127 fall he was trained on the use of computer and how to find the ADL Kardex. He said the Kardex had the information on what level of care each resident required. He said on the day of the incident he went by himself to provide incontinent care for Resident #127. NA B said he had repositioned Resident #127 to face the door, and his back was facing him. He said with his right hand he was holding him from the hip area, and with the left hand he was pushing down an incontinent pad. He said Resident #127 started to shake and fell to the floor. He said was not aware that he was a two person assist for toileting or incontinent care. 2) Record review of Resident #128's Face Sheet, dated 06/12/21, revealed Resident #128 was a [AGE] year-old male and was admitted to the facility on [DATE]. Resident #128's diagnoses included: End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Autonomic (Poly) [CONDITION(S)], Dependence on Renal [CONDITION(S)], Hypertension, Presence of Cardiac Pacemaker, Obstructive and Reflux [CONDITION(S)], acquired absence of right leg above knee, Age-related [CONDITION(S)] without current pathological fracture, [CONDITION(S)] liver disease, vascular dementia with behavioral disturbance, [CONDITION(S)], peripheral vascular disease, and acquired absence of left leg below knee. Record review of Resident #128's quarterly MDS, dated [DATE], revealed Resident#128: -Brief Interview of Mental Status score of 10, -required extensive assistance with two-person physical assist for bed mobility, dressing, and toilet assistance (catheter) -total dependence with two-person assist for transfers -was always incontinent for bowel, and -had no falls since admission or last assessment. Record review of Resident #128's Care Plan, date initiated 05/18/21, revealed: -The resident is (High) risk for falls. -I have a Self Care deficit r/t (related to) I have above the knee amputation on left leg. 6/11/2021 Therapy reassessed resident for bed mobility. Bed Mobility: x 1 person assistance Revision on 06/11/2021. Record review of Resident #128's 06/11/2021 Visual/Bedside Kardex Report revealed: -Toileting/Bowel and Bladder Status: Incontinent Care x 2 person assistance. -Bed Mobility: x 2 person assistance. -Transfers: x 2 person assistance with Hoyer Lift. -Turning & Repositioning: x 2 person assistance. Observation on 06/11/21 at 10:13 a.m., revealed CNA C entering Resident 128's room. CNA C was observed performing bowel incontinent care on Resident#128 in resident's room. Observation of Point Click Care (PCC) revealed resident was Extensive 2+ person assist for bed mobility, dressing, and toilet assistance per MDS and Care Plan revealed resident was a 2 person assist for bed mobility and a 2 person assist for Toilet use/incontinent care, and 2 person assist for transfers. In an interview on 06/11/21 at 10:13 a.m., CNA C stated, I have worked here for 2 ½ - 3 years. I am training on the computer and I was given training for CNA. I can see how many CNAs are needed to transfer, change, etc., for a resident in the book or on the kiosk. He (Resident 128) is able to turn himself. I usually have help, but I realized that he needed changed and changed him. The only time I check the information (in the computer) is when there is a new resident because I work this hall and I know the residents. In an interview on 06/11/21 at 01:30 p.m., DON stated that new hire CNAs are trained by another CNA who has been working at the facility for longer. The CNA is responsible for training the new hire on the kiosk for level of care areas. ADON makes sure CNAs are being trained. There is no documentation of the ADON checking that the CNA has been trained on level of care. Record review of Resident #112's Face Sheet, dated 06/12/21, revealed Resident #112 was a [AGE] year-old male and was admitted to the facility on [DATE]. Resident #112's diagnoses included: Chronic Obstructive Pulmonary Disease, Acute Kidney Failure, Type 2 Diabetes Mellitus without complications, [CONDITION(S)], Chronic Diastolic (Congestive) Heart Failure, Hypertension, [CONDITION(S)], Acquired absence of other specified parts of digestive tract, retinal [CONDITION(S)], Gastro-[CONDITION(S)] Reflux Disease, anxiety disorder, [CONDITION(S)] without current pathological fracture, abnormalities of gait and mobility. Record review of Resident #112's quarterly MDS, dated [DATE], revealed Resident#112: -Brief Interview of Mental Status score of 11, -required extensive assistance with two-person physical assist for bed mobility, transfer, and toilet use -required extensive assistance with one-person physical assist for dressing -frequent urinary incontinence and occasional incontinent for bowel, and -had no falls since admission or last assessment. Record review of Resident #112's Care Plan, date initiated 05/04/21, revealed: -The resident has an ADL self-care performance deficit r/t (related to) CHF (Congestive Heart Failure). SCIC [significant change of condition] done 6/11/2021 due to improvement in ADLs. -Bed Mobility: The resident requires no assistance from staff for bed mobility. Revision on 06/11/2021. -Toilet use/incontinent care: The resident requires assistance x 1 person. Revision on 06/12/2021. -Transfer: The resident requires assistance x1 staff. Revision on 06/12/2021 (after surveyor intervention). Record review of Resident #112's 06/11/2021 Visual/Bedside Kardex Report revealed: -Toileting: The resident requires assistance from one person staff for toileting. -Bed Mobility: The resident requires assistance from 1-2 person staff to turn and reposition in bed as necessary. -Transferring: The resident requires assistance from one - 2 staff to move between surfaces as necessary. Observation on 06/11/21 at 10:20 a.m., revealed NA D entering Resident#112's room. NA D came out of Resident#112's room carrying a clear plastic trash bag containing a used adult brief. Observation of Point Click Care (PCC) revealed resident was Extensive 2+ person assist for bed mobility, transfer, and toilet use. In an interview on 06/11/21 at 10:24 a.m., NA D stated she had changed (incontinent care) Resident#112 alone. NA D said that she was trained at the facility. She said, I watched videos at first then they put me with someone. There were two others on the hall working and I went with them. I did that for about a week. They showed me how to mark on the computer. They said I could check details on the computer. When I'm not sure, I check 'Details' on the resident on the computer. I've been working here for about a year next month. I had some time off but came back. They did a skills check off within the first month of being here, but nothing since then. (Resident#112) helps me lift and gets up. He doesn't want CNA C to go in there because she doesn't speak English. If he would fall when I was in there by myself, that would be on me because I don't want to upset him by having CNA C in there. He tells me when he can help and when he can't. If he can't, I get someone to help. I did not know the record said he needs two people. In an interview 06/11/21 at 11:24 a.m. ADON stated that the ADONs make sure the CNAs are trained on level of care. There is no documentation to show that the CNAs have been trained. They show them, but don't write anything down. In an interview on 06/11/21 at 03:20 p.m., with Resident#112 stated the ADON already came to tell him that he had to have two people helping him. He said that there were times that he did not need help, but if it was in his care plan, then he would be good with it. He said that it was a problem if they (CNAs) did not speak English, but he could deal with it. Record review of Facility's policy on Fall Management, revised 03/04/14, revealed: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents, for one Resident (R#1) of eight residents reviewed for accidents/supervision. OTA A failed to place footrests on R#1's wheelchair prior to transporting R#1 to therapy, causing R#1 to sustain a fracture below her right knee. This failure could place dependent residents at risk for neglect and injuries. The findings were: Record review of R#1's March 2020 Order Summary Report revealed R#1 was 96-years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Significant change in status Minimum Data Set, dated dated [DATE], revealed R#1: -had clear speech; -was usually understood by others; -usually understood others; -had adequate vision; -had severe cognitive impairment; -required limited assistance from staff with personal hygiene and eating; -required extensive assistance from staff with locomotion on unit, locomotion off unit, dressing, and toilet use; -was totally dependent on staff with bed mobility, transfers, and bathing; -was not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; -had a lower extremity functional limitation in range of motion impairment on one side; and -received physical therapy. Record review of the facility's Provider Investigation Report, dated 03/12/20, revealed on 03/10/20 at approximately 4:38 p.m., OTA A went to the 800 hall to take R#1 to the rehab gym for her therapy session. OTA A pushed R#1 in her wheelchair down the 800 hall, while R#1 lifted her legs off the floor. As OTA A continued wheeling R#1, OTA A heard R#1 scream. R#1's right leg was bent backwards and towards/under the seat portion of the wheelchair. R#1 was sent to the hospital where x-rays were obtained of her right leg. The x-rays revealed a non-displaced tibial fracture. The facility's investigation revealed R#1's wheelchair did not have footrests when OTA A was wheeling her to the rehab gym. Review of R#1's Care Plan, dated 05/04/20, revealed in part, the Focus area: As I was being wheeled down the hallway in 800 hall, my leg dragged under when I was being wheeled. 3/12/2020 Resident with fracture right below the knee, resident is not a candidate for surgery due to age and cor-morbidities (sic). Resident will be bedbound for 4 weeks. Date Initiated: 03/11/20. Created on: 03/11/20. Revision on: 03/12/20. This focus area revealed the following Interventions: .2. Leave leg immobilizer to right lower leg .5. Make sure that I have foot rest when I am in wheelchair. Date Initiated: 03/11/20, Created On: 03/11/20, Revision On: 05/07/20. Review of an untitled and undated facility form from the activities of daily living book, which listed residents from the 800 hall and indicated if the residents used wheelchairs and footrests revealed R#1 used a wheelchair with footrests. During an interview on 05/07/20 at 2:22 p.m., OTA A said she did not notice footrests on R#1's wheelchair when she went to pick R#1 up for therapy. OTA A said she asked R#1 to hold her feet up and, because R#1 could do this, she thought R#1 did not need footrests. OTA A said R#1 had used footrests on her wheelchair in the past. OTA A said she overlooked that R#1 did not have footrests on her wheelchair that day. OTA A said she was wheeling R#1 down the hallway with her feet up when she heard R#1 scream. OTA A said she went around and found R#1's left foot out front and her right foot a little under her wheelchair. During an interview on 05/07/20 at 3:25 p.m., R#1 said she did not remember when her right leg was injured. During an interview on 05/08/20 at 2:45 p.m., the Director of Nursing said she had been in a meeting when she was notified of R#1's injury. The Director of Nursing said OTA A should have placed footrests on R#1's wheelchair before taking her to therapy. The Director of Nursing said OTA A did not place footrests on R#1's wheelchair, which caused R#1 to sustain a fracture. Record review revealed that, after this incident, the facility conducted an audit of all wheelchairs and created a spreadsheet for each hall. Staff to use this spreadsheet to understand which residents required wheelchairs with footrests. There have been no further incidents. Record review revealed in-services 03/10/20 and 03/11/20 on, When placing resident in wheelchair, if resident does not self-propel please ensure footrests are in place. If resident does not want footrests, let charge nurse know so it can be care planned. Review of the facility policy titled, Adequate supervision and assistance devices to prevent accidents, with a revision date of 05/19/15, revealed: The community identified residents who may be at risk for accidents and/or falls. An 'accident' is an unexpected, unintended event that can cause a resident bodily injury. It does not include adverse outcomes associated with consequences of treatment or care. Assessments and care plans are used to develop and implement procedures to prevent accidents.

Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents and ensure safety for one Resident (R#1) of six residents reviewed for falls, in that: -The facility failed to implement effective measures of supervision when R#1 continued to fall, including falls with injury. -Within a three month period on the Memory Support Unit (MSU), R#1 fell 12 times, including six falls in the common area, sustaining injuries which included abrasion, bleeding, and bruising to the top left side of the head, abrasion to the buttocks, and a Cerebral Hemorrhage. -R#1 sustained a fracture of unknown origin to the collarbone. -Staff failed to replace R#1's wheelchair body alarm after providing care for R#1. These failures could place all 53 residents on the MSU at risk for falls and serious injuries. The findings were: Undated Admission Record revealed R#1 was an [AGE] year-old male with an admission date of [DATE]. October 2014 Physician order [REDACTED]. Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -was able to hear adequately, -had clear speech, -exhibited wandering behavior which occurred 4 to 6 days, but less than daily, -required supervision (setup help only) from staff for bed mobility, walking in room, walking in corridor, locomotion on unit, eating, and personal hygiene, -required limited assistance from one staff for transfers, locomotion off unit, dressing, and toilet use. Surveyor Occurrence Report dated 07/02/14 indicated R#1 fell in the common area because his left shoe had no strap, causing him to stumble while ambulating. No injuries were noted. A Certified Nurse Aide (CNA) was quick to prevent the fall and thus intercepted the fall and she lowered R#1 to the floor. Acute Care Plan-Falls dated 07/02/14 indicated R#1 had falls related to mental status, history of falls and ambulation status/unsteady. Approaches included: -place call light in reach, -encourage resident to ask for assistance for transfers and ambulation, -ensure that resident has proper footwear when ambulating, -ensure that lighting in room will support visual mobility, -orient resident to room environment, -encourage resident to call for assistance. Surveyor Occurrence Report dated 07/06/14 indicated R#1 had an unwitnessed fall in another resident's room. R#1 had no complaints of pain or discomfort, after complete assessment was done, and no injuries noted. Acute Care Plan-Falls dated 07/06/14 indicated R#1 had falls related to mental status. Approaches included: -place call light in reach, -encourage resident to ask for assistance for transfers and ambulation, -ensure that resident has proper footwear when ambulating, -ensure that lighting in room will support visual mobility, -use magnetic alarm (body alarm with a string attached to the resident's clothing on one end and attached to a magnet on the other. The alarm sounds when movement of the resident detaches the magnet from the alarm box). Fall Risk Evaluation dated 07/06/14 indicated R#1: -was disoriented at all times, -had 1-2 falls in the past 3 months, -was ambulatory/incontinent, -had adequate vision, -had balance problems while standing or walking -had decreased muscular coordination, -had gait problems: jerking, unstable when making turns, unsteady gait, and shuffling gait, -had no noted drop in systolic blood pressure between lying and standing, and, -had 3 or more predisposing diseases. The Fall Risk Evaluation form indicated a score of 10 or above represented High Risk for falls. R#1's score was 19. Surveyor Occurrence Report dated 07/29/14 indicated R#1 was ambulating in the 700 hallway and entered room 716. R#1 was, "later found on the floor face down between A bed and B bed, no witness to fall noted. No injuries were noted after a head to toe assessment was done." Recommendations were: -"Place call light within reach." (R#1 was found on the floor of another resident's room), -"Encourage resident to ask for assistance for transfers and ambulation.", -"Toilet resident according to plan.", -"Ensure resident had proper footwear when ambulating.", -"Ensure that lighting in room will support visual mobility." (R#1 was found on the floor of another resident's room), -"Orient resident to room environment." (R#1 was found on the floor of another resident's room), and, -"When awake keep in common area for monitoring." Acute Care Plan-Falls dated 07/29/14 indicated R#1 had history of falls related to unsteady gait. Approaches included: -place call light in reach, -encourage resident to ask for assistance for transfers and ambulation, -toilet resident according to plan, -ensure that resident has proper footwear when ambulating, -ensure that lighting in room will support visual mobility, -orient resident to room environment, -when awake keep in common area for monitoring. Surveyor Occurrence Report dated 07/30/14 indicated R#1 was sitting in a chair in the common area, then stood up, lost his balance, and fell on his side, no injuries noted. R#1 was sent to the hospital emergency room for evaluation, no fractures were found. Acute Care Plan-Falls dated 07/30/14 indicated R#1 had history of falls related to gait/balance. Approaches included: -place call light in reach, -encourage resident to ask for assistance for transfers and ambulation, -toilet resident according to plan, -ensure that resident has proper footwear when ambulating, -ensure that lighting in room will support visual mobility, -use magnetic alarm, -use pressure pad alarm (pad placed under the resident's body which activates an alarm when the resident attempts to rise). Fall Risk Evaluation dated 07/30/14 indicated R#1: -was disoriented at all times, -had 1-2 falls in the past 3 months, -was ambulatory/incontinent, -had adequate vision, and, -had balance problems while standing or walking -had decreased muscular coordination, -had gait problems: jerking, unstable when making turns, unsteady gait, and shuffling gait, -had no noted drop in systolic blood pressure between lying and standing, -had 3 or more predisposing diseases. The Fall Risk Evaluation form indicated a score of 10 or above represented High Risk for falls. R#1's score was 19. Surveyor Occurrence Report dated 08/14/14 indicated R#1 was in the common area and had an episode of "orthostatic hypertension" (a sudden increase in blood pressure when a person stands up). R#1 was left unattended when the night staff had already left. R#1 stood up and fell . A total body assessment was done and no injuries were noted. Acute Care Plan-Falls dated 08/14/14 indicated R#1 had history of falls related to gait/balance. Approaches included: -place call light in reach, -encourage resident to ask for assistance for transfers and ambulation, -toilet resident according to plan, -ensure that resident has proper footwear when ambulating, -encourage resident to call for assistance when getting out of bed transferring to chair, -monitor for complaints of pain No new interventions were noted on this Care Plan. Fall Risk Evaluation dated 08/14/14 indicated R#1: -was disoriented at all times, -had 1-2 falls in the past 3 months, -was ambulatory/incontinent, -had adequate vision, and, -had balance problems while standing or walking -had decreased muscular coordination, -had gait problems: jerking, unstable when making turns, unsteady gait, and shuffling gait, and, -had 3 or more predisposing diseases. The Fall Risk Evaluation form indicated a score of 10 or above represented High Risk for falls. R#1's score was 19. Surveyor Occurrence Report dated 08/26/14 indicated R#1 was in the common area when he attempted to stand up from the wheelchair to go to the bathroom, lost his balance, and fell . No injuries were noted. Surveyor Occurrence Report indicated the fall was unwitnessed. Acute Care Plan-Falls dated 08/26/14 indicated R#1 had history of falls, related to mental status, and gait/balance. Approaches included: -ensure that lighting in room will support visual mobility, -orient resident to room environment, -provide assistive device for wheelchair, -encourage resident to call for assistance when getting out of bed, transferring to chair, -use magnetic alarm. Surveyor Occurrence Report dated 08/30/14 indicated staff placed R#1 in a locked wheelchair in the common area. R#1 tipped over in his wheelchair, onto his right side. R#1 sustained an abrasion to the left side of the back of the head, red blood noted, no signs and symptoms of infections noted, and bruising to the top left side of the head. R#1 was sent to the emergency room for evaluation. Surveyor Occurrence Report indicated the fall was unwitnessed. Hospital record, under "Emergency Department", dated 09/09/14 indicated R#1 was admitted to the hospital on [DATE] and discharged on [DATE] for [DIAGNOSES REDACTED]. Hospital record, under "Computed Tomography (CT)" dated 09/09/14 indicated R#1 CT Head Without Contrast revealed, "Impression: 1. No acute intracranial hemorrhage or extra-axial fluid collection. 2. Chronic microvascular ischemic changes. If neurological symptoms remain of clinical concern further characterization with MRI (magnetic resonance imaging) may be beneficial in view of its greater sensitivity in evaluating underlying neurological pathology." MDS assessment (Discharge assessment - return anticipated) dated 08/30/14 indicated R#1: -had memory problems, -had moderately impaired cognition (decisions poor, cues/supervision required), -exhibited wandering behavior which occurred 1 to 3 days, -required supervision from staff for bed mobility, walking in room, walking in corridor, locomotion on unit, eating, and personal hygiene, -required limited assistance from staff for transfers and toilet use, -had falls since admission/entry or reentry, -had two or more falls with no injury, -had one fall with injury, and, -had no falls with major injury. Surveyor Occurrence Report dated 09/08/14 indicated staff heard R#1's alarm sounding. R#1 was found standing next to his bed. R#1 had an abrasion to the buttock measuring 7.5 cm (centimeters) by 1 cm. No other injuries were noted. R#1's incontinent brief was noted torn in the same spot as where the abrasions were. When asked what happened, resident stated, "I don't know", and voiced no complaint pain or discomfort. Investigation revealed R#1 had been in bed, and rolled out of bed to get up and sustained the abrasion from the zipper on the pad cover. Acute Care Plan-Falls dated 09/08/14 indicated R#1 had a history of [REDACTED]. -place call light in reach. -encourage resident to ask for assistance for transfers and ambulation, -toilet resident according to plan, -ensure that resident has proper footwear when ambulating, -ensure that lighting in room will support visual mobility, -encourage resident to call for assistance when getting out of bed; transferring to chair, -use magnetic alarm, and, -monitor for complaints of pain. There were no new approaches implemented to prevent falls. Fall Risk Evaluation dated 09/08/14 indicated R#1: -had intermittent confusion, -had 1-2 falls in the past 3 months, -was ambulatory/incontinent, -had adequate vision, and, -had balance problems while standing or walking, and, -had 3 or more predisposing diseases. The Fall Risk Evaluation form indicated a score of 10 or above represented High Risk for falls. R#1's score was 20. Surveyor Occurrence Report dated 09/12/14 indicated R#1 was noted with bruises "green in color to the left shoulder with Edema." Mobile x-rays dated 09/12/14 indicated R#1 had a undisplaced acute fracture, distal tip, left clavicle, with osteopenia. Mobile x-rays, second opinion, dated 09/12/14 indicated recent fracture of the left distal clavicle with minimal displacement. Mobile x-rays dated 09/12/14 indicated R#1 indicated acute process involving the left shoulder except for the undisplaced distal tip left clavicle fracture and osteopenia and an intact left shoulder prosthesis. Surveyor Occurrence Report dated 09/13/14 indicated R#1 was noted with a bruise and bump to the left shoulder. X-ray revealed a fracture to the left clavicle. The injury was of unknown origin. Acute Care Plan-Change in Condition dated 09/13/14 indicated R#1 had a recent fracture to the left distal clavicle (collarbone). Approaches included: -toilet every 2 hours and PRN (as needed), -encourage resident to ask for assistance, and, -wear appropriate foot wear. Hospital record dated 09/13/14 indicated R#1 was admitted to the hospital 09/13/14 and discharged on [DATE] for a [DIAGNOSES REDACTED]." Surveyor Occurrence Report dated 09/15/14 indicated R#1 slid from his low bed onto the blue mat beside his bed. No injuries were noted. Acute Care Plan-Falls dated 09/15/14 indicated R#1 was at risk for falls related to mental status. There were no new approaches from the Acute Care Plan-Falls dated 09/08/14 other than use of a pressure pad alarm. Physician's Telephone Orders dated 09/16/14 indicated to discontinue the pressure alarm on R#1's wheelchair and start a wheelchair body alarm while up to wheelchair for fall prevention. Surveyor Occurrence Report dated 09/22/14 indicated R#1 stood up from his wheelchair, lost his balance and fell forward onto his left side, hitting his head on the side of the wall in his room. Head to toe assessment done. No lacerations, bruising, or redness noted at this assessment. Interventions were, "Resident requires constant monitoring, staff to place in common area for observation when up in chair and to use pressure alarm while in bed ..." R#1 was sent to the emergency room and returned with a [DIAGNOSES REDACTED]. Hospital record dated 09/22/14 indicated R#1 was admitted to the hospital on [DATE] and discharged on [DATE] from the hospital to the facility. Hospital record, under "Consultation" dated 09/22/14, indicated the following: -"There is no step-off of the cervical spine, and the CT scan of the brain without contrast has shown a very tiny blood spot in the right left frontal area. It has been probably accidentally, erroneously reported as left frontal region, but there is no mass effect, and there are significant calcifications of the vertebrobasilar system, and some chronic small vessel ischemic changes in the deep white matter. -"There is enlarged cardiac silhouette with coronary artery bypass graft surgery changes on the chest x-ray and subclavian pacemaker. By the way, the patient does have bilateral sun setting of the eyes with down gaze and there is considerable [DIAGNOSES REDACTED]... I do not believe it will help to have him undergo any shunting operation because he does have [DIAGNOSES REDACTED] with periventricular secretion of cerebrospinal fluid, and though it is probably real, and caused to some extent some his changes, unfortunately there is no return from the extent to which the patient has suffered from dementia, and he would only get into trouble with consideration of shunting, and I therefore elected not to pursue this topic..." Patient Transfer form dated 09/24/14 indicated R#1 returned to the facility on 09/24/14 with [DIAGNOSES REDACTED]. Further review revealed R#1s Primary Care Physician was informed, no new orders were given. Nurses Notes dated 09/24/14 at 11:30 a.m. indicated R#1 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]." Acute Care Plan-Falls dated 09/22/14 indicated R#1 was at risk for falls related to mental status, history of falls, gait/balance. There were no new approaches from the Acute Care Plan-Falls dated 09/08/14 and 09/15/14 other than use of a pressure pad alarm and a magnetic alarm. Nurse's Notes dated 09/26/14 at 8:05 p.m. indicated R#1 attempted to stand up from a recliner in the common area, "near fall, resident was lowered to the floor ...Resident needs continuous monitoring d/t (due to) falls. MD notified and no new order." Surveyor Occurrence Report dated 09/29/14 indicated R#1 attempted to get up and go to the bathroom and slid off his bed, no injuries noted. R#1 was, ... placed in the lounge area for constant monitoring while awaiting for breakfast." There were no documented interventions to prevent further falls. Nurses notes dated 09/29/14 revealed R#1's Primary Care Physician ordered to "monitor for falls and neurochecks." Acute Care Plan-Falls dated 09/29/14 indicated R#1 was at risk for falls, unsteady gait related to mental status, history of falls, gait/balance. There were no new approaches from the Acute Care Plan-Falls dated 09/08/14 and 09/15/14 other than, "place in common area for constant monitoring." (Six of 12 documented falls for R#1 occurred in the common area). The facility's Fall Management Program, revised June 2010, under "Procedure" revealed: " ...4. If a resident triggers high risk for falls on the initial fall risk assessment, or has a previous history of falls initial interventions might include: Instruction on proper use of assistive or adaptive devices/equipment (call light, locking wheels on wheelchair prior to rising, hand rails, use of rolling walker, etc. 5. The resident's care plan will include goals with interventions to assist the staff in caring for the resident and in preventing falls." On 10/01/14 at 10:27 a.m., surveyor observed R#1 sitting in a wheelchair inside the Memory Support Unit. R#1 did not have a wheelchair alarm. In response to surveyor inquiry, Certified Nurse Aide (CNA) "A" said R#1 had his brief changed and the alarm was not replaced. CNA "A" said R#1 had to have the alarm because R#1 tended to lean forward and slip from the wheelchair. On 10/01/14 at 10:35 a.m., surveyor observed CNA "A" and CNA "B" place the pressure pad alarm on R#1's wheelchair. On 10/01/14 at 1:40 p.m., CNA "A" said bed and wheelchair alarms were used for fall precautions. CNA "A" said she monitored the residents by making rounds. Residents who were awake were placed in the common area to be monitored by staff. On 10/01/14 at 1:55 p.m., CNA "C" said she did not recall if R#1 had a wheelchair alarm. CNA "C" stated it was an accident that she forgot to check the wheelchair alarm. CNA "C" said wheelchair alarms were necessary because they helped the staff know when residents attempted to get up. CNA "C" said she monitored residents in the Memory Support Unit by making rounds and checking on the residents. On 10/01/14 at 2:10 p.m., CNA "B" said alarms were used to prevent falls. CNA "B" said she changed R#1's brief and pants, but she forgot to put the wheelchair alarm back on R#1's wheelchair. CNA "B" said she should have checked that the wheelchair alarm was on the wheelchair, but she forgot. CNA "B" said she monitored the residents in the Memory Support Unit by checking residents' alarms, low beds, placing floor mats, keeping call lights in reach of the residents, and making rounds throughout the day. On 10/01/14 at 4:27 p.m., LVN "E" said he monitored residents in the Memory Support Unit by making rounds of the unit. LVN "E" said residents were placed in the common area to be monitored. On 10/01/14 at 4:49 p.m., LVN "F" said residents in the Memory Support Unit were monitored by having residents in the common area and having a CNA monitoring the residents. On 10/01/14 at 6:30 p.m., Assistant Director of Nurses (ADON) "G" said R#1 had a history of [REDACTED].#1 had a low bed, positioning pillows, a blue floor mat, and a wheelchair alarm as interventions. ADON "G" said staff placed R#1 in the common area for monitoring. Minimum Data Set (MDS) assessment (Discharge assessment - return anticipated) dated 10/05/14 indicated R#1: -had memory problems, -had moderately impaired cognition (decisions poor, cues/supervision required), -wandering behavior not exhibited, -required supervision from staff for bed mobility, -required limited supervision from staff for transfers, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene, -had two or more falls with no injury, -had no falls with injury, and, -had no falls with major injury. On 10/15/14 at 9:30 a.m., Rehabilitation Director "H" said he received an order for [REDACTED].#1 was not evaluated for rehabilitation services because R#1 did not qualify for rehabilitation services due to R#1's medical insurance. Rehabilitation Director "H" said he did not recall receiving information regarding R#1's unsteady gait or balance. On 10/15/14 at 9:47 a.m., Admission Coordinator "I" said R#1 did not qualify for rehabiliation services because he had no qualifying acute days. Admission Coordinator "I" said R#1 did not have secondary insurance. Admission Coordinator "I" said R#1 needed to have three qualifying acute [DIAGNOSES REDACTED]. On 10/15/14 at 10:51 a.m., R#1's Physician said he was notified by the facility regarding R#1's falls and, at times, the facility provided one-to-one monitoring, but at times it was impossible. R#1's Physician said he reviewed R#1's medications and discontinued some medications, as he tried to adhere to Medicare information by keeping residents at nine medications or less. R#1's Physician said R#1 had several medical conditions, such as, diabetes, hypertension, and open heart surgery (many years ago). R#1's Physician said he was aware of R#1 having a Cerebral Hemorrhage, however, it was small. R#1's Physician said R#1 had poor cerebral and heart circulation, as well as severe Dementia. R#1's Physician said R#1 was at high risk for interventional surgery due to his age and medical conditions. On 10/15/14 at 11:20 a.m., Director of Nurses (DON) said R#1 was not provided with restorative services to address R#1's unsteady gait and balance, as R#1 was being transferred in and out from the facility to the hospital. The DON said she did not recall any new interventions regarding R#1. The DON said she would need to talk to ADON "G", but did not know why no new interventions were in place. The DON said that, at times, interventions were done but not documented, such as, anticipating the needs of the resident and having the resident in the common area to be monitored. The DON said the facility had a risk meeting every Tuesday to discuss information about falls, look for the root causes, implement interventions and discuss what else could be done. The DON said assistive devices were used to prevent falls, such as, low beds, blue floor mat, answering call lights, magnetic alarms, and pressure pad alarms on bed and wheelchair. The DON said one-to-one supervision was sometimes impossible. On 10/15/14 at 1:20 p.m., ADON "G" said some interventions were done daily but were not documented, such as, extra activities and monitoring. ADON "G" said one-to-one monitoring was not provided. ADON "G" said R#1 had low dosages of medication and was taking few medications. ADON "G" said R#1's falls were related to R#1's medical condition. ADON "G" said R#1's Physician was notified of R#1's falls. ADON "G" said falls were prevented by making rounds, answering call lights, bed and wheelchair alarms. During the exit conference conducted on 10/15/14 at 2:00 p.m., the facility was given an opportunity to provide additional information related to supervision of R#1. No additional information was provided. The facility's Roster/Sample Matrix form, provided on 10/01/14, identified 53 residents on the MSU.

Based on observation, record review, and interview, the facility failed to prevent the development of a new pressure ulcer for one Resident (R#7) of three residents reviewed with pressure ulcers. R#7 had an existing pressure ulcer and developed a new pressure ulcer in the facility, and, Failure to keep residents free of pressure ulcers could result in residents experiencing pain and discomfort which could affect the health and quality of life of all eight residents with pressure ulcers. The findings were: R#7's May 2012 physician's orders [REDACTED]. Current [DIAGNOSES REDACTED].), [MEDICAL CONDITIONS] (narrowing of blood vessels), [MEDICAL CONDITION], Multicystic Kidney Disease (cysts on the kidneys), and Dementia. R#7's May 2012 physician's orders [REDACTED]." R#7's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R#7: - was able to make himself understood and understand others, - was able to particpate in a Brief Interview for Mental Status, - required extensive assistance from staff for bed mobility and transfers, - had a urinary catheter and was continent of bowel, and, - was at risk for developing pressure ulcers, but had no pressure ulcers at the time of assessment. R#7's Braden Scale - For Predicting Pressure Ulcer Risk assessment dated [DATE] indicated R#7: - had no impairment in sensory perception, - had skin that was usually dry, skin usually not exposed to moisture, - was chairfast, - had no limitations in mobility and was able to make major and frequent changes in position without assistance, - had excellent food intake patterns, and, - had potential problems with friction and shear, during a move, skin probably slides to some extent against sheets, chair etc... Braden Scale indicated a score of 12 or less indicated high risk for development of pressure ulcers and a score of 15-18 indicated a mild risk for development of pressure ulcers. R#7's score on the assessment was 20. Weekly Wound Report dated 05/25/12 indicated R#7 had a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) on his right buttock measuring one cm (centimeter) by one cm. Surveyor reviewed 300 Hall CNA (Certified Nurse Aide) Assignment Sheet dated 06/02/12. The sheet documented R#7 had one pressure ulcer on the right buttock. The assignment sheets are tools used to immediately report changes in skin conditions that occur between weekly skin assessments. On 06/05/12 at 3:18 p.m., surveyor observed Licensed Vocational Nurse (LVN) "P" providing wound treatment for [REDACTED]. LVN "P" was being assisted by CNA "Q". LVN "P" was about to clean the wound when surveyor pointed to another area that was red and raw. The area was approximately 7 centimeters (cm) below (toward the leg) the wound being treated and was approximately 0.8 cm X 0.6 cm in size. LVN "P" said she would need to call R#7's Physician to get an order to treat the newly discovered area. LVN "P" then told R#7 he would need to stay off his back because he had another pressure ulcer. Nurses Notes dated 06/05/12 at 4:40 p.m. documented R#7 was noted with a Stage 2 pressure ulcer to his right lower buttocks measuring 0.8 X 1 with superficial serous drainage (watery fluid excretion on the surface of the skin) noted. Physician's Telephone Order dated 06/05/12 for R#7 documented, "Clean wound to right buttock with normal saline, pat dry, apply [MEDICATION NAME] 1% cream (topical antibiotic), cover with dressing and secure with tape twice daily until healed." On 06/05/12 at 4:35 p.m., surveyor interviewed CNA "Q". CNA "Q" said R#7 received showers on Tuesdays, Thursdays, and Saturdays. CNA "Q" said she showered R#7 around 6:30 a.m. that morning (06/05/12) and had changed R#7's brief that afternoon (06/05/12). CNA "Q" said she did not see any change of condition with R#7. On 06/05/12 at 5:45 p.m., surveyor interviewed CNA "Q". CNA "Q" said she assisted LVN "P" with wound treatment on R#7's buttock that afternoon. CNA "Q" said she saw "another" open area on R#7's buttock. CNA "Q" said R#7 originally had one open area, but a new area was discovered during treatment. CNA "Q" said she had not seen the additional open area when caring for R#7 that morning. On 06/05/12 at 5:50 p.m., surveyor interviewed LVN "P." LVN "P" said she did not know why R#7's new pressure ulcer was not seen by any CNA. LVN "P" said the CNAs were trained to report any changes in skin condition. LVN "P" said as of the afternoon of 06/04/12, R#7 had only one pressure ulcer. She said she treated the original wound that morning (06/05/12). LVN "P" said R#7 had been sitting up a lot in his recliner that day (06/05/12). On 06/06/12 at 11:58 a.m., surveyor interviewed Assistant Director of Nurses (ADON) "C." ADON "C" said weekly full-body skin assessments were done on residents. ADON "C" said the last weekly assessment of R#7 was conducted 05/31/12. On 06/06/12 at 4:35 p.m., surveyor interviewed R#7 while he was sitting in his wheelchair in his room. Surveyor observed the cushion R#7 was sitting on. The cushion was square with a triangular section cut out of the rear side to center R#7 over the opening to avoid R#7's coccyx and inner buttocks from touching the wheelchair seat. The cushion was approximately 2 inches thick. R#7 said the cushion was too soft. R#7 said he had a sore on his buttock and the cushion allowed his buttocks to hit the seat of the wheelchair, causing pain when he sat down. R#7 said he used the same cushion in his recliner as well as his wheelchair. On 06/07/12 at 11:55 a.m., surveyor interviewed Medication Aide (MA) "R". MA "R" said R#7 liked to be up in his wheelchair or recliner most of the time. She said R#7 did not like to lie in bed. On 06/07/12 at 2:30 p.m., surveyor interviewed LVN "S". LVN "S" said R#7 preferred to be in his wheelchair or recliner. LVN "S" said R#7 only wanted to go to bed when it was bedtime. LVN "S" said she tried to get R#7 to lie down and rest that day (06/07/12) but R#7 wanted to stay up. R#7's Care Plan dated 05/25/12 documented R#7 had a Stage 2 pressure ulcer on his right buttock. Approaches were to have a pressure reduction mattress, checks for incontinence every two hours, incontinent care as needed, weekly full body checks, Vitamin C 500 milligrams two times per day, and Zinc 220 milligrams daily. It also documented the pressure ulcer was to be cleaned and [MEDICATION NAME] cream applied twice daily. The approach of applying a pressure reduction cushion was not checked on the care plan.The care plan did not address R#7's behavior of sitting in his wheelchair and recliner throughout the day and not wanting to lie down in his bed. On 06/07/12 at 2:40 p.m., surveyor interviewed R#7 and Family Member (FM) "T." FM "T" stated she felt the first wound should be healed already and the physician had not seen the wound but had only been told about it. On 06/07/12 at 3:07 p.m., accompanied by Van Driver "U", surveyor observed R#7's chair cushion. Van Driver "U" procured the chair cushions for the residents of the facility. Surveyor asked Van Driver "U" if the cushion was a gel cushion. Van Driver "U" said the cushion was a "sponge" cushion. R#7 told Van Driver "U" there was a different cushion in his closet. Van Driver "U" retrieved the cushion out of the closet. The cushion was a gel cushion. Van Driver "U" asked R#7 if he would like to use the gel cushion. R#7 said he would like to use the cushion but "the nurse" (unknown) wanted him to use the sponge cushion. On 06/07/12 at 3:10 p.m., surveyor interviewed LVN "S". Surveyor asked LVN "S" about R#7 saying "the nurse" wanted him on the sponge cushion. LVN "S" said she did not know why R#7 said that. LVN "S" said LVN "P" may have suggested the sponge cushion but LVN "P" wasn't there to ask as LVN "P" was off that day. Surveyor reviewed the facility's policy entitled "Prevention of Pressure Areas" dated September 2005. The policy contained the following under the section entitled "detail instructions for preventive measures": -relieve pressure by encouraging and assisting the resident to keep active -maintain good skin hygiene -ambulate as appropriate -use pressure relieving devices -inspect the skin regularly -monitor fit of immobilizing devices/adaptive equipment -monitor nutritional status During the exit conference on 06/07/12 at 6:30 p.m., the Administrator and Director of Nurses (DON) were given the opportunity to provide additional information regarding pressure ulcers. No additional information was provided. The Centers for Medicare & Medicaid Services (CMS) Resident Census and Conditions of Residents form (672) identified eight residents with pressure ulcers.

Based on observation, interview, and record review, the Administrator failed to administer the facility in a manner, which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for one Resident (R#1) of six residents reviewed for resident rights and quality of life. The Administrator failed to: 1) protect R#1's right to refuse treatment, 2) follow the facility's policy for admission to the locked unit, 3) promote R#1's dignity and respect, and, 4) supervise and monitor the facility Social Worker to ensure R#1 was provided discharge planning and assistance with alternate placement. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response the facility: -failed to assist R#1 with discharge planning/alternative placement, and, -placed R#1 in a locked unit against his wishes and in violation of facility policy. The facility did not assess R#1 prior to placement on the locked unit to determine whether the placement was appropriate, resulting in R#1 remaining on the locked unit for 79 days. R#1 was still on the locked unit on the day of exit ([DATE]). The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's placement in the locked unit and placement of a wanderguard bracelet on R#1's leg. Failure to allow R#1 to make his own decisions regarding treatment denied him the right to refuse treatment if he chose to do so, and denied him control over his own decisions and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 26 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, - had no behavioral issues and - had no signs of [MEDICAL CONDITION] R#1's Discharge Plan from MDS assessment dated [DATE] indicated R#1 and his family participated in the assessment. The assessment indicated a, "Guardian or legally authorized representative" did not participate in the assessment. The assessment also indicated: -Resident's Overall Expectation: Resident's overall goal established during assessment process - (Blank). Discharge Plan: Is there an active discharge plan in place for the resident to return to the community? "No." was marked. Discharge Plan: What determination was made by the resident and the care planning team regarding discharge to the community: "Discharge to the community determined to be not feasible." was written. R#1's Nurses Notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." Out of Hospital Do-Not-Resuscitate order; Texas Department of State Health Services form: -A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advance airway management, artificial ventilation. The form was signed by R#1 after his admission to the locked unit and after surveyor intervention. -B. Declaration by legal guardian, agent or proxy on behalf of the adult who is incompetent or otherwise incapable of communication: Legal Guardian (blank), agent in a Medical Power of attorney (blank) or Proxy (blank). -C. Declaration by a qualified relative of the adult who is incompetent or otherwise incapable of communication: I am the above-noted person's: adult child (checked), " To my knowledge the adult person is incompetent or other wise mentally or physically in capable of communication and is without a legal guardian, agent or proxy. Signed by FM "Z", date [DATE]. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" arrived at the facility and informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in another city (approximately 240 miles away). Social Progress Notes for [DATE] further revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard (wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area) on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "No" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? "No" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "No" was indicated. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated and "poor decisions" was circled. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. Does the resident receive any medication that increases the restlessness or agitation? "No" was indicated. Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "Yes" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? "Yes" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "Yes" was indicated. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he cannot leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent from FM "Z", received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: "The person authorized by law to consent on behalf of the resident (guardian)." Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because, for her personal health reasons, she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety." R#1's Social Progress Notes dated [DATE] further revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurse's station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." D. Family consent and agreement to operating policies and philosophies. E. The resident's needs must be within one of the following groups: 1. Needs direction to function in a familiar surrounding and can respond to instruction. 2. Needs assistance to function and cannot respond to direction alone. 3. Needs assistance to function and cannot communicate verbally in a meaningful fashion. R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. *The following information was gathered from the CMS 2567 form dated [DATE]:* -On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" is not not R#1's medical power of attorney. The SW reported that R#1 needed to have the wanderguard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet. The family has cancelled twice." -On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." -On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. -On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and then I would be released." -In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." -In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). -On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." Geriatric Psychiatric Evaluation on R#1 dated [DATE] documented: Chief Complaint - "Depression, adjustment difficult, patient wants to go home constantly calling family. Irritability, agitation." History of presenting problem - "I'm not doing good, I don't like it here. My daughter put me here. Anxiety, I have never been locked up." "Patient had provider at home. Patient is disoriented to time, oriented to self & circumstances. Patient is compliant with care. Patient asking for alternative living arrangements." Signs of Dementia - Moderate. No thoughts of hurting self or others. Thought Stream - Logical, Goal directed. Diagnosis: [REDACTED]. On [DATE] at 11:45 a.m. surveyor met with the Administrator about R#1. The Administrator said, "(R#1) is still in the locked unit, is doing much better/adjusting, and likes being in the unit." The Administrator said R#1's family was pleased with R#1's stay in the locked unit. On [DATE] at 1:30 p.m. surveyor observed R#1 in the locked unit. R#1 was observed in the lobby area by the nurses station. R#1 was observed sitting in his wheelchair. Surveyor asked R#1 in Spanish if surveyor could speak to him in private, and R#1 said we could talk in his room. Interview was conducted entirely in Spanish. R#1 was alert, oriented, able to converse with surveyor and answer surveyor's questions. Surveyor asked R#1 what he thought about the facility. R#1 responded, "No me gusta aqui" (I don't like it here). R#1 said FM "Z" "me mentio"(lied) and "traiciono"(deceived) him by telling him he would only be in the facility for a few weeks for rehabilitation for his leg. R#1 said his leg was fine now and he wanted to go home to his house and see about his son who was mentally ill and lived with him and FM "Z". R#1 said that both he and his son had a home provider that took care of them during the day, cleaning and cooking for them. R#1 said he had the same provider for many years. R#1 said he was concerned that possibly FM "Z" was trying to sell his house. R#1 said he did not belong in the locked unit or any other part of the facility. R#1 told surveyor, "They even put a "pulsera" (bracelet) on my "pie" (foot) to keep me from leaving", "No quiero estar aqui" (I don't want to be here). Surveyor asked R#1 how he felt about being in the facility. He replied in Spanish "me siento mal" (I feel badly). Surveyor asked R#1 how he felt about FM "Z" placing him in the facility. R#1 said, "Me siento como si quiero llorar" (I feel as if I want to cry). On [DATE] at 2:00 p.m. surveyor met with the Administrator and R#1's two family members, FM "Z" and FM "Y". FM "Z" told surveyor her that R#1 had been living with her and her disabled brother for many years. FM "Z" said, "I can no longer take care of him and my brother both." FM "Z" said R#1 had a history of [REDACTED]. FM "Z" said, "(R#1) at times gets confused, has wandered off at times, and at times takes my disabled brother with him." FM "Z" said, "(R#1) gets angry and at times gets verbally abusive with my brother; at times doesn't even know he is there." On [DATE] at 2:30 p.m. surveyor conducted a telephone interview with the Physician's Assistant (PA) to R#1's Psychiatrist. The PA said she did the psychiatric evaluation on R#1 on [DATE]. The PA said R#1 was complaining that he wanted to go home and was having problems adjusting to the facility. The PA said R#1 was started on medications. The PA said R#1 had some memory and adjustment problems but was, and would be, "OK." Surveyor asked the PA, since R#1 was doing better, if it was necessary or required for R#1 to be in the Memory locked unit? The PA said R#1 could be placed in an area of the facility outside the locked unit on a trial basis to see how he did, initially using a wanderguard, then giving him some options and seeing how he would do. On [DATE] at 9:25 a.m. surveyor observed R#1 in the locked unit of the facility. Surveyor interviewed R#1 in his room. R#1 told surveyor in Spanish that he still wanted to go home, and if his daughters would not take him back, he would contact one of his sons so he could move in with them. R#1 said he had a provider that had taken care of him and his son for many years and could come with him. R#1 said, "Yo no debo de estar aqui con este typo de gente. Yo necesito que irme de aqui." (I don't belong here with these kind of people. I need to go home.) On [DATE] at 9:48 a.m. surveyor interviewed the facility SW. The SW said FM "Z" and FM "Y" did not want to tell R#1 that he would be in the facility for a long time. The SW said R#1 had been living with with FM "Z" and his son who was mentally ill. SW said FM "Z" told her she could no longer care for both R#1 and her brother. SW said she had asked R#1 if he had someone else he could stay with and R#1 had replied that he did not and that he wanted to go home with FM "Z." The SW said she called the local appraisal district and checked to see who owned the home where R#1 said he lived. SW said she was told the property (home) was owned by FM "Z" and her husband. Surveyor asked the SW if she asked the appraisal office if R#1 had ever owned the home. The SW said she had not. Surveyor asked the SW if R#1 had ever actually attempted to leave the facility. The SW replied that at one time R#1 opened a back door to the 300 hallway and apparently the alarm had not sounded. The SW said it was found out that R#1's wanderguard might not have been working. The SW said that the facility had a care plan meeting to discusss R#1's attempt to leave the facility, but R#1's family was not present. At the meeting RN "B" ordered that a wanderguard be placed on R#1 and told LVN "A" to call R#1's Physician to get an order for [REDACTED]. It was not until he was told by his family that he was staying long term that he began having problems and wanting to leave. The SW said she had never spoken to FM "Z" about getting a provider for R#1. The SW said she kept trying to meet with FM "Z" for care planning meetings, but FM "Z" kept refusing to meet. The SW said that FM "Z" told her that it was her brother that had a provider. Surveyor asked SW if R#1 had ever told her that he had three other sons and he was certain he could go and live with one of them. The SW replied "No." Surveyor asked the SW if she had assisted R#1 with discharge planning/alternative placement. The SW replied she had not. The SW said she tried to get FM "Z" to attend care plan meetings but FM "Z" would not show up. Surveyor asked the SW if she had followed-up on possible discharge planning and the SW said she had not. The SW said, in her opinion, R#1 could make his own decisions of what he wanted or did not want. Surveyor interviewed the facility Case Manager (CM) on [DATE] at 10:35 a.m. Surveyor asked the CM if R#1 could make his own decisions. CM replied, "Yes, he is able to tell us what he wants to do. He would tell us he wanted to go home, but recently he has stopped asking us." The CM said FM "Z" told her that R#1 used to have a provider, but he would, "run them off." The CM said R#1 was placed in the locked unit after he kept wanting to leave the facility and asking people in the front lobby if they could take him home. Surveyor interviewed LVN "E" on [DATE] at 11:40 a.m. LVN "E" said he had worked on the locked unit for about a month. LVN "E" said R#1 had improved and was conversing more with other residents in the unit. LVN "E" said R#1 told him several times that he wanted to go home.` Surveyor interviewed Administrator on [DATE] at 12:28 p.m. The Administrator stated that a new MDS was completed on [DATE]. He further stated that the updated MDS reflected active discharge planning including a referral to DADS "Money Follows the Person" to assist R#1 with community placment. The Administrator said a Relocation Specialist had been assigned to R#1 and would be assisting him with the program. The Administrator said the facility had R#1's Psychiatrist conduct a psychiatric evaluation for R#1. Surveyor conducted a telephone interview with a DADS Relocation Specialist on [DATE] at 1:23 p.m. The Relocation Specialist said she had been contacted by the facility Administrator regarding R#1 and wanted to make referral for assistance for possible community placement. The Relocation Specialist said a full assessment would need to be conducted to determine if R#1 met the financial requirements(Social Security, Medicaid etc..) for the program. Surveyor observed R#1 in the Memory locked unit on [DATE] at 2:40 p.m. Surveyor observed R#1 walking down the hallway pushing his wheelchair. Surveyor approached R#1 and asked him if he remembered me. R#1 replied in Spanish "si" (yes). Surveyor and R#1 moved to a more private area of the Memory locked unit. Surveyor asked R#1 for the names of his sons. R#1 replied he had three sons, two who were married and one who was mentally disabled and had lived with him. R#1 gave the names of the sons. Surveyor asked R#1 if his sons would be able to take him in to live them. R#1 chuckled and said "No, le tienen miedo a mi hija" (No, they are afraid of my daughter). R#1 said his daughter would not allow his sons to take care of him. Psychiatric Evaluation by R#1's Psychiatrist on [DATE] (after surveyor entered the facility for a follow up visit on [DATE]) documented: "[DIAGNOSES REDACTED]. History (HX) of progressive memory loss wants to go home. Patient has a HX of progressive memory loss, intellectual permanent personality deterioration recently compounded with depressive symptoms. On [MEDICATION NAME] (anit-Alzheimers medication), [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (medication for Dementia). 0 family HX. On examination, pleasant but becomes easily irritated when tested . Affect is responsive though mood depressed. Denied suicidality. Significant thought poverty. No hallucinations. Some referential thinking. Moderately confused limited insight into his confusion. DX (diagnosis) Primary [MEDICAL CONDITION] Dementia with Depression and behavioral disturbances. Recommendations: Patient is in need of 24 hour supervision, Re-orientation, redirection. Continue same [MEDICAL CONDITION] medications, consider adding atypical antipsychotic, low dose if agitated. Monitor clinical response." Surveyor conducted a telephone interview with R#1's Psychiatrist on [DATE] at 11:30 a.m. The Psychiatrist said he conducted R#1's evaluation on [DATE]. The Psychiatrist said R#1 had a [DIAGNOSES REDACTED]. Surveyor asked the Psychiatrist if R#1 was able to make his own decisions, and he replied "No." The Psychiatrist said R#1 was not cognitively aware of his health status, R#1 thought he was cured of his [MEDICAL CONDITION]. The Psychiatrist said R#1 needed 24 hour supervision and the family was not able to provide that for him. The Psychiatrist said R#1's thinking was poor, he was "irrational"at times and would be, "easy prey to be taken advantage of or hurt if out on his own. He would be at risk." Surveyor asked Psychiatrist if R#1 could function off the locked unit, perhaps with a wanderguard. The Psychiatrist said that even if R#1 had a wanderguard, he would still be at risk of leaving the facility. Review of R#1's Physician's letter to facility ADON "C" documented: Title: Letter to Acknowledge a Resident Incompetent. "This letter serves to inform the (name of facility) that R#1 has a [DIAGNOSES REDACTED]." The letter was not dated. Date of fax at the top of the page was [DATE]. Surveyor conducted telephone interview with R#1's Physician on [DATE] at 11:45 a.m. The Physician said R#1 was irrational at times. The Physician said, "I don't think (R#1) is able to make rational decisions for safety and care. I don't think he would be safe at home or in the skilled unit with a wanderguard." Physician said R#1 needed 24 hour care. Surveyor read R#1's Psychiatric Evaluation by R#1's Psychiatrist to his Physician. R#1's Physician said he agreed with R#1's Psychiatrist's findings/[DIAGNOSES REDACTED]. R#1's Physician said, "(R#1) is better off in the Memory locked unit." Surveyor interviewed the facility Physical Therapist on [DATE] at 11:00 a.m. Physical Therapist said R#1 had suffered a [MEDICAL CONDITION] in [DATE] while living at home. When R#1 was admitted to the facility, physical therapy (PT) was ordered for strengthening of the hip area, improvement of his ablity to transfer himself, and strengthening of his lower extremities. The Physical Therapist said R#1 was admitted for PT services on [DATE] and discharged from PT on [DATE]. The Physical Therapist said R#1's goals were met. R#1 was able to stand and push his wheelchair and had strengthened his hip area and extremities. Surveyor interviewed LVN "E"/ MDS Coordinator on [DATE] at 12:05 p.m. LVN "E" said family had requested Hospice services after R#1's Physician had talked to them because R#1 had [MEDICAL CONDITION] and Melanoma (cancer neck area). LVN "E" said R#1's family called the facility requesting Hospice services and information about available Hospice companies was provided to them. LVN "E" said family chose a Hospice company and a telephone physician's orders [REDACTED]. Surveyor interviewed facility Administrator on [DATE] at 1:00 p.m. The Administrator told surveyor that the facility's Medical Director was aware of R#1's condition and was R#1's attending physician. Surveyor asked Administrator if she had

Based on observation, record review, and interview, the facility failed to ensure the resident's right to: 1. refuse treatment, and, 2. formulate a power of attorney for health care, for one Resident (R#1) of two residents reviewed for resident rights. Without R#1's permission or discussing the issues with R#1, the facility: -placed a wanderguard bracelet on R#1, with no history of elopement and in violation of facility policy, -placed R#1 in a locked unit with no history of wandering or elopement and in violation of facility policy, and, -allowed family members, with no medical Power of Attorney for R#1, to make decisions concerning R#1's advance directives. Failure to ensure R#1's right to refuse treatment and formulate a power of attorney for health care resulted in R#1 having a wanderguard placed on his leg, being placed on a locked unit, and being designated as DNR status. This failure could affect all 25 residents not assessed as cognitively impaired. The findings were: 1. R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, and, - had no behavioal issues. R#1's Discharge Plan from MDS assessment dated [DATE] indicated, "Is there an active discharge plan in place for the resident to return to the community? No." "What determination was made by the resident and the care planning team regarding discharge to the community? Discharge to the community determined to be not feasible." R#1 nurses notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." On [DATE] at 2:00 p.m. surveyor observed R#1 to propel himself from his room to the nurses station. R#1 was asking anyone at the nurses station to make arrangements to send him home. He said he wanted to go home. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in San Antonio. Social Progress Notes for [DATE] revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? No. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? No. Does the wandering significantly intrude on the privacy or activities of others? No. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. ("poor decisions" was circled) Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes. Does the resident receive any medication that increases the restlessness or agitation? No." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? Yes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? Yes. Does the wandering significantly intrude on the privacy or activities of others? Yes. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes." R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he can not leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: The person authorized by law to consent on behalf of the resident (guardian). Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because for her personal health reasons she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety. R#1's Social Progress Notes dated [DATE] revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit. [DATE] Ombudsman was at nh to speak with SW about family council meeting. (R#1) was in reception area and Ombusdman asked if she could speak with him. (R#1) stated that he was waiting for a ride to go home. After, Ombudsman spoke with (R#1) in private she approached SW and advised (R#1) that he had every right to return home because he voiced to her that he owned the property where (FM "Z") lived with his mentally retarded son. Ombudsman asked (R#1) if he had any money for a taxi so that he could return home and stated no. SW advised Ombudsman (R#1's) RP is responsible for his money. SW explained that at this time even if (R#1) is stating to return home his (family members) are not in agreement that they can not care for him at home. SW explained to Ombudsman that (R#1) had made threats and attempts to leave nh and (family members) agreed that placement in memory support unit for safety was what they wanted to do at this time. Ombudsman told SW that if (R#1) owned the home he has every right to return despite (family members') objections. Ombudsman stated that nursing home could not place (R#1) in memory support unit just because he attempted to leave. The Ombudsman stated she would follow up with SW to see if (R#1) had returned home." R#1's Social Progress Notes (continued) dated [DATE] revealed: "SW was present as Administrator contacted RP for (R#1) and discussed Ombudsman's concerns that he should return home. (FM "Z") stated they were upset because they want (R#1) placed in the memory support unit for his safety due to his attempts and threats to leave nh. Administrator stated to RP that the Doctor has not been to nursing home to determine that (R#1) has dementia. RP stated that the Veteran's Administration has documentation with (R#1's) [DIAGNOSES REDACTED]. Administrator discussed with them switching to another primary physician because (R#1's) Doctor does not come to nh. RP stated at this time they do not want to switch physicians. RP stated that (R#1) better be moved to the memory support unit today." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurses station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. R#1's Social Progress Notes dated [DATE] revealed: "SW received call from Ombudsman and she stated that she was following up on (R#1's) return home. SW advised that he was moved to memory support unit after family spoke with Administrator by phone. Ombudsman advised that she would be contacting state and requested the face sheet because (R#1) did not have a [DIAGNOSES REDACTED]. Administrator advised SW that family met with her yesterday and brought paperwork from VA that showed a [DIAGNOSES REDACTED]. SW contacted (family members) to inform them that Ombudsman was going to contact the state regarding (R#1's) placement in the memory support unit because she felt the nh had violated his rights. (R#1's family members) were very upset stating that they did not want (R#1) moved. They stated they never met with the Ombudsman and she did not know the situation of (R#1's) history. Family members met with SW and Administrator because they did not understand how the Ombudsman could demand that (R#1) be allowed to return home. Administrator explained that nh was not in agreement and felt that for his safety due to wandering and threats of leaving nh the memory support unit was best for him. Administrator explained to family that discharging a resident home is a process in which the nh includes the family. (R#1's family members) voiced understanding and also agreed that (R#1) primary physician needed to be changed because he has not seen him at the nh." The facility's policy, Admission and Assessment Process-Nursing and Alzheimer's Care Centers, Effective date: [DATE], indicated: "Procedure: 1. Admissions Coordinator will interview family and/or prospective resident. The family and/or the prospective resident will complete form ,[DATE]SH (State Home Program Application for Veteran Medical Certification) and form ,[DATE]EZ (Application for Health Benefits). Form ,[DATE]SH must be signed by the resident's attending/admitting physician. 2. If the Prospective resident meets the guidelines as stipulated in Section 51.50 listed above for the admission criteria, the prospective resident is scheduled for an assessment coordinated by a Registered nurse along with the Interdisciplinary Team which usually consist of the administrator, Director of Nursing, Director of Social Work and Admissions Coordinator or their respective designees). The Administrator and nursing administration will review the residents' medication with the pharmacy prior to admission. 6. The Admissions Coordinator will set an appointment with the resident and/or responsible party at which time all relevant SDI policies and procedures will be reviewed including stipulations for discharge and transfer policies when health condition changes occur. 7. The following paperwork must be completed and returned before admission or at the time of admission: a. Application for Admission (form,[DATE]EZ) signed in designated places by resident and/or responsible party. b. Doctor's orders completed and signed by a licensed physician (form ,[DATE]SH). c. History and physical, [DIAGNOSES REDACTED]. d. Photocopy of legal documents for Health Care Decision (Health Care Power of Attorney, Directive to Physician (Living Will) Family/ Physician Directive, Out of hospital DNR if applicable). e. Residency and Care Agreement Contract signed by resident and/or responsible party." The facility's policy on Secure Care System dated [DATE] revealed: "Care plan based on the goals, needs, risks and interventions attempted prior to initiation." The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. On [DATE] at 8:40 a.m. the Admissions Coordinator said, "The ,[DATE]SH should be in (R#1's) chart. I am assuming that it was done. I know the policy says the ,[DATE]SH must be signed by the physician. I think it is the Social Worker that takes care of that.) On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. The SW reported that R#1 needed to have the wander guard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet, the family has cancelled twice." On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and than I would be released." In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." 2. R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. The Admission Record "Advance Directives" section indicated, "Do Not Resuscitate." R#1's physician's orders [REDACTED].#1's Advanced Directive was "Full Code" with an order date of [DATE] (Full Code is defined as in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy have directed that cardiopulmonary resuscitation (CPR) or other life saving measures are to be used.) R#1's Initial Plan of Care dated [DATE] revealed: Code status-Full Code. R#1 nurses notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." The facility's Advance Directive Review revealed that on [DATE], "No CPR" (No cardiopulmonary resuscitation) was checked off for R#1 and signed by R#1's Family Member (FM) "Z." R#1's plan of care dated [DATE] indicated R#1, "desires no resuscitation in the event of cardiopulmonary arrest." Goal was for R#1 to "receive no CPR in the event of cardiopulmonary resuscitation during the next 90 days." Approach was, "Ensure that proper paperwork is in the chart: physicians orders, out of hospital DNR, no CPR stickers, flags. Answer any questions that resident or family may have regarding death or dying. Provide social service and clergy referrals as needed." R#1's Social Progress Notes dated [DATE] revealed R#1 was admitted to the facility from the hospital. "He is alert and able to communicate needs to staff with episodes of forgetfulness/confusion. The (family members) report he has a history of wandering. At this time (family members) have selected a DNR status and are planning a long term stay, but state they have not told (R#1) that he will be here a long time." R#1's Out Of Hospital Do Not Resuscitate Order from the Texas Department of State Health Services dated [DATE] was signed by FM "Z." On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's Do Not Resuscitate (DNR) order was not R#1's choice, it was R#1's family's choice. During exit conference held on [DATE] at 3:00 p.m the Administrator was given the opportunity to present any additional information regarding R#1's right to refuse treatment and formulate an Advance Directive. No additional information was presented. The facility's Roster/Sample Matrix listed 25 residents who were not assessed as cognitively impaired.

Based on observation, record review, and interview, the facility failed to ensure the resident's right to refuse treatment for one Resident (R#1) of six residents reviewed for resident rights. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response the facility: -failed to assist R#1 with discharge planning/alternative placement, and, -placed R#1 in a locked unit against his wishes and in violation of facility policy. The facility did not assess R#1 prior to placement on the locked unit to determine whether the placement was appropriate, resulting in R#1 remaining on the locked unit for 79 days. R#1 was still on the locked unit on the day of exit ([DATE]). The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's placement in the locked unit and placement of a wanderguard bracelet on R#1's leg. Failure to allow R#1 to make his own decisions regarding treatment denied him the right to refuse treatment if he chose to do so, and denied him control over his own decisions and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 26 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, - had no behavioral issues and - had no signs of [MEDICAL CONDITION] R#1's Discharge Plan from MDS assessment dated [DATE] indicated R#1 and his family participated in the assessment. The assessment indicated a, "Guardian or legally authorized representative" did not participate in the assessment. The assessment also indicated: -Resident's Overall Expectation: Resident's overall goal established during assessment process - (Blank). Discharge Plan: Is there an active discharge plan in place for the resident to return to the community? "No." was marked. Discharge Plan: What determination was made by the resident and the care planning team regarding discharge to the community: "Discharge to the community determined to be not feasible." was written. R#1's Nurses Notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." Out of Hospital Do-Not-Resuscitate order; Texas Department of State Health Services form: -A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advance airway management, artificial ventilation. The form was signed by R#1 after his admission to the locked unit and after surveyor intervention. -B. Declaration by legal guardian, agent or proxy on behalf of the adult who is incompetent or otherwise incapable of communication: Legal Guardian (blank), agent in a Medical Power of attorney (blank) or Proxy (blank). -C. Declaration by a qualified relative of the adult who is incompetent or otherwise incapable of communication: I am the above-noted person's: adult child (checked), " To my knowledge the adult person is incompetent or other wise mentally or physically in capable of communication and is without a legal guardian, agent or proxy. Signed by FM "Z", date [DATE]. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" arrived at the facility and informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in another city (approximately 240 miles away). Social Progress Notes for [DATE] further revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard (wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area) on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "No" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? "No" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "No" was indicated. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated and "poor decisions" was circled. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. Does the resident receive any medication that increases the restlessness or agitation? "No" was indicated. Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "Yes" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? "Yes" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "Yes" was indicated. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he cannot leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent from FM "Z", received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: "The person authorized by law to consent on behalf of the resident (guardian)." Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because, for her personal health reasons, she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety." R#1's Social Progress Notes dated [DATE] further revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurse's station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." D. Family consent and agreement to operating policies and philosophies. E. The resident's needs must be within one of the following groups: 1. Needs direction to function in a familiar surrounding and can respond to instruction. 2. Needs assistance to function and cannot respond to direction alone. 3. Needs assistance to function and cannot communicate verbally in a meaningful fashion. R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. *The following information was gathered from the CMS 2567 form dated [DATE]:* -On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" is not not R#1's medical power of attorney. The SW reported that R#1 needed to have the wanderguard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet. The family has cancelled twice." -On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." -On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. -On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and then I would be released." -In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." -In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). -On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." Geriatric Psychiatric Evaluation on R#1 dated [DATE] documented: Chief Complaint - "Depression, adjustment difficult, patient wants to go home constantly calling family. Irritability, agitation." History of presenting problem - "I'm not doing good, I don't like it here. My daughter put me here. Anxiety, I have never been locked up." "Patient had provider at home. Patient is disoriented to time, oriented to self & circumstances. Patient is compliant with care. Patient asking for alternative living arrangements." Signs of Dementia - Moderate. No thoughts of hurting self or others. Thought Stream - Logical, Goal directed. Diagnosis: [REDACTED]. On [DATE] at 11:45 a.m. surveyor met with the Administrator about R#1. The Administrator said, "(R#1) is still in the locked unit, is doing much better/adjusting, and likes being in the unit." The Administrator said R#1's family was pleased with R#1's stay in the locked unit. On [DATE] at 1:30 p.m. surveyor observed R#1 in the locked unit. R#1 was observed in the lobby area by the nurses station. R#1 was observed sitting in his wheelchair. Surveyor asked R#1 in Spanish if surveyor could speak to him in private, and R#1 said we could talk in his room. Interview was conducted entirely in Spanish. R#1 was alert, oriented, able to converse with surveyor and answer surveyor's questions. Surveyor asked R#1 what he thought about the facility. R#1 responded, "No me gusta aqui" (I don't like it here). R#1 said FM "Z" "me mentio"(lied) and "traiciono"(deceived) him by telling him he would only be in the facility for a few weeks for rehabilitation for his leg. R#1 said his leg was fine now and he wanted to go home to his house and see about his son who was mentally ill and lived with him and FM "Z". R#1 said that both he and his son had a home provider that took care of them during the day, cleaning and cooking for them. R#1 said he had the same provider for many years. R#1 said he was concerned that possibly FM "Z" was trying to sell his house. R#1 said he did not belong in the locked unit or any other part of the facility. R#1 told surveyor, "They even put a "pulsera" (bracelet) on my "pie" (foot) to keep me from leaving", "No quiero estar aqui" (I don't want to be here). Surveyor asked R#1 how he felt about being in the facility. He replied in Spanish "me siento mal" (I feel badly). Surveyor asked R#1 how he felt about FM "Z" placing him in the facility. R#1 said, "Me siento como si quiero llorar" (I feel as if I want to cry). On [DATE] at 2:00 p.m. surveyor met with the Administrator and R#1's two family members, FM "Z" and FM "Y". FM "Z" told surveyor her that R#1 had been living with her and her disabled brother for many years. FM "Z" said, "I can no longer take care of him and my brother both." FM "Z" said R#1 had a history of [REDACTED]. FM "Z" said, "(R#1) at times gets confused, has wandered off at times, and at times takes my disabled brother with him." FM "Z" said, "(R#1) gets angry and at times gets verbally abusive with my brother; at times doesn't even know he is there." On [DATE] at 2:30 p.m. surveyor conducted a telephone interview with the Physician's Assistant (PA) to R#1's Psychiatrist. The PA said she did the psychiatric evaluation on R#1 on [DATE]. The PA said R#1 was complaining that he wanted to go home and was having problems adjusting to the facility. The PA said R#1 was started on medications. The PA said R#1 had some memory and adjustment problems but was, and would be, "OK." Surveyor asked the PA, since R#1 was doing better, if it was necessary or required for R#1 to be in the Memory locked unit? The PA said R#1 could be placed in an area of the facility outside the locked unit on a trial basis to see how he did, initially using a wanderguard, then giving him some options and seeing how he would do. On [DATE] at 9:25 a.m. surveyor observed R#1 in the locked unit of the facility. Surveyor interviewed R#1 in his room. R#1 told surveyor in Spanish that he still wanted to go home, and if his daughters would not take him back, he would contact one of his sons so he could move in with them. R#1 said he had a provider that had taken care of him and his son for many years and could come with him. R#1 said, "Yo no debo de estar aqui con este typo de gente. Yo necesito que irme de aqui." (I don't belong here with these kind of people. I need to go home.) On [DATE] at 9:48 a.m. surveyor interviewed the facility SW. The SW said FM "Z" and FM "Y" did not want to tell R#1 that he would be in the facility for a long time. The SW said R#1 had been living with with FM "Z" and his son who was mentally ill. SW said FM "Z" told her she could no longer care for both R#1 and her brother. SW said she had asked R#1 if he had someone else he could stay with and R#1 had replied that he did not and that he wanted to go home with FM "Z." The SW said she called the local appraisal district and checked to see who owned the home where R#1 said he lived. SW said she was told the property (home) was owned by FM "Z" and her husband. Surveyor asked the SW if she asked the appraisal office if R#1 had ever owned the home. The SW said she had not. Surveyor asked the SW if R#1 had ever actually attempted to leave the facility. The SW replied that at one time R#1 opened a back door to the 300 hallway and apparently the alarm had not sounded. The SW said it was found out that R#1's wanderguard might not have been working. The SW said that the facility had a care plan meeting to discusss R#1's attempt to leave the facility, but R#1's family was not present. At the meeting RN "B" ordered that a wanderguard be placed on R#1 and told LVN "A" to call R#1's Physician to get an order for [REDACTED]. It was not until he was told by his family that he was staying long term that he began having problems and wanting to leave. The SW said she had never spoken to FM "Z" about getting a provider for R#1. The SW said she kept trying to meet with FM "Z" for care planning meetings, but FM "Z" kept refusing to meet. The SW said that FM "Z" told her that it was her brother that had a provider. Surveyor asked SW if R#1 had ever told her that he had three other sons and he was certain he could go and live with one of them. The SW replied "No." Surveyor asked the SW if she had assisted R#1 with discharge planning/alternative placement. The SW replied she had not. The SW said she tried to get FM "Z" to attend care plan meetings but FM "Z" would not show up. Surveyor asked the SW if she had followed-up on possible discharge planning and the SW said she had not. The SW said, in her opinion, R#1 could make his own decisions of what he wanted or did not want. Surveyor interviewed the facility Case Manager (CM) on [DATE] at 10:35 a.m. Surveyor asked the CM if R#1 could make his own decisions. CM replied, "Yes, he is able to tell us what he wants to do. He would tell us he wanted to go home, but recently he has stopped asking us." The CM said FM "Z" told her that R#1 used to have a provider, but he would, "run them off." The CM said R#1 was placed in the locked unit after he kept wanting to leave the facility and asking people in the front lobby if they could take him home. Surveyor interviewed LVN "E" on [DATE] at 11:40 a.m. LVN "E" said he had worked on the locked unit for about a month. LVN "E" said R#1 had improved and was conversing more with other residents in the unit. LVN "E" said R#1 told him several times that he wanted to go home.` Surveyor interviewed Administrator on [DATE] at 12:28 p.m. The Administrator stated that a new MDS was completed on [DATE]. He further stated that the updated MDS reflected active discharge planning including a referral to DADS "Money Follows the Person" to assist R#1 with community placment. The Administrator said a Relocation Specialist had been assigned to R#1 and would be assisting him with the program. The Administrator said the facility had R#1's Psychiatrist conduct a psychiatric evaluation for R#1. Surveyor conducted a telephone interview with a DADS Relocation Specialist on [DATE] at 1:23 p.m. The Relocation Specialist said she had been contacted by the facility Administrator regarding R#1 and wanted to make referral for assistance for possible community placement. The Relocation Specialist said a full assessment would need to be conducted to determine if R#1 met the financial requirements(Social Security, Medicaid etc..) for the program. Surveyor observed R#1 in the Memory locked unit on [DATE] at 2:40 p.m. Surveyor observed R#1 walking down the hallway pushing his wheelchair. Surveyor approached R#1 and asked him if he remembered me. R#1 replied in Spanish "si" (yes). Surveyor and R#1 moved to a more private area of the Memory locked unit. Surveyor asked R#1 for the names of his sons. R#1 replied he had three sons, two who were married and one who was mentally disabled and had lived with him. R#1 gave the names of the sons. Surveyor asked R#1 if his sons would be able to take him in to live them. R#1 chuckled and said "No, le tienen miedo a mi hija" (No, they are afraid of my daughter). R#1 said his daughter would not allow his sons to take care of him. Psychiatric Evaluation by R#1's Psychiatrist on [DATE] (after surveyor entered the facility for a follow up visit on [DATE]) documented: "[DIAGNOSES REDACTED]. History (HX) of progressive memory loss wants to go home. Patient has a HX of progressive memory loss, intellectual permanent personality deterioration recently compounded with depressive symptoms. On [MEDICATION NAME] (anit-Alzheimers medication), [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (medication for Dementia). 0 family HX. On examination, pleasant but becomes easily irritated when tested . Affect is responsive though mood depressed. Denied suicidality. Significant thought poverty. No hallucinations. Some referential thinking. Moderately confused limited insight into his confusion. DX (diagnosis) Primary [MEDICAL CONDITION] Dementia with Depression and behavioral disturbances. Recommendations: Patient is in need of 24 hour supervision, Re-orientation, redirection. Continue same [MEDICAL CONDITION] medications, consider adding atypical antipsychotic, low dose if agitated. Monitor clinical response." Surveyor conducted a telephone interview with R#1's Psychiatrist on [DATE] at 11:30 a.m. The Psychiatrist said he conducted R#1's evaluation on [DATE]. The Psychiatrist said R#1 had a [DIAGNOSES REDACTED]. Surveyor asked the Psychiatrist if R#1 was able to make his own decisions, and he replied "No." The Psychiatrist said R#1 was not cognitively aware of his health status, R#1 thought he was cured of his [MEDICAL CONDITION]. The Psychiatrist said R#1 needed 24 hour supervision and the family was not able to provide that for him. The Psychiatrist said R#1's thinking was poor, he was "irrational"at times and would be, "easy prey to be taken advantage of or hurt if out on his own. He would be at risk." Surveyor asked Psychiatrist if R#1 could function off the locked unit, perhaps with a wanderguard. The Psychiatrist said that even if R#1 had a wanderguard, he would still be at risk of leaving the facility. Review of R#1's Physician's letter to facility ADON "C" documented: Title: Letter to Acknowledge a Resident Incompetent. "This letter serves to inform the (name of facility) that R#1 has a [DIAGNOSES REDACTED]." The letter was not dated. Date of fax at the top of the page was [DATE]. Surveyor conducted telephone interview with R#1's Physician on [DATE] at 11:45 a.m. The Physician said R#1 was irrational at times. The Physician said, "I don't think (R#1) is able to make rational decisions for safety and care. I don't think he would be safe at home or in the skilled unit with a wanderguard." Physician said R#1 needed 24 hour care. Surveyor read R#1's Psychiatric Evaluation by R#1's Psychiatrist to his Physician. R#1's Physician said he agreed with R#1's Psychiatrist's findings/[DIAGNOSES REDACTED]. R#1's Physician said, "(R#1) is better off in the Memory locked unit." Surveyor interviewed the facility Physical Therapist on [DATE] at 11:00 a.m. Physical Therapist said R#1 had suffered a [MEDICAL CONDITION] in [DATE] while living at home. When R#1 was admitted to the facility, physical therapy (PT) was ordered for strengthening of the hip area, improvement of his ablity to transfer himself, and strengthening of his lower extremities. The Physical Therapist said R#1 was admitted for PT services on [DATE] and discharged from PT on [DATE]. The Physical Therapist said R#1's goals were met. R#1 was able to stand and push his wheelchair and had strengthened his hip area and extremities. Surveyor interviewed LVN "E"/ MDS Coordinator on [DATE] at 12:05 p.m. LVN "E" said family had requested Hospice services after R#1's Physician had talked to them because R#1 had [MEDICAL CONDITION] and Melanoma (cancer neck area). LVN "E" said R#1's family called the facility requesting Hospice services and information about available Hospice companies was provided to them. LVN "E" said family chose a Hospice company and a telephone physician's orders [REDACTED]. Surveyor interviewed facility Administrator on [DATE] at 1:00 p.m. The Administrator told surveyor that the facility's Medical Director was aware of R#1's condition and was R#1's attending physician. Surveyor asked Administrator if she had ever spoken directly to R#1. The Administrator replied that she had not spoken directly to R#1, but that she got feedback from her staff on R#1 and also read psychiatric notes about R#1. The Administrator said the appropriateness of each resident's placement in the locked unit was reviewed at quarterly meetings. The family was asked if they still wanted the resident in the unit. If the unit ADON saw a change of condition, she would initiate a new assessment. The Administrator said the ADON would

Based on observation, interview and record review the facility failed to promote care of residents in a manner which maintained residents' dignity and respect, for one Resident (R#1) of two residents reviewed for dignity issues. Without R#1's permission or discussing the issues with R#1, the facility: -placed a wanderguard bracelet on R#1's leg, with no history of elopement and in violation of facility policy, and, -placed R#1 in a locked unit with no history of wandering or elopement and in violation of facility policy. R#1 stated he had been told he was in the facility only for short term rehabilitation and that he was going home. After being placed on the locked unit he stated, "I don't know why I am here. I feel I am in prison here." Failure to promote care for R#1 in an environment that promoted his dignity could result in R#1 experiencing feelings of agitation, frustration and low self-esteem, and could affect all 25 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, and, - had no behavioal issues. R#1's Discharge Plan from MDS assessment dated [DATE] indicated, "Is there an active discharge plan in place for the resident to return to the community? No." "What determination was made by the resident and the care planning team regarding discharge to the community? Discharge to the community determined to be not feasible." R#1 nurses notes dated 01/11/12 at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated 01/12/12, section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated 01/12/12 indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." On 03/06/12 at 2:00 p.m. surveyor observed R#1 to propel himself from his room to the nurses station. R#1 was asking anyone at the nurses station to make arrangements to send him home. He said he wanted to go home. Social Progress Notes for 02/16/12 revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" (02/16/12) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in San Antonio. Social Progress Notes for 02/16/12 revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard on (R#1) on 02/16/12 and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated 01/18/12 revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? No. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? No. Does the wandering significantly intrude on the privacy or activities of others? No. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. ("poor decisions" was circled) Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes. Does the resident receive any medication that increases the restlessness or agitation? No." Review of Wander Data Collection for R#1 dated 02/16/12 revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? Yes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? Yes. Does the wandering significantly intrude on the privacy or activities of others? Yes. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes." R#1's Skilled Nurses Notes dated 02/16/12 at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he can not leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated 02/16/12 at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated 02/16/12 was a verbal telephone consent received by LVN "A." R#1's Telephone Order dated 02/16/12 revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated 03/01/12 revealed: The person authorized by law to consent on behalf of the resident (guardian). Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated 02/17/12 through 02/23/12 revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from January 2012 and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated 02/27/12 revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for 03/01/12 at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated 02/28/12 revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because for her personal health reasons she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety. R#1's Social Progress Notes dated 02/28/12 revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit. 02/28/12 Ombudsman was at nh to speak with SW about family council meeting. (R#1) was in reception area and Ombusdman asked if she could speak with him. (R#1) stated that he was waiting for a ride to go home. After, Ombudsman spoke with (R#1) in private she approached SW and advised (R#1) that he had every right to return home because he voiced to her that he owned the property where (FM "Z") lived with his mentally retarded son. Ombudsman asked (R#1) if he had any money for a taxi so that he could return home and stated no. SW advised Ombudsman (R#1's) RP is responsible for his money. SW explained that at this time even if (R#1) is stating to return home his (family members) are not in agreement that they can not care for him at home. SW explained to Ombudsman that (R#1) had made threats and attempts to leave nh and (family members) agreed that placement in memory support unit for safety was what they wanted to do at this time. Ombudsman told SW that if (R#1) owned the home he has every right to return despite (family members') objections. Ombudsman stated that nursing home could not place (R#1) in memory support unit just because he attempted to leave. The Ombudsman stated she would follow up with SW to see if (R#1) had returned home." R#1's Social Progress Notes (continued) dated 02/28/12 revealed: "SW was present as Administrator contacted RP for (R#1) and discussed Ombudsman's concerns that he should return home. (FM "Z") stated they were upset because they want (R#1) placed in the memory support unit for his safety due to his attempts and threats to leave nh. Administrator stated to RP that the Doctor has not been to nursing home to determine that (R#1) has dementia. RP stated that the Veteran's Administration has documentation with (R#1's) [DIAGNOSES REDACTED]. Administrator discussed with them switching to another primary physician because (R#1's) Doctor does not come to nh. RP stated at this time they do not want to switch physicians. RP stated that (R#1) better be moved to the memory support unit today." R#1's Telephone Order dated 02/28/12 at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated 02/29/12 at 5:00 p.m. revealed: "Resident came up to nurses station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated 02/29/12 indicated to refer R#1 to hospice as per family's request. R#1's Social Progress Notes dated 03/01/12 revealed: "SW received call from Ombudsman and she stated that she was following up on (R#1's) return home. SW advised that he was moved to memory support unit after family spoke with Administrator by phone. Ombudsman advised that she would be contacting state and requested the face sheet because (R#1) did not have a [DIAGNOSES REDACTED]. Administrator advised SW that family met with her yesterday and brought paperwork from VA that showed a [DIAGNOSES REDACTED]. SW contacted (family members) to inform them that Ombudsman was going to contact the state regarding (R#1's) placement in the memory support unit because she felt the nh had violated his rights. (R#1's family members) were very upset stating that they did not want (R#1) moved. They stated they never met with the Ombudsman and she did not know the situation of (R#1's) history. Family members met with SW and Administrator because they did not understand how the Ombudsman could demand that (R#1) be allowed to return home. Administrator explained that nh was not in agreement and felt that for his safety due to wandering and threats of leaving nh the memory support unit was best for him. Administrator explained to family that discharging a resident home is a process in which the nh includes the family. (R#1's family members) voiced understanding and also agreed that (R#1) primary physician needed to be changed because he has not seen him at the nh." The facility's policy, Admission and Assessment Process-Nursing and Alzheimer's Care Centers, Effective date: October 2005, indicated: "Procedure: 1. Admissions Coordinator will interview family and/or prospective resident. The family and/or the prospective resident will complete form 10-10SH (State Home Program Application for Veteran Medical Certification) and form 10-10EZ (Application for Health Benefits). Form 10-10SH must be signed by the resident's attending/admitting physician. 2. If the Prospective resident meets the guidelines as stipulated in Section 51.50 listed above for the admission criteria, the prospective resident is scheduled for an assessment coordinated by a Registered nurse along with the Interdisciplinary Team which usually consist of the administrator, Director of Nursing, Director of Social Work and Admissions Coordinator or their respective designees). The Administrator and nursing administration will review the residents' medication with the pharmacy prior to admission. 6. The Admissions Coordinator will set an appointment with the resident and/or responsible party at which time all relevant SDI policies and procedures will be reviewed including stipulations for discharge and transfer policies when health condition changes occur. 7. The following paperwork must be completed and returned before admission or at the time of admission: a. Application for Admission (form10-10EZ) signed in designated places by resident and/or responsible party. b. Doctor's orders completed and signed by a licensed physician (form 10-10SH). c. History and physical, [DIAGNOSES REDACTED]. d. Photocopy of legal documents for Health Care Decision (Health Care Power of Attorney, Directive to Physician (Living Will) Family/ Physician Directive, Out of hospital DNR if applicable). e. Residency and Care Agreement Contract signed by resident and/or responsible party." The facility's policy on Secure Care System dated August 2010 revealed: "Care plan based on the goals, needs, risks and interventions attempted prior to initiation." The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date January 2004, indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (10-10SH) form dated 03/05/12 indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form 10-10SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on 03/05/2012. On 03/07/12 at 8:40 a.m. the Admissions Coordinator said, "The 10-10SH should be in (R#1's) chart. I am assuming that it was done. I know the policy says the 10-10SH must be signed by the physician. I think it is the Social Worker that takes care of that.) On 03/06/12 at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. The SW reported that R#1 needed to have the wander guard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet, the family has cancelled twice." On 03/06/12 at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." On 03/06/12 at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. On 03/06/12 at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and than I would be released." In an interview on 03/06/12 at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." In an interview on 03/06/12 at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). On 03/07/12 at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." During exit conference held on 03/07/12 at 3:00 p.m the Administrator was given the opportunity to present any additional information regarding promotion of R#1's dignity. No additional information was presented. The facility's Roster/Sample Matrix listed 25 residents who were not assessed as cognitively impaired.

Based on observation, record review, and interview, the facility failed to promote care of residents in a manner which maintained residents' dignity and respect, for one Resident (R#1)of six residents reviewed for dignity issues. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response the facility: -failed to assist R#1 with discharge planning/alternative placement, and, -placed R#1 in a locked unit against his wishes and in violation of facility policy. The facility did not assess R#1 prior to placement on the locked unit to determine whether the placement was appropriate, resulting in R#1 remaining on the locked unit for 79 days. R#1 was still on the locked unit on the day of exit ([DATE]). The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's placement in the locked unit and placement of a wanderguard bracelet on R#1's leg. Failure to allow R#1 to make his own decisions regarding treatment denied him the right to refuse treatment if he chose to do so, and denied him control over his own decisions and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 26 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, - had no behavioral issues and - had no signs of [MEDICAL CONDITION] R#1's Discharge Plan from MDS assessment dated [DATE] indicated R#1 and his family participated in the assessment. The assessment indicated a, "Guardian or legally authorized representative" did not participate in the assessment. The assessment also indicated: -Resident's Overall Expectation: Resident's overall goal established during assessment process - (Blank). Discharge Plan: Is there an active discharge plan in place for the resident to return to the community? "No." was marked. Discharge Plan: What determination was made by the resident and the care planning team regarding discharge to the community: "Discharge to the community determined to be not feasible." was written. R#1's Nurses Notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." Out of Hospital Do-Not-Resuscitate order; Texas Department of State Health Services form: -A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advance airway management, artificial ventilation. The form was signed by R#1 after his admission to the locked unit and after surveyor intervention. -B. Declaration by legal guardian, agent or proxy on behalf of the adult who is incompetent or otherwise incapable of communication: Legal Guardian (blank), agent in a Medical Power of attorney (blank) or Proxy (blank). -C. Declaration by a qualified relative of the adult who is incompetent or otherwise incapable of communication: I am the above-noted person's: adult child (checked), " To my knowledge the adult person is incompetent or other wise mentally or physically in capable of communication and is without a legal guardian, agent or proxy. Signed by FM "Z", date [DATE]. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" arrived at the facility and informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in another city (approximately 240 miles away). Social Progress Notes for [DATE] further revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard (wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area) on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "No" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? "No" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "No" was indicated. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated and "poor decisions" was circled. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. Does the resident receive any medication that increases the restlessness or agitation? "No" was indicated. Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "Yes" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? "Yes" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "Yes" was indicated. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he cannot leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent from FM "Z", received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: "The person authorized by law to consent on behalf of the resident (guardian)." Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because, for her personal health reasons, she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety." R#1's Social Progress Notes dated [DATE] further revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurse's station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." D. Family consent and agreement to operating policies and philosophies. E. The resident's needs must be within one of the following groups: 1. Needs direction to function in a familiar surrounding and can respond to instruction. 2. Needs assistance to function and cannot respond to direction alone. 3. Needs assistance to function and cannot communicate verbally in a meaningful fashion. R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. *The following information was gathered from the CMS 2567 form dated [DATE]:* -On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" is not not R#1's medical power of attorney. The SW reported that R#1 needed to have the wanderguard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet. The family has cancelled twice." -On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." -On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. -On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and then I would be released." -In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." -In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). -On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." Geriatric Psychiatric Evaluation on R#1 dated [DATE] documented: Chief Complaint - "Depression, adjustment difficult, patient wants to go home constantly calling family. Irritability, agitation." History of presenting problem - "I'm not doing good, I don't like it here. My daughter put me here. Anxiety, I have never been locked up." "Patient had provider at home. Patient is disoriented to time, oriented to self & circumstances. Patient is compliant with care. Patient asking for alternative living arrangements." Signs of Dementia - Moderate. No thoughts of hurting self or others. Thought Stream - Logical, Goal directed. Diagnosis: [REDACTED]. On [DATE] at 11:45 a.m. surveyor met with the Administrator about R#1. The Administrator said, "(R#1) is still in the locked unit, is doing much better/adjusting, and likes being in the unit." The Administrator said R#1's family was pleased with R#1's stay in the locked unit. On [DATE] at 1:30 p.m. surveyor observed R#1 in the locked unit. R#1 was observed in the lobby area by the nurses station. R#1 was observed sitting in his wheelchair. Surveyor asked R#1 in Spanish if surveyor could speak to him in private, and R#1 said we could talk in his room. Interview was conducted entirely in Spanish. R#1 was alert, oriented, able to converse with surveyor and answer surveyor's questions. Surveyor asked R#1 what he thought about the facility. R#1 responded, "No me gusta aqui" (I don't like it here). R#1 said FM "Z" "me mentio"(lied) and "traiciono"(deceived) him by telling him he would only be in the facility for a few weeks for rehabilitation for his leg. R#1 said his leg was fine now and he wanted to go home to his house and see about his son who was mentally ill and lived with him and FM "Z". R#1 said that both he and his son had a home provider that took care of them during the day, cleaning and cooking for them. R#1 said he had the same provider for many years. R#1 said he was concerned that possibly FM "Z" was trying to sell his house. R#1 said he did not belong in the locked unit or any other part of the facility. R#1 told surveyor, "They even put a "pulsera" (bracelet) on my "pie" (foot) to keep me from leaving", "No quiero estar aqui" (I don't want to be here). Surveyor asked R#1 how he felt about being in the facility. He replied in Spanish "me siento mal" (I feel badly). Surveyor asked R#1 how he felt about FM "Z" placing him in the facility. R#1 said, "Me siento como si quiero llorar" (I feel as if I want to cry). On [DATE] at 2:00 p.m. surveyor met with the Administrator and R#1's two family members, FM "Z" and FM "Y". FM "Z" told surveyor her that R#1 had been living with her and her disabled brother for many years. FM "Z" said, "I can no longer take care of him and my brother both." FM "Z" said R#1 had a history of [REDACTED]. FM "Z" said, "(R#1) at times gets confused, has wandered off at times, and at times takes my disabled brother with him." FM "Z" said, "(R#1) gets angry and at times gets verbally abusive with my brother; at times doesn't even know he is there." On [DATE] at 2:30 p.m. surveyor conducted a telephone interview with the Physician's Assistant (PA) to R#1's Psychiatrist. The PA said she did the psychiatric evaluation on R#1 on [DATE]. The PA said R#1 was complaining that he wanted to go home and was having problems adjusting to the facility. The PA said R#1 was started on medications. The PA said R#1 had some memory and adjustment problems but was, and would be, "OK." Surveyor asked the PA, since R#1 was doing better, if it was necessary or required for R#1 to be in the Memory locked unit? The PA said R#1 could be placed in an area of the facility outside the locked unit on a trial basis to see how he did, initially using a wanderguard, then giving him some options and seeing how he would do. On [DATE] at 9:25 a.m. surveyor observed R#1 in the locked unit of the facility. Surveyor interviewed R#1 in his room. R#1 told surveyor in Spanish that he still wanted to go home, and if his daughters would not take him back, he would contact one of his sons so he could move in with them. R#1 said he had a provider that had taken care of him and his son for many years and could come with him. R#1 said, "Yo no debo de estar aqui con este typo de gente. Yo necesito que irme de aqui." (I don't belong here with these kind of people. I need to go home.) On [DATE] at 9:48 a.m. surveyor interviewed the facility SW. The SW said FM "Z" and FM "Y" did not want to tell R#1 that he would be in the facility for a long time. The SW said R#1 had been living with with FM "Z" and his son who was mentally ill. SW said FM "Z" told her she could no longer care for both R#1 and her brother. SW said she had asked R#1 if he had someone else he could stay with and R#1 had replied that he did not and that he wanted to go home with FM "Z." The SW said she called the local appraisal district and checked to see who owned the home where R#1 said he lived. SW said she was told the property (home) was owned by FM "Z" and her husband. Surveyor asked the SW if she asked the appraisal office if R#1 had ever owned the home. The SW said she had not. Surveyor asked the SW if R#1 had ever actually attempted to leave the facility. The SW replied that at one time R#1 opened a back door to the 300 hallway and apparently the alarm had not sounded. The SW said it was found out that R#1's wanderguard might not have been working. The SW said that the facility had a care plan meeting to discusss R#1's attempt to leave the facility, but R#1's family was not present. At the meeting RN "B" ordered that a wanderguard be placed on R#1 and told LVN "A" to call R#1's Physician to get an order for [REDACTED]. It was not until he was told by his family that he was staying long term that he began having problems and wanting to leave. The SW said she had never spoken to FM "Z" about getting a provider for R#1. The SW said she kept trying to meet with FM "Z" for care planning meetings, but FM "Z" kept refusing to meet. The SW said that FM "Z" told her that it was her brother that had a provider. Surveyor asked SW if R#1 had ever told her that he had three other sons and he was certain he could go and live with one of them. The SW replied "No." Surveyor asked the SW if she had assisted R#1 with discharge planning/alternative placement. The SW replied she had not. The SW said she tried to get FM "Z" to attend care plan meetings but FM "Z" would not show up. Surveyor asked the SW if she had followed-up on possible discharge planning and the SW said she had not. The SW said, in her opinion, R#1 could make his own decisions of what he wanted or did not want. Surveyor interviewed the facility Case Manager (CM) on [DATE] at 10:35 a.m. Surveyor asked the CM if R#1 could make his own decisions. CM replied, "Yes, he is able to tell us what he wants to do. He would tell us he wanted to go home, but recently he has stopped asking us." The CM said FM "Z" told her that R#1 used to have a provider, but he would, "run them off." The CM said R#1 was placed in the locked unit after he kept wanting to leave the facility and asking people in the front lobby if they could take him home. Surveyor interviewed LVN "E" on [DATE] at 11:40 a.m. LVN "E" said he had worked on the locked unit for about a month. LVN "E" said R#1 had improved and was conversing more with other residents in the unit. LVN "E" said R#1 told him several times that he wanted to go home.` Surveyor interviewed Administrator on [DATE] at 12:28 p.m. The Administrator stated that a new MDS was completed on [DATE]. He further stated that the updated MDS reflected active discharge planning including a referral to DADS "Money Follows the Person" to assist R#1 with community placment. The Administrator said a Relocation Specialist had been assigned to R#1 and would be assisting him with the program. The Administrator said the facility had R#1's Psychiatrist conduct a psychiatric evaluation for R#1. Surveyor conducted a telephone interview with a DADS Relocation Specialist on [DATE] at 1:23 p.m. The Relocation Specialist said she had been contacted by the facility Administrator regarding R#1 and wanted to make referral for assistance for possible community placement. The Relocation Specialist said a full assessment would need to be conducted to determine if R#1 met the financial requirements(Social Security, Medicaid etc..) for the program. Surveyor observed R#1 in the Memory locked unit on [DATE] at 2:40 p.m. Surveyor observed R#1 walking down the hallway pushing his wheelchair. Surveyor approached R#1 and asked him if he remembered me. R#1 replied in Spanish "si" (yes). Surveyor and R#1 moved to a more private area of the Memory locked unit. Surveyor asked R#1 for the names of his sons. R#1 replied he had three sons, two who were married and one who was mentally disabled and had lived with him. R#1 gave the names of the sons. Surveyor asked R#1 if his sons would be able to take him in to live them. R#1 chuckled and said "No, le tienen miedo a mi hija" (No, they are afraid of my daughter). R#1 said his daughter would not allow his sons to take care of him. Psychiatric Evaluation by R#1's Psychiatrist on [DATE] (after surveyor entered the facility for a follow up visit on [DATE]) documented: "[DIAGNOSES REDACTED]. History (HX) of progressive memory loss wants to go home. Patient has a HX of progressive memory loss, intellectual permanent personality deterioration recently compounded with depressive symptoms. On [MEDICATION NAME] (anit-Alzheimers medication), [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (medication for Dementia). 0 family HX. On examination, pleasant but becomes easily irritated when tested . Affect is responsive though mood depressed. Denied suicidality. Significant thought poverty. No hallucinations. Some referential thinking. Moderately confused limited insight into his confusion. DX (diagnosis) Primary [MEDICAL CONDITION] Dementia with Depression and behavioral disturbances. Recommendations: Patient is in need of 24 hour supervision, Re-orientation, redirection. Continue same [MEDICAL CONDITION] medications, consider adding atypical antipsychotic, low dose if agitated. Monitor clinical response." Surveyor conducted a telephone interview with R#1's Psychiatrist on [DATE] at 11:30 a.m. The Psychiatrist said he conducted R#1's evaluation on [DATE]. The Psychiatrist said R#1 had a [DIAGNOSES REDACTED]. Surveyor asked the Psychiatrist if R#1 was able to make his own decisions, and he replied "No." The Psychiatrist said R#1 was not cognitively aware of his health status, R#1 thought he was cured of his [MEDICAL CONDITION]. The Psychiatrist said R#1 needed 24 hour supervision and the family was not able to provide that for him. The Psychiatrist said R#1's thinking was poor, he was "irrational"at times and would be, "easy prey to be taken advantage of or hurt if out on his own. He would be at risk." Surveyor asked Psychiatrist if R#1 could function off the locked unit, perhaps with a wanderguard. The Psychiatrist said that even if R#1 had a wanderguard, he would still be at risk of leaving the facility. Review of R#1's Physician's letter to facility ADON "C" documented: Title: Letter to Acknowledge a Resident Incompetent. "This letter serves to inform the (name of facility) that R#1 has a [DIAGNOSES REDACTED]." The letter was not dated. Date of fax at the top of the page was [DATE]. Surveyor conducted telephone interview with R#1's Physician on [DATE] at 11:45 a.m. The Physician said R#1 was irrational at times. The Physician said, "I don't think (R#1) is able to make rational decisions for safety and care. I don't think he would be safe at home or in the skilled unit with a wanderguard." Physician said R#1 needed 24 hour care. Surveyor read R#1's Psychiatric Evaluation by R#1's Psychiatrist to his Physician. R#1's Physician said he agreed with R#1's Psychiatrist's findings/[DIAGNOSES REDACTED]. R#1's Physician said, "(R#1) is better off in the Memory locked unit." Surveyor interviewed the facility Physical Therapist on [DATE] at 11:00 a.m. Physical Therapist said R#1 had suffered a [MEDICAL CONDITION] in [DATE] while living at home. When R#1 was admitted to the facility, physical therapy (PT) was ordered for strengthening of the hip area, improvement of his ablity to transfer himself, and strengthening of his lower extremities. The Physical Therapist said R#1 was admitted for PT services on [DATE] and discharged from PT on [DATE]. The Physical Therapist said R#1's goals were met. R#1 was able to stand and push his wheelchair and had strengthened his hip area and extremities. Surveyor interviewed LVN "E"/ MDS Coordinator on [DATE] at 12:05 p.m. LVN "E" said family had requested Hospice services after R#1's Physician had talked to them because R#1 had [MEDICAL CONDITION] and Melanoma (cancer neck area). LVN "E" said R#1's family called the facility requesting Hospice services and information about available Hospice companies was provided to them. LVN "E" said family chose a Hospice company and a telephone physician's orders [REDACTED]. Surveyor interviewed facility Administrator on [DATE] at 1:00 p.m. The Administrator told surveyor that the facility's Medical Director was aware of R#1's condition and was R#1's attending physician. Surveyor asked Administrator if she had ever spoken directly to R#1. The Administrator replied that she had not spoken directly to R#1, but that she got feedback from her staff on R#1 and also read psychiatric notes about R#1. The Administrator said the appropriateness of each resident's placement in the locked unit was reviewed at quarterly meetings. The family was asked if they still wanted the resident in the unit. If the unit ADON saw a change of condition, she would initiate a new

Based on observation, interview and record review, the facility failed to ensure one Resident (R#1) of two residents reviewed for quality of life had the right to make choices about significant aspects of his life. Without R#1's permission or discussing the issues with R#1, the facility: -placed a wanderguard bracelet on R#1's leg, with no history of elopement and in violation of facility policy, and, -placed R#1 in a locked unit with no history of wandering or elopement and in violation of facility policy. R#1 stated he had been told he was in the facility only for short term rehabilitation and that he was going home. After being placed on the locked unit he stated, "I don't know why I am here. I feel I am in prison here." Failure to provide care and services for R#1 in an environment that allowed R#1 to make decisions about significant aspects of his life could result in R#1 experiencing feelings of agitation, frustration and low self-esteem and could affect all 25 residents not assessed to be cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, and, - had no behavioal issues. R#1's Discharge Plan from MDS assessment dated [DATE] indicated, "Is there an active discharge plan in place for the resident to return to the community? No." "What determination was made by the resident and the care planning team regarding discharge to the community? Discharge to the community determined to be not feasible." R#1 nurses notes dated 01/11/12 at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated 01/12/12, section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated 01/12/12 indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." On 03/06/12 at 2:00 p.m. surveyor observed R#1 to propel himself from his room to the nurses station. R#1 was asking anyone at the nurses station to make arrangements to send him home. He said he wanted to go home. Social Progress Notes for 02/16/12 revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" (02/16/12) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in San Antonio. Social Progress Notes for 02/16/12 revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard on (R#1) on 02/16/12 and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated 01/18/12 revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? No. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? No. Does the wandering significantly intrude on the privacy or activities of others? No. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. ("poor decisions" was circled) Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes. Does the resident receive any medication that increases the restlessness or agitation? No." Review of Wander Data Collection for R#1 dated 02/16/12 revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? Yes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? Yes. Does the wandering significantly intrude on the privacy or activities of others? Yes. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes." R#1's Skilled Nurses Notes dated 02/16/12 at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he can not leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated 02/16/12 at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated 02/16/12 was a verbal telephone consent received by LVN "A." R#1's Telephone Order dated 02/16/12 revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated 03/01/12 revealed: The person authorized by law to consent on behalf of the resident (guardian). Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated 02/17/12 through 02/23/12 revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from January 2012 and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated 02/27/12 revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for 03/01/12 at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated 02/28/12 revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because for her personal health reasons she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety. R#1's Social Progress Notes dated 02/28/12 revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit. 02/28/12 Ombudsman was at nh to speak with SW about family council meeting. (R#1) was in reception area and Ombusdman asked if she could speak with him. (R#1) stated that he was waiting for a ride to go home. After, Ombudsman spoke with (R#1) in private she approached SW and advised (R#1) that he had every right to return home because he voiced to her that he owned the property where (FM "Z") lived with his mentally retarded son. Ombudsman asked (R#1) if he had any money for a taxi so that he could return home and stated no. SW advised Ombudsman (R#1's) RP is responsible for his money. SW explained that at this time even if (R#1) is stating to return home his (family members) are not in agreement that they can not care for him at home. SW explained to Ombudsman that (R#1) had made threats and attempts to leave nh and (family members) agreed that placement in memory support unit for safety was what they wanted to do at this time. Ombudsman told SW that if (R#1) owned the home he has every right to return despite (family members') objections. Ombudsman stated that nursing home could not place (R#1) in memory support unit just because he attempted to leave. The Ombudsman stated she would follow up with SW to see if (R#1) had returned home." R#1's Social Progress Notes (continued) dated 02/28/12 revealed: "SW was present as Administrator contacted RP for (R#1) and discussed Ombudsman's concerns that he should return home. (FM "Z") stated they were upset because they want (R#1) placed in the memory support unit for his safety due to his attempts and threats to leave nh. Administrator stated to RP that the Doctor has not been to nursing home to determine that (R#1) has dementia. RP stated that the Veteran's Administration has documentation with (R#1's) [DIAGNOSES REDACTED]. Administrator discussed with them switching to another primary physician because (R#1's) Doctor does not come to nh. RP stated at this time they do not want to switch physicians. RP stated that (R#1) better be moved to the memory support unit today." R#1's Telephone Order dated 02/28/12 at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated 02/29/12 at 5:00 p.m. revealed: "Resident came up to nurses station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated 02/29/12 indicated to refer R#1 to hospice as per family's request. R#1's Social Progress Notes dated 03/01/12 revealed: "SW received call from Ombudsman and she stated that she was following up on (R#1's) return home. SW advised that he was moved to memory support unit after family spoke with Administrator by phone. Ombudsman advised that she would be contacting state and requested the face sheet because (R#1) did not have a [DIAGNOSES REDACTED]. Administrator advised SW that family met with her yesterday and brought paperwork from VA that showed a [DIAGNOSES REDACTED]. SW contacted (family members) to inform them that Ombudsman was going to contact the state regarding (R#1's) placement in the memory support unit because she felt the nh had violated his rights. (R#1's family members) were very upset stating that they did not want (R#1) moved. They stated they never met with the Ombudsman and she did not know the situation of (R#1's) history. Family members met with SW and Administrator because they did not understand how the Ombudsman could demand that (R#1) be allowed to return home. Administrator explained that nh was not in agreement and felt that for his safety due to wandering and threats of leaving nh the memory support unit was best for him. Administrator explained to family that discharging a resident home is a process in which the nh includes the family. (R#1's family members) voiced understanding and also agreed that (R#1) primary physician needed to be changed because he has not seen him at the nh." The facility's policy, Admission and Assessment Process-Nursing and Alzheimer's Care Centers, Effective date: October 2005, indicated: "Procedure: 1. Admissions Coordinator will interview family and/or prospective resident. The family and/or the prospective resident will complete form 10-10SH (State Home Program Application for Veteran Medical Certification) and form 10-10EZ (Application for Health Benefits). Form 10-10SH must be signed by the resident's attending/admitting physician. 2. If the Prospective resident meets the guidelines as stipulated in Section 51.50 listed above for the admission criteria, the prospective resident is scheduled for an assessment coordinated by a Registered nurse along with the Interdisciplinary Team which usually consist of the administrator, Director of Nursing, Director of Social Work and Admissions Coordinator or their respective designees). The Administrator and nursing administration will review the residents' medication with the pharmacy prior to admission. 6. The Admissions Coordinator will set an appointment with the resident and/or responsible party at which time all relevant SDI policies and procedures will be reviewed including stipulations for discharge and transfer policies when health condition changes occur. 7. The following paperwork must be completed and returned before admission or at the time of admission: a. Application for Admission (form10-10EZ) signed in designated places by resident and/or responsible party. b. Doctor's orders completed and signed by a licensed physician (form 10-10SH). c. History and physical, [DIAGNOSES REDACTED]. d. Photocopy of legal documents for Health Care Decision (Health Care Power of Attorney, Directive to Physician (Living Will) Family/ Physician Directive, Out of hospital DNR if applicable). e. Residency and Care Agreement Contract signed by resident and/or responsible party." The facility's policy on Secure Care System dated August 2010 revealed: "Care plan based on the goals, needs, risks and interventions attempted prior to initiation." The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date January 2004, indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (10-10SH) form dated 03/05/12 indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form 10-10SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on 03/05/2012. On 03/07/12 at 8:40 a.m. the Admissions Coordinator said, "The 10-10SH should be in (R#1's) chart. I am assuming that it was done. I know the policy says the 10-10SH must be signed by the physician. I think it is the Social Worker that takes care of that.) On 03/06/12 at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. The SW reported that R#1 needed to have the wander guard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet, the family has cancelled twice." On 03/06/12 at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." On 03/06/12 at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. On 03/06/12 at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and than I would be released." In an interview on 03/06/12 at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." In an interview on 03/06/12 at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). On 03/07/12 at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." During exit conference held on 03/07/12 at 3:00 p.m the Administrator was given the opportunity to present any additional information regarding promotion of R#1's quality of life. No additional information was presented. The facility's Roster/Sample Matrix listed 25 residents who were not assessed as cognitively impaired.

Based on observation, record review, and interview, the facility failed to ensure one Resident (R#1) of six residents reviewed for quality of life had the right to make choices about significant aspects of his life. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response the facility: -failed to assist R#1 with discharge planning/alternative placement, and, -placed R#1 in a locked unit against his wishes and in violation of facility policy. The facility did not assess R#1 prior to placement on the locked unit to determine whether the placement was appropriate, resulting in R#1 remaining on the locked unit for 79 days. R#1 was still on the locked unit on the day of exit ([DATE]). The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's placement in the locked unit and placement of a wanderguard bracelet on R#1's leg. Failure to allow R#1 to make his own decisions regarding treatment denied him the right to refuse treatment if he chose to do so, and denied him control over his own decisions and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 26 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, - had no behavioral issues and - had no signs of [MEDICAL CONDITION] R#1's Discharge Plan from MDS assessment dated [DATE] indicated R#1 and his family participated in the assessment. The assessment indicated a, "Guardian or legally authorized representative" did not participate in the assessment. The assessment also indicated: -Resident's Overall Expectation: Resident's overall goal established during assessment process - (Blank). Discharge Plan: Is there an active discharge plan in place for the resident to return to the community? "No." was marked. Discharge Plan: What determination was made by the resident and the care planning team regarding discharge to the community: "Discharge to the community determined to be not feasible." was written. R#1's Nurses Notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." Out of Hospital Do-Not-Resuscitate order; Texas Department of State Health Services form: -A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advance airway management, artificial ventilation. The form was signed by R#1 after his admission to the locked unit and after surveyor intervention. -B. Declaration by legal guardian, agent or proxy on behalf of the adult who is incompetent or otherwise incapable of communication: Legal Guardian (blank), agent in a Medical Power of attorney (blank) or Proxy (blank). -C. Declaration by a qualified relative of the adult who is incompetent or otherwise incapable of communication: I am the above-noted person's: adult child (checked), " To my knowledge the adult person is incompetent or other wise mentally or physically in capable of communication and is without a legal guardian, agent or proxy. Signed by FM "Z", date [DATE]. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" arrived at the facility and informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in another city (approximately 240 miles away). Social Progress Notes for [DATE] further revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard (wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area) on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "No" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? "No" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "No" was indicated. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated and "poor decisions" was circled. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. Does the resident receive any medication that increases the restlessness or agitation? "No" was indicated. Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "Yes" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? "Yes" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "Yes" was indicated. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he cannot leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent from FM "Z", received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "[MEDICATION NAME] gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: "The person authorized by law to consent on behalf of the resident (guardian)." Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because, for her personal health reasons, she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety." R#1's Social Progress Notes dated [DATE] further revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurse's station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." D. Family consent and agreement to operating policies and philosophies. E. The resident's needs must be within one of the following groups: 1. Needs direction to function in a familiar surrounding and can respond to instruction. 2. Needs assistance to function and cannot respond to direction alone. 3. Needs assistance to function and cannot communicate verbally in a meaningful fashion. R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [MEDICAL CONDITIONS], Vascular disease, [MEDICAL CONDITIONS], status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. *The following information was gathered from the CMS 2567 form dated [DATE]:* -On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" is not not R#1's medical power of attorney. The SW reported that R#1 needed to have the wanderguard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet. The family has cancelled twice." -On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." -On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. -On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and then I would be released." -In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." -In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). -On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." Geriatric Psychiatric Evaluation on R#1 dated [DATE] documented: Chief Complaint - "Depression, adjustment difficult, patient wants to go home constantly calling family. Irritability, agitation." History of presenting problem - "I'm not doing good, I don't like it here. My daughter put me here. Anxiety, I have never been locked up." "Patient had provider at home. Patient is disoriented to time, oriented to self & circumstances. Patient is compliant with care. Patient asking for alternative living arrangements." Signs of Dementia - Moderate. No thoughts of hurting self or others. Thought Stream - Logical, Goal directed. Diagnosis: [REDACTED]. On [DATE] at 11:45 a.m. surveyor met with the Administrator about R#1. The Administrator said, "(R#1) is still in the locked unit, is doing much better/adjusting, and likes being in the unit." The Administrator said R#1's family was pleased with R#1's stay in the locked unit. On [DATE] at 1:30 p.m. surveyor observed R#1 in the locked unit. R#1 was observed in the lobby area by the nurses station. R#1 was observed sitting in his wheelchair. Surveyor asked R#1 in Spanish if surveyor could speak to him in private, and R#1 said we could talk in his room. Interview was conducted entirely in Spanish. R#1 was alert, oriented, able to converse with surveyor and answer surveyor's questions. Surveyor asked R#1 what he thought about the facility. R#1 responded, "No me gusta aqui" (I don't like it here). R#1 said FM "Z" "me mentio"(lied) and "traiciono"(deceived) him by telling him he would only be in the facility for a few weeks for rehabilitation for his leg. R#1 said his leg was fine now and he wanted to go home to his house and see about his son who was mentally ill and lived with him and FM "Z". R#1 said that both he and his son had a home provider that took care of them during the day, cleaning and cooking for them. R#1 said he had the same provider for many years. R#1 said he was concerned that possibly FM "Z" was trying to sell his house. R#1 said he did not belong in the locked unit or any other part of the facility. R#1 told surveyor, "They even put a "pulsera" (bracelet) on my "pie" (foot) to keep me from leaving", "No quiero estar aqui" (I don't want to be here). Surveyor asked R#1 how he felt about being in the facility. He replied in Spanish "me siento mal" (I feel badly). Surveyor asked R#1 how he felt about FM "Z" placing him in the facility. R#1 said, "Me siento como si quiero llorar" (I feel as if I want to cry). On [DATE] at 2:00 p.m. surveyor met with the Administrator and R#1's two family members, FM "Z" and FM "Y". FM "Z" told surveyor her that R#1 had been living with her and her disabled brother for many years. FM "Z" said, "I can no longer take care of him and my brother both." FM "Z" said R#1 had a history of [REDACTED]. FM "Z" said, "(R#1) at times gets confused, has wandered off at times, and at times takes my disabled brother with him." FM "Z" said, "(R#1) gets angry and at times gets verbally abusive with my brother; at times doesn't even know he is there." On [DATE] at 2:30 p.m. surveyor conducted a telephone interview with the Physician's Assistant (PA) to R#1's Psychiatrist. The PA said she did the psychiatric evaluation on R#1 on [DATE]. The PA said R#1 was complaining that he wanted to go home and was having problems adjusting to the facility. The PA said R#1 was started on medications. The PA said R#1 had some memory and adjustment problems but was, and would be, "OK." Surveyor asked the PA, since R#1 was doing better, if it was necessary or required for R#1 to be in the Memory locked unit? The PA said R#1 could be placed in an area of the facility outside the locked unit on a trial basis to see how he did, initially using a wanderguard, then giving him some options and seeing how he would do. On [DATE] at 9:25 a.m. surveyor observed R#1 in the locked unit of the facility. Surveyor interviewed R#1 in his room. R#1 told surveyor in Spanish that he still wanted to go home, and if his daughters would not take him back, he would contact one of his sons so he could move in with them. R#1 said he had a provider that had taken care of him and his son for many years and could come with him. R#1 said, "Yo no debo de estar aqui con este typo de gente. Yo necesito que irme de aqui." (I don't belong here with these kind of people. I need to go home.) On [DATE] at 9:48 a.m. surveyor interviewed the facility SW. The SW said FM "Z" and FM "Y" did not want to tell R#1 that he would be in the facility for a long time. The SW said R#1 had been living with with FM "Z" and his son who was mentally ill. SW said FM "Z" told her she could no longer care for both R#1 and her brother. SW said she had asked R#1 if he had someone else he could stay with and R#1 had replied that he did not and that he wanted to go home with FM "Z." The SW said she called the local appraisal district and checked to see who owned the home where R#1 said he lived. SW said she was told the property (home) was owned by FM "Z" and her husband. Surveyor asked the SW if she asked the appraisal office if R#1 had ever owned the home. The SW said she had not. Surveyor asked the SW if R#1 had ever actually attempted to leave the facility. The SW replied that at one time R#1 opened a back door to the 300 hallway and apparently the alarm had not sounded. The SW said it was found out that R#1's wanderguard might not have been working. The SW said that the facility had a care plan meeting to discusss R#1's attempt to leave the facility, but R#1's family was not present. At the meeting RN "B" ordered that a wanderguard be placed on R#1 and told LVN "A" to call R#1's Physician to get an order for [REDACTED]. It was not until he was told by his family that he was staying long term that he began having problems and wanting to leave. The SW said she had never spoken to FM "Z" about getting a provider for R#1. The SW said she kept trying to meet with FM "Z" for care planning meetings, but FM "Z" kept refusing to meet. The SW said that FM "Z" told her that it was her brother that had a provider. Surveyor asked SW if R#1 had ever told her that he had three other sons and he was certain he could go and live with one of them. The SW replied "No." Surveyor asked the SW if she had assisted R#1 with discharge planning/alternative placement. The SW replied she had not. The SW said she tried to get FM "Z" to attend care plan meetings but FM "Z" would not show up. Surveyor asked the SW if she had followed-up on possible discharge planning and the SW said she had not. The SW said, in her opinion, R#1 could make his own decisions of what he wanted or did not want. Surveyor interviewed the facility Case Manager (CM) on [DATE] at 10:35 a.m. Surveyor asked the CM if R#1 could make his own decisions. CM replied, "Yes, he is able to tell us what he wants to do. He would tell us he wanted to go home, but recently he has stopped asking us." The CM said FM "Z" told her that R#1 used to have a provider, but he would, "run them off." The CM said R#1 was placed in the locked unit after he kept wanting to leave the facility and asking people in the front lobby if they could take him home. Surveyor interviewed LVN "E" on [DATE] at 11:40 a.m. LVN "E" said he had worked on the locked unit for about a month. LVN "E" said R#1 had improved and was conversing more with other residents in the unit. LVN "E" said R#1 told him several times that he wanted to go home.` Surveyor interviewed Administrator on [DATE] at 12:28 p.m. The Administrator stated that a new MDS was completed on [DATE]. He further stated that the updated MDS reflected active discharge planning including a referral to DADS "Money Follows the Person" to assist R#1 with community placment. The Administrator said a Relocation Specialist had been assigned to R#1 and would be assisting him with the program. The Administrator said the facility had R#1's Psychiatrist conduct a psychiatric evaluation for R#1. Surveyor conducted a telephone interview with a DADS Relocation Specialist on [DATE] at 1:23 p.m. The Relocation Specialist said she had been contacted by the facility Administrator regarding R#1 and wanted to make referral for assistance for possible community placement. The Relocation Specialist said a full assessment would need to be conducted to determine if R#1 met the financial requirements(Social Security, Medicaid etc..) for the program. Surveyor observed R#1 in the Memory locked unit on [DATE] at 2:40 p.m. Surveyor observed R#1 walking down the hallway pushing his wheelchair. Surveyor approached R#1 and asked him if he remembered me. R#1 replied in Spanish "si" (yes). Surveyor and R#1 moved to a more private area of the Memory locked unit. Surveyor asked R#1 for the names of his sons. R#1 replied he had three sons, two who were married and one who was mentally disabled and had lived with him. R#1 gave the names of the sons. Surveyor asked R#1 if his sons would be able to take him in to live them. R#1 chuckled and said "No, le tienen miedo a mi hija" (No, they are afraid of my daughter). R#1 said his daughter would not allow his sons to take care of him. Psychiatric Evaluation by R#1's Psychiatrist on [DATE] (after surveyor entered the facility for a follow up visit on [DATE]) documented: "[DIAGNOSES REDACTED]. History (HX) of progressive memory loss wants to go home. Patient has a HX of progressive memory loss, intellectual permanent personality deterioration recently compounded with depressive symptoms. On [MEDICATION NAME] (anit-Alzheimers medication), [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (medication for Dementia). 0 family HX. On examination, pleasant but becomes easily irritated when tested . Affect is responsive though mood depressed. Denied suicidality. Significant thought poverty. No hallucinations. Some referential thinking. Moderately confused limited insight into his confusion. DX (diagnosis) Primary [MEDICAL CONDITION] Dementia with Depression and behavioral disturbances. Recommendations: Patient is in need of 24 hour supervision, Re-orientation, redirection. Continue same [MEDICAL CONDITION] medications, consider adding atypical antipsychotic, low dose if agitated. Monitor clinical response." Surveyor conducted a telephone interview with R#1's Psychiatrist on [DATE] at 11:30 a.m. The Psychiatrist said he conducted R#1's evaluation on [DATE]. The Psychiatrist said R#1 had a [DIAGNOSES REDACTED]. Surveyor asked the Psychiatrist if R#1 was able to make his own decisions, and he replied "No." The Psychiatrist said R#1 was not cognitively aware of his health status, R#1 thought he was cured of his [MEDICAL CONDITION]. The Psychiatrist said R#1 needed 24 hour supervision and the family was not able to provide that for him. The Psychiatrist said R#1's thinking was poor, he was "irrational"at times and would be, "easy prey to be taken advantage of or hurt if out on his own. He would be at risk." Surveyor asked Psychiatrist if R#1 could function off the locked unit, perhaps with a wanderguard. The Psychiatrist said that even if R#1 had a wanderguard, he would still be at risk of leaving the facility. Review of R#1's Physician's letter to facility ADON "C" documented: Title: Letter to Acknowledge a Resident Incompetent. "This letter serves to inform the (name of facility) that R#1 has a [DIAGNOSES REDACTED]." The letter was not dated. Date of fax at the top of the page was [DATE]. Surveyor conducted telephone interview with R#1's Physician on [DATE] at 11:45 a.m. The Physician said R#1 was irrational at times. The Physician said, "I don't think (R#1) is able to make rational decisions for safety and care. I don't think he would be safe at home or in the skilled unit with a wanderguard." Physician said R#1 needed 24 hour care. Surveyor read R#1's Psychiatric Evaluation by R#1's Psychiatrist to his Physician. R#1's Physician said he agreed with R#1's Psychiatrist's findings/[DIAGNOSES REDACTED]. R#1's Physician said, "(R#1) is better off in the Memory locked unit." Surveyor interviewed the facility Physical Therapist on [DATE] at 11:00 a.m. Physical Therapist said R#1 had suffered a [MEDICAL CONDITION] in [DATE] while living at home. When R#1 was admitted to the facility, physical therapy (PT) was ordered for strengthening of the hip area, improvement of his ablity to transfer himself, and strengthening of his lower extremities. The Physical Therapist said R#1 was admitted for PT services on [DATE] and discharged from PT on [DATE]. The Physical Therapist said R#1's goals were met. R#1 was able to stand and push his wheelchair and had strengthened his hip area and extremities. Surveyor interviewed LVN "E"/ MDS Coordinator on [DATE] at 12:05 p.m. LVN "E" said family had requested Hospice services after R#1's Physician had talked to them because R#1 had [MEDICAL CONDITION] and Melanoma (cancer neck area). LVN "E" said R#1's family called the facility requesting Hospice services and information about available Hospice companies was provided to them. LVN "E" said family chose a Hospice company and a telephone physician's orders [REDACTED]. Surveyor interviewed facility Administrator on [DATE] at 1:00 p.m. The Administrator told surveyor that the facility's Medical Director was aware of R#1's condition and was R#1's attending physician. Surveyor asked Administrator if she had ever spoken directly to R#1. The Administrator replied that she had not spoken directly to R#1, but that she got feedback from her staff on R#1 and also read psychiatric notes about R#1. The Administrator said the appropriateness of each resident's placement in the locked unit was reviewed at quarterly meetings. The family was asked if they still wanted the resident in the unit. If the unit ADON saw a change of condition, she would initiate a new assessment. The Administrat

Based on observation, record review, and interview, the facility failed to provide medically related social services to one Resident (R#1) of two residents reviewed for social services, by not assisting R#1 in maintaining or improving his ability to manage his everyday physical, mental, and psychosocial needs. The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's advanced directive. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response, the facility: -placed a wanderguard bracelet on R#1's leg with no history of elopement, against his wishes, and in violation of facility policy, and, -placed R#1 in a locked unit with no history of elopement, against his wishes, and in violation of facility policy. Failure to provide medically related social services denied R#1 the right to a home-like environment, control over his own decisions, and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 25 residents not determined to be cognitively impaired. The findings were: The findings were: 1. R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, and, - had no behavioal issues. R#1's Discharge Plan from MDS assessment dated [DATE] indicated, "Is there an active discharge plan in place for the resident to return to the community? No." "What determination was made by the resident and the care planning team regarding discharge to the community? Discharge to the community determined to be not feasible." R#1 nurses notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." On [DATE] at 2:00 p.m. surveyor observed R#1 to propel himself from his room to the nurses station. R#1 was asking anyone at the nurses station to make arrangements to send him home. He said he wanted to go home. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in San Antonio. Social Progress Notes for [DATE] revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? No. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? No. Does the wandering significantly intrude on the privacy or activities of others? No. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. ("poor decisions" was circled) Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes. Does the resident receive any medication that increases the restlessness or agitation? No." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: "Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? Yes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? Yes. Does the wandering significantly intrude on the privacy or activities of others? Yes. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. Does the resident have any visual, auditory or communication deficits? No. Does the resident verbally express the desire to go home or packed belongings to leave? Yes." R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he can not leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "Ativan gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: The person authorized by law to consent on behalf of the resident (guardian). Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because for her personal health reasons she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety. R#1's Social Progress Notes dated [DATE] revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit. [DATE] Ombudsman was at nh to speak with SW about family council meeting. (R#1) was in reception area and Ombusdman asked if she could speak with him. (R#1) stated that he was waiting for a ride to go home. After, Ombudsman spoke with (R#1) in private she approached SW and advised (R#1) that he had every right to return home because he voiced to her that he owned the property where (FM "Z") lived with his mentally retarded son. Ombudsman asked (R#1) if he had any money for a taxi so that he could return home and stated no. SW advised Ombudsman (R#1's) RP is responsible for his money. SW explained that at this time even if (R#1) is stating to return home his (family members) are not in agreement that they can not care for him at home. SW explained to Ombudsman that (R#1) had made threats and attempts to leave nh and (family members) agreed that placement in memory support unit for safety was what they wanted to do at this time. Ombudsman told SW that if (R#1) owned the home he has every right to return despite (family members') objections. Ombudsman stated that nursing home could not place (R#1) in memory support unit just because he attempted to leave. The Ombudsman stated she would follow up with SW to see if (R#1) had returned home." R#1's Social Progress Notes (continued) dated [DATE] revealed: "SW was present as Administrator contacted RP for (R#1) and discussed Ombudsman's concerns that he should return home. (FM "Z") stated they were upset because they want (R#1) placed in the memory support unit for his safety due to his attempts and threats to leave nh. Administrator stated to RP that the Doctor has not been to nursing home to determine that (R#1) has dementia. RP stated that the Veteran's Administration has documentation with (R#1's) [DIAGNOSES REDACTED]. Administrator discussed with them switching to another primary physician because (R#1's) Doctor does not come to nh. RP stated at this time they do not want to switch physicians. RP stated that (R#1) better be moved to the memory support unit today." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurses station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. R#1's Social Progress Notes dated [DATE] revealed: "SW received call from Ombudsman and she stated that she was following up on (R#1's) return home. SW advised that he was moved to memory support unit after family spoke with Administrator by phone. Ombudsman advised that she would be contacting state and requested the face sheet because (R#1) did not have a [DIAGNOSES REDACTED]. Administrator advised SW that family met with her yesterday and brought paperwork from VA that showed a [DIAGNOSES REDACTED]. SW contacted (family members) to inform them that Ombudsman was going to contact the state regarding (R#1's) placement in the memory support unit because she felt the nh had violated his rights. (R#1's family members) were very upset stating that they did not want (R#1) moved. They stated they never met with the Ombudsman and she did not know the situation of (R#1's) history. Family members met with SW and Administrator because they did not understand how the Ombudsman could demand that (R#1) be allowed to return home. Administrator explained that nh was not in agreement and felt that for his safety due to wandering and threats of leaving nh the memory support unit was best for him. Administrator explained to family that discharging a resident home is a process in which the nh includes the family. (R#1's family members) voiced understanding and also agreed that (R#1) primary physician needed to be changed because he has not seen him at the nh." The facility's policy, Admission and Assessment Process-Nursing and Alzheimer's Care Centers, Effective date: [DATE], indicated: "Procedure: 1. Admissions Coordinator will interview family and/or prospective resident. The family and/or the prospective resident will complete form ,[DATE]SH (State Home Program Application for Veteran Medical Certification) and form ,[DATE]EZ (Application for Health Benefits). Form ,[DATE]SH must be signed by the resident's attending/admitting physician. 2. If the Prospective resident meets the guidelines as stipulated in Section 51.50 listed above for the admission criteria, the prospective resident is scheduled for an assessment coordinated by a Registered nurse along with the Interdisciplinary Team which usually consist of the administrator, Director of Nursing, Director of Social Work and Admissions Coordinator or their respective designees). The Administrator and nursing administration will review the residents' medication with the pharmacy prior to admission. 6. The Admissions Coordinator will set an appointment with the resident and/or responsible party at which time all relevant SDI policies and procedures will be reviewed including stipulations for discharge and transfer policies when health condition changes occur. 7. The following paperwork must be completed and returned before admission or at the time of admission: a. Application for Admission (form,[DATE]EZ) signed in designated places by resident and/or responsible party. b. Doctor's orders completed and signed by a licensed physician (form ,[DATE]SH). c. History and physical, [DIAGNOSES REDACTED]. d. Photocopy of legal documents for Health Care Decision (Health Care Power of Attorney, Directive to Physician (Living Will) Family/ Physician Directive, Out of hospital DNR if applicable). e. Residency and Care Agreement Contract signed by resident and/or responsible party." The facility's policy on Secure Care System dated [DATE] revealed: "Care plan based on the goals, needs, risks and interventions attempted prior to initiation." The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [DIAGNOSES REDACTED], Coronary Artery Disease, Vascular disease, Arteriosclerosis, Osteoporosis, status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. On [DATE] at 8:40 a.m. the Admissions Coordinator said, "The ,[DATE]SH should be in (R#1's) chart. I am assuming that it was done. I know the policy says the ,[DATE]SH must be signed by the physician. I think it is the Social Worker that takes care of that.) On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. The SW reported that R#1 needed to have the wander guard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet, the family has cancelled twice." On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and than I would be released." In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." 2. R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. The Admission Record "Advance Directives" section indicated, "Do Not Resuscitate." R#1's physician's orders [REDACTED].#1's Advanced Directive was "Full Code" with an order date of [DATE] (Full Code is defined as in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy have directed that cardiopulmonary resuscitation (CPR) or other life saving measures are to be used.) R#1's Initial Plan of Care dated [DATE] revealed: Code status-Full Code. R#1 nurses notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." The facility's Advance Directive Review revealed that on [DATE], "No CPR" (No cardiopulmonary resuscitation) was checked off for R#1 and signed by R#1's Family Member (FM) "Z." R#1's plan of care dated [DATE] indicated R#1, "desires no resuscitation in the event of cardiopulmonary arrest." Goal was for R#1 to "receive no CPR in the event of cardiopulmonary resuscitation during the next 90 days." Approach was, "Ensure that proper paperwork is in the chart: physicians orders, out of hospital DNR, no CPR stickers, flags. Answer any questions that resident or family may have regarding death or dying. Provide social service and clergy referrals as needed." R#1's Social Progress Notes dated [DATE] revealed R#1 was admitted to the facility from the hospital. "He is alert and able to communicate needs to staff with episodes of forgetfulness/confusion. The (family members) report he has a history of wandering. At this time (family members) have selected a DNR status and are planning a long term stay, but state they have not told (R#1) that he will be here a long time." R#1's Out Of Hospital Do Not Resuscitate Order from the Texas Department of State Health Services dated [DATE] was signed by FM "Z." On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" was not R#1's medical power of attorney. On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's Do Not Resuscitate (DNR) order was not R#1's choice, it was R#1's family's choice. During exit conference held on [DATE] at 3:00 p.m the Administrator was given the opportunity to present any additional information regarding medically related social services. No additional information was presented. The facility's Roster/Sample Matrix listed 25 residents who were not assessed as cognitively impaired.

Based on observation, record review, and interview, the facility failed to provide medically related social services to one Resident (R#1) of six residents reviewed for social services, by not assisting R#1 in maintaining or improving his ability to manage his everyday physical, mental, and psychosocial needs. R#1 repeatedly expressed that he wanted to leave the facility and return home. In response the facility: -failed to assist R#1 with discharge planning/alternative placement, and, -placed R#1 in a locked unit against his wishes and in violation of facility policy. The facility did not assess R#1 prior to placement on the locked unit to determine whether the placement was appropriate, resulting in R#1 remaining on the locked unit for 79 days. R#1 was still on the locked unit on the day of exit ([DATE]). The facility allowed R#1's family members, who did not have medical Power of Attorney over R#1, to make decisions regarding R#1's placement in the locked unit and placement of a wanderguard bracelet on R#1's leg. Failure to provide medically related social services denied R#1 the right to a home-like environment, control over his own decisions, and dignity. This failure could negatively affect R#1's physical, mental and psychosocial well-being and could affect all 26 residents who were not assessed as cognitively impaired. The findings were: R#1's Admission Record revealed R#1 was admitted on [DATE]. The Admission Record listed Family Member (FM) "Z" as Guarantor and Primary/Emergency Contact. R#1's physician's orders [REDACTED]. R#1's Minimum Data Set (MDS) assessment dated [DATE] revealed R#1: - had adequate hearing, vision, and clear speech, - was able to understand and make himself understood, - had clear comprehension, - was able to complete the Brief Interview for Mental Status, - had no behavioral issues and - had no signs of delirium R#1's Discharge Plan from MDS assessment dated [DATE] indicated R#1 and his family participated in the assessment. The assessment indicated a, "Guardian or legally authorized representative" did not participate in the assessment. The assessment also indicated: -Resident's Overall Expectation: Resident's overall goal established during assessment process - (Blank). Discharge Plan: Is there an active discharge plan in place for the resident to return to the community? "No." was marked. Discharge Plan: What determination was made by the resident and the care planning team regarding discharge to the community: "Discharge to the community determined to be not feasible." was written. R#1's Nurses Notes dated [DATE] at 6:50 p.m. revealed, "Resident assessed from head to toe. He is alert and oriented to place, time and person." R#1's Initial Psychosocial Assessment and Social History dated [DATE], section on resident rights revealed: "A. If able to understand, has the resident read the information concerning resident rights?" "Yes" was checked. "B. If the resident is incompetent (incapacitated), has a Guardian, Durable Power of Attorney or Surrogate been identified in the chart?" "N/A" (not applicable) was written. "C. If the resident has an Advanced Directive, is the resident satisfied with the Advance Directive they have written?" "DNR" and "Yes" were checked. "D. Does the resident know how to obtain spending money?" "Yes" was checked. R#1's Initial Psychosocial Assessment and Social History, section to, "provide description from your own observation" completed by the Social Worker and dated [DATE] indicated R#1, "is alert and able to communicate needs. He is helpful and compliant. He is able to interact with others and participate in activities of his choice." Out of Hospital Do-Not-Resuscitate order; Texas Department of State Health Services form: -A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advance airway management, artificial ventilation. The form was signed by R#1 after his admission to the locked unit and after surveyor intervention. -B. Declaration by legal guardian, agent or proxy on behalf of the adult who is incompetent or otherwise incapable of communication: Legal Guardian (blank), agent in a Medical Power of attorney (blank) or Proxy (blank). -C. Declaration by a qualified relative of the adult who is incompetent or otherwise incapable of communication: I am the above-noted person's: adult child (checked), " To my knowledge the adult person is incompetent or other wise mentally or physically in capable of communication and is without a legal guardian, agent or proxy. Signed by FM "Z", date [DATE]. Social Progress Notes for [DATE] revealed the Social Worker (SW) spoke with R#1 because he was "upset", stating that he wanted to go home. He stated to SW that he was ready because he needed to go home and care for his son. The SW advised him that FM "Z", the responsible party (RP), would be in the nursing home because SW wanted to discuss with FM "Z" if long term stay was still planned. R#1 voiced understanding. FM "Z" and FM "Y" arrived at the facility and informed SW that they were still planning a long term stay for R#1 and they could not care for him at home. The SW advised the family that a care plan meeting could be held "today" ([DATE]) to discuss this with R #1 and explain to him a long term stay was planned. RP stated that she did not want a care plan meeting because they already spoken with R#1 and informed him he would be staying here or they would him take him to the Veteran Administration hospital (VA) in another city (approximately 240 miles away). Social Progress Notes for [DATE] further revealed R#1, "was voicing to nursing staff that he wanted to go home and that he was going to ask someone to take him. SW met with (R#1) in (Dr.'s office) and also present was (Licensed Vocational Nurse - LVN "A") and (Registered Nurse - RN "B"). (R#1) stated that he wanted to go home and he knew his (family members) weren't going to help him. SW asked (R#1) if anyone else could take him home and care for him and he stated no. SW explained to (R#1) that it was not safe for him to ask strangers to take him home because a doctor's order is needed for discharge and his (family members) have to agree that they can care for him. (R#1) appeared calmer and stated he was going back to skilled unit. SW asked if he was planning on leaving the building and he stated no. (RN "B") asked nurse to place a wanderguard (wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area) on (R#1) on [DATE] and also order urinalysis. SW informed the nurse that (family members) asked for (R#1) to be redirected by telling him that they would take him to the VA hospital in San Antonio." Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "No" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? "No" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "No" was indicated. Is the resident cognitively impaired with poor decision-making skill (i.e.poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated and "poor decisions" was circled. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. Does the resident receive any medication that increases the restlessness or agitation? "No" was indicated. Review of Wander Data Collection for R#1 dated [DATE] revealed in the evaluation factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? "Yes" was indicated. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs outside the the facility)? "Yes" was indicated. Does the wandering significantly intrude on the privacy or activities of others? "Yes" was indicated. Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? "Yes" was indicated. Does the resident have any visual, auditory or communication deficits? "No" was indicated. Does the resident verbally express the desire to go home or packed belongings to leave? "Yes" was indicated. R#1's Skilled Nurses Notes dated [DATE] at 3:00 p.m. indicated R#1 "continues asking family members of other residents for a ride home..." and, "Resident asked to leave building through 300 hall north end exit. When asked why he opened door he said 'I want to go home.' Explained to resident that he cannot leave on his own. We are responsible for him. Resident apologized said he would not do this again." R#1's Telephone Order dated [DATE] at 4:00 p.m. revealed, "apply wanderguard to lower right leg Dx: Resident wandering out of facility." R#1's Authorization to Use Wander Guard Transmitter consent dated [DATE] was a verbal telephone consent from FM "Z", received by LVN "A." R#1's Telephone Order dated [DATE] revealed: "Ativan gel 0.5 mg (milligrams) apply to inner wrist every six hours whenever necessary Diagnosis: [REDACTED]. R#1's Consent for Psychoactive Medication Therapy dated [DATE] revealed: "The person authorized by law to consent on behalf of the resident (guardian)." Name of person giving verbal/telephone consent was FM "Z." R#1's Skilled Nurses Notes dated [DATE] through [DATE] revealed R#1 was stable, with no signs or symptoms of distress. There was no documentation that R#1 attempted to elope or wandered into other residents' rooms. Review of Incidents and Accident Reports from [DATE] and February 2012 revealed R#1 had no incidents or accidents recorded during this time period. R#1's Social Progress Notes dated [DATE] revealed: "(R#1) located in reception area of nursing home voicing to receptionist that he was leaving. He stated that he was leaving the home at night time because he no longer needed to be there. His foot was healed. SW reminded (R#1) the doctor needs to be aware. SW advised (R#1) that she would contact (family members) and inform them of what he is voicing. SW informed (FM "Z") that (R#1) sits in reception area waiting to ask someone for a ride home and that he would be attempting to leave at night. SW asked (FM "Z") to consider placement in memory support unit because it has a locked area and (R#1) is threatening to leave. (FM "Z") stated that she did not feel (R#1) would benefit from being in a locked area. SW advised that if (R#1) continued to threaten leaving or attempted to leave nursing home (nh) the memory support unit placement would be determined by nh for his safety. SW scheduled for [DATE] at 10 am to discuss (R#1's) continued wandering behavior and threats with family." R#1's Social Progress Notes dated [DATE] revealed: "SW met with (R#1) in reception area of nh because he was out of wheel chair ambulating towards the exit voicing that he was going to walk home. He stated that he had been unable to find anyone to take him home. He voiced to SW that he believes his (family members) do not want to take him home because they sold the house and are afraid he will be upset. SW informed (R#1) that (FM "Z") could not take him home because, for her personal health reasons, she can not take care of him. SW informed (R#1) his (family members) would be notified of today's incident. SW explained to (R#1) if there was anyone he needed to call to assist him in leaving nh that staff can assist, but staff must also notify RP and Doctor. SW contacted (R#1's family members) and left message informing them of (R#1) attempt to leave and again asking them to consider memory support unit placement for his safety." R#1's Social Progress Notes dated [DATE] further revealed: "SW received a phone call from (FM "Z") (RP). She stated that she had discussed with the Doctor placement in memory support unit and that Doctor stated he felt the memory support unit would be beneficial to (R#1). She stated that she would like for him to move to memory support unit and that she would stop at nh to sign the consent. RP at nh with her sister toured memory support unit with SW and agreed to place because of (R#1's) attempt to leave in the morning. Room change consent was signed by RP, SW informed (R#1) and asked nurse to notify the Doctor and receive order for placement in memory support unit." R#1's Telephone Order dated [DATE] at 3:57 p.m. revealed, "Transfer (R#1) to memory support per family request." R#1's nurses notes dated [DATE] at 5:00 p.m. revealed: "Resident came up to nurse's station wanting to leave facility stating, 'I was sent here by accident.' Resident confused and disoriented. Family came in to request hospice, notified Doctor, spoke to nurse at Doctor's office and Doctor order obtained." R#1's Telephone Order dated [DATE] indicated to refer R#1 to hospice as per family's request. The facility's policy titled, Resident Criteria for Alzheimer's Care Centers, effective date [DATE], indicated, "Pre-Admission Criteria for each of the Alzheimer's Unit is as follows" A. Primary medical [DIAGNOSES REDACTED]. B. Physician's approval. C. Absence of severe personality disorder. A psychiatric evaluation may be required." D. Family consent and agreement to operating policies and philosophies. E. The resident's needs must be within one of the following groups: 1. Needs direction to function in a familiar surrounding and can respond to instruction. 2. Needs assistance to function and cannot respond to direction alone. 3. Needs assistance to function and cannot communicate verbally in a meaningful fashion. R#1's Department of Veterans Affairs State Home Program for Veteran Care Medical Certification (,[DATE]SH) form dated [DATE] indicated R#1: - was admitted to the facility on [DATE], - was neurologically intact and oriented times 3 (to person, place, time), - was continent of bowel and bladder, - had no primary [DIAGNOSES REDACTED]. - had no [DIAGNOSES REDACTED]. - had not received mental services within the past two years, - was not a danger to himself or others, - had diagnoses of Hypertension, GERD, [DIAGNOSES REDACTED], Coronary Artery Disease, Vascular disease, Arteriosclerosis, Osteoporosis, status [REDACTED]. - was able to transmit messages/receive information, - had slightly impaired hearing, - was able to speak clearly, - was able to ambulate, - had "mental and behavior status-alert." R#1's form ,[DATE]SH also indicated, "Social Work Assessment (To be completed by Social Worker), Long Range Plan: long term nursing, Adjustment to Illness or Disability: not adjusting well. " The form was signed by the RN and SW on [DATE]. *The following information was gathered from the CMS 2567 form dated [DATE]:* -On [DATE] at 10:00 a.m. surveyor interviewed the SW. The SW said FM "Z" is not not R#1's medical power of attorney. The SW reported that R#1 needed to have the wanderguard because he was threatening to leave, and they had a doctor's order. The SW said, "I asked the family to consider the memory unit, it is more secure. There has been no care plan meeting with (R#1's family members) as of yet. The family has cancelled twice." -On [DATE] at 2:00 p.m. surveyor interviewed ADON "D." ADON "D" said she thought R#1 was at the facility only for rehabilitation. ADON "D" said, "He was going to rehab as scheduled and was doing fine." -On [DATE] at 2:15 p.m. surveyor interviewed LVN "A." LVN "A" said R#1's family members told LVN "A" that they could not take care of R#1. LVN "A" stated, "I do not think he was ever told that he was not going home." LVN "A" said R#1's family members called LVN "A" because R#1 would call home. The family members asked LVN "A", "Why do you guys keep allowing him to call home?" LVN "A" said R#1's family members wanted LVN "A" to tell R#1 that he was not going to come home for a year because the Doctor had ordered it. LVN "A" said he told R#1's family members that he could not tell R#1 that. -On [DATE] at 2:50 p.m. surveyor interviewed R#1. R#1 said, "I was told by my (family member) that I was going to be here one night in this section and that I was going home. I was told that my stay was going to be a short visit in this unit. When I first came in it was in the other section. I don't know why I am here. I feel I am in prison here. I fought in World War II and know I am in this place. I got the alarm placed and immediately they tell me 'You want to leave' if I get close to the door. The Doctor told me I was just coming for rehabilitation and then I would be released." -In an interview on [DATE] at 4:00 p.m. with the facility's Veteran Land Board Representative he said, "The veteran needs to have a [DIAGNOSES REDACTED]." -In an interview on [DATE] at 4:05 p.m. with the Administrator, she said, "We do not have the medical power of attorney on (R#1). -On [DATE] at 9:30 a.m. surveyor interviewed the Medical Assistant for R#1's Primary Physician. The Medical Assistant stated she did not believe that R#1's Physician received any forms from the facility or Veterans Affairs for R#1 to be placed in the secured unit." Geriatric Psychiatric Evaluation on R#1 dated [DATE] documented: Chief Complaint - "Depression, adjustment difficult, patient wants to go home constantly calling family. Irritability, agitation." History of presenting problem - "I'm not doing good, I don't like it here. My daughter put me here. Anxiety, I have never been locked up." "Patient had provider at home. Patient is disoriented to time, oriented to self & circumstances. Patient is compliant with care. Patient asking for alternative living arrangements." Signs of Dementia - Moderate. No thoughts of hurting self or others. Thought Stream - Logical, Goal directed. Diagnosis: [REDACTED]. On [DATE] at 11:45 a.m. surveyor met with the Administrator about R#1. The Administrator said, "(R#1) is still in the locked unit, is doing much better/adjusting, and likes being in the unit." The Administrator said R#1's family was pleased with R#1's stay in the locked unit. On [DATE] at 1:30 p.m. surveyor observed R#1 in the locked unit. R#1 was observed in the lobby area by the nurses station. R#1 was observed sitting in his wheelchair. Surveyor asked R#1 in Spanish if surveyor could speak to him in private, and R#1 said we could talk in his room. Interview was conducted entirely in Spanish. R#1 was alert, oriented, able to converse with surveyor and answer surveyor's questions. Surveyor asked R#1 what he thought about the facility. R#1 responded, "No me gusta aqui" (I don't like it here). R#1 said FM "Z" "me mentio"(lied) and "traiciono"(deceived) him by telling him he would only be in the facility for a few weeks for rehabilitation for his leg. R#1 said his leg was fine now and he wanted to go home to his house and see about his son who was mentally ill and lived with him and FM "Z". R#1 said that both he and his son had a home provider that took care of them during the day, cleaning and cooking for them. R#1 said he had the same provider for many years. R#1 said he was concerned that possibly FM "Z" was trying to sell his house. R#1 said he did not belong in the locked unit or any other part of the facility. R#1 told surveyor, "They even put a "pulsera" (bracelet) on my "pie" (foot) to keep me from leaving", "No quiero estar aqui" (I don't want to be here). Surveyor asked R#1 how he felt about being in the facility. He replied in Spanish "me siento mal" (I feel badly). Surveyor asked R#1 how he felt about FM "Z" placing him in the facility. R#1 said, "Me siento como si quiero llorar" (I feel as if I want to cry). On [DATE] at 2:00 p.m. surveyor met with the Administrator and R#1's two family members, FM "Z" and FM "Y". FM "Z" told surveyor her that R#1 had been living with her and her disabled brother for many years. FM "Z" said, "I can no longer take care of him and my brother both." FM "Z" said R#1 had a history of [REDACTED]. FM "Z" said, "(R#1) at times gets confused, has wandered off at times, and at times takes my disabled brother with him." FM "Z" said, "(R#1) gets angry and at times gets verbally abusive with my brother; at times doesn't even know he is there." On [DATE] at 2:30 p.m. surveyor conducted a telephone interview with the Physician's Assistant (PA) to R#1's Psychiatrist. The PA said she did the psychiatric evaluation on R#1 on [DATE]. The PA said R#1 was complaining that he wanted to go home and was having problems adjusting to the facility. The PA said R#1 was started on medications. The PA said R#1 had some memory and adjustment problems but was, and would be, "OK." Surveyor asked the PA, since R#1 was doing better, if it was necessary or required for R#1 to be in the Memory locked unit? The PA said R#1 could be placed in an area of the facility outside the locked unit on a trial basis to see how he did, initially using a wanderguard, then giving him some options and seeing how he would do. On [DATE] at 9:25 a.m. surveyor observed R#1 in the locked unit of the facility. Surveyor interviewed R#1 in his room. R#1 told surveyor in Spanish that he still wanted to go home, and if his daughters would not take him back, he would contact one of his sons so he could move in with them. R#1 said he had a provider that had taken care of him and his son for many years and could come with him. R#1 said, "Yo no debo de estar aqui con este typo de gente. Yo necesito que irme de aqui." (I don't belong here with these kind of people. I need to go home.) On [DATE] at 9:48 a.m. surveyor interviewed the facility SW. The SW said FM "Z" and FM "Y" did not want to tell R#1 that he would be in the facility for a long time. The SW said R#1 had been living with with FM "Z" and his son who was mentally ill. SW said FM "Z" told her she could no longer care for both R#1 and her brother. SW said she had asked R#1 if he had someone else he could stay with and R#1 had replied that he did not and that he wanted to go home with FM "Z." The SW said she called the local appraisal district and checked to see who owned the home where R#1 said he lived. SW said she was told the property (home) was owned by FM "Z" and her husband. Surveyor asked the SW if she asked the appraisal office if R#1 had ever owned the home. The SW said she had not. Surveyor asked the SW if R#1 had ever actually attempted to leave the facility. The SW replied that at one time R#1 opened a back door to the 300 hallway and apparently the alarm had not sounded. The SW said it was found out that R#1's wanderguard might not have been working. The SW said that the facility had a care plan meeting to discusss R#1's attempt to leave the facility, but R#1's family was not present. At the meeting RN "B" ordered that a wanderguard be placed on R#1 and told LVN "A" to call R#1's Physician to get an order for [REDACTED]. It was not until he was told by his family that he was staying long term that he began having problems and wanting to leave. The SW said she had never spoken to FM "Z" about getting a provider for R#1. The SW said she kept trying to meet with FM "Z" for care planning meetings, but FM "Z" kept refusing to meet. The SW said that FM "Z" told her that it was her brother that had a provider. Surveyor asked SW if R#1 had ever told her that he had three other sons and he was certain he could go and live with one of them. The SW replied "No." Surveyor asked the SW if she had assisted R#1 with discharge planning/alternative placement. The SW replied she had not. The SW said she tried to get FM "Z" to attend care plan meetings but FM "Z" would not show up. Surveyor asked the SW if she had followed-up on possible discharge planning and the SW said she had not. The SW said, in her opinion, R#1 could make his own decisions of what he wanted or did not want. Surveyor interviewed the facility Case Manager (CM) on [DATE] at 10:35 a.m. Surveyor asked the CM if R#1 could make his own decisions. CM replied, "Yes, he is able to tell us what he wants to do. He would tell us he wanted to go home, but recently he has stopped asking us." The CM said FM "Z" told her that R#1 used to have a provider, but he would, "run them off." The CM said R#1 was placed in the locked unit after he kept wanting to leave the facility and asking people in the front lobby if they could take him home. Surveyor interviewed LVN "E" on [DATE] at 11:40 a.m. LVN "E" said he had worked on the locked unit for about a month. LVN "E" said R#1 had improved and was conversing more with other residents in the unit. LVN "E" said R#1 told him several times that he wanted to go home.` Surveyor interviewed Administrator on [DATE] at 12:28 p.m. The Administrator stated that a new MDS was completed on [DATE]. He further stated that the updated MDS reflected active discharge planning including a referral to DADS "Money Follows the Person" to assist R#1 with community placment. The Administrator said a Relocation Specialist had been assigned to R#1 and would be assisting him with the program. The Administrator said the facility had R#1's Psychiatrist conduct a psychiatric evaluation for R#1. Surveyor conducted a telephone interview with a DADS Relocation Specialist on [DATE] at 1:23 p.m. The Relocation Specialist said she had been contacted by the facility Administrator regarding R#1 and wanted to make referral for assistance for possible community placement. The Relocation Specialist said a full assessment would need to be conducted to determine if R#1 met the financial requirements(Social Security, Medicaid etc..) for the program. Surveyor observed R#1 in the Memory locked unit on [DATE] at 2:40 p.m. Surveyor observed R#1 walking down the hallway pushing his wheelchair. Surveyor approached R#1 and asked him if he remembered me. R#1 replied in Spanish "si" (yes). Surveyor and R#1 moved to a more private area of the Memory locked unit. Surveyor asked R#1 for the names of his sons. R#1 replied he had three sons, two who were married and one who was mentally disabled and had lived with him. R#1 gave the names of the sons. Surveyor asked R#1 if his sons would be able to take him in to live them. R#1 chuckled and said "No, le tienen miedo a mi hija" (No, they are afraid of my daughter). R#1 said his daughter would not allow his sons to take care of him. Psychiatric Evaluation by R#1's Psychiatrist on [DATE] (after surveyor entered the facility for a follow up visit on [DATE]) documented: "[DIAGNOSES REDACTED]. History (HX) of progressive memory loss wants to go home. Patient has a HX of progressive memory loss, intellectual permanent personality deterioration recently compounded with depressive symptoms. On Namenda (anit-Alzheimers medication), Lexapro (antidepressant medication) and Aricept (medication for Dementia). 0 family HX. On examination, pleasant but becomes easily irritated when tested . Affect is responsive though mood depressed. Denied suicidality. Significant thought poverty. No hallucinations. Some referential thinking. Moderately confused limited insight into his confusion. DX (diagnosis) Primary Degenerative Dementia with Depression and behavioral disturbances. Recommendations: Patient is in need of 24 hour supervision, Re-orientation, redirection. Continue same psychotropic medications, consider adding atypical antipsychotic, low dose if agitated. Monitor clinical response." Surveyor conducted a telephone interview with R#1's Psychiatrist on [DATE] at 11:30 a.m. The Psychiatrist said he conducted R#1's evaluation on [DATE]. The Psychiatrist said R#1 had a [DIAGNOSES REDACTED]. Surveyor asked the Psychiatrist if R#1 was able to make his own decisions, and he replied "No." The Psychiatrist said R#1 was not cognitively aware of his health status, R#1 thought he was cured of his [DIAGNOSES REDACTED]. The Psychiatrist said R#1 needed 24 hour supervision and the family was not able to provide that for him. The Psychiatrist said R#1's thinking was poor, he was "irrational"at times and would be, "easy prey to be taken advantage of or hurt if out on his own. He would be at risk." Surveyor asked Psychiatrist if R#1 could function off the locked unit, perhaps with a wanderguard. The Psychiatrist said that even if R#1 had a wanderguard, he would still be at risk of leaving the facility. Review of R#1's Physician's letter to facility ADON "C" documented: Title: Letter to Acknowledge a Resident Incompetent. "This letter serves to inform the (name of facility) that R#1 has a [DIAGNOSES REDACTED]." The letter was not dated. Date of fax at the top of the page was [DATE]. Surveyor conducted telephone interview with R#1's Physician on [DATE] at 11:45 a.m. The Physician said R#1 was irrational at times. The Physician said, "I don't think (R#1) is able to make rational decisions for safety and care. I don't think he would be safe at home or in the skilled unit with a wanderguard." Physician said R#1 needed 24 hour care. Surveyor read R#1's Psychiatric Evaluation by R#1's Psychiatrist to his Physician. R#1's Physician said he agreed with R#1's Psychiatrist's findings/[DIAGNOSES REDACTED]. R#1's Physician said, "(R#1) is better off in the Memory locked unit." Surveyor interviewed the facility Physical Therapist on [DATE] at 11:00 a.m. Physical Therapist said R#1 had suffered a hip fracture in [DATE] while living at home. When R#1 was admitted to the facility, physical therapy (PT) was ordered for strengthening of the hip area, improvement of his ablity to transfer himself, and strengthening of his lower extremities. The Physical Therapist said R#1 was admitted for PT services on [DATE] and discharged from PT on [DATE]. The Physical Therapist said R#1's goals were met. R#1 was able to stand and push his wheelchair and had strengthened his hip area and extremities. Surveyor interviewed LVN "E"/ MDS Coordinator on [DATE] at 12:05 p.m. LVN "E" said family had requested Hospice services after R#1's Physician had talked to them because R#1 had [DIAGNOSES REDACTED] and Melanoma (cancer neck area). LVN "E" said R#1's family called the facility requesting Hospice services and information about available Hospice companies was provided to them. LVN "E" said family chose a Hospice company and a telephone physician's orders [REDACTED]. Surveyor interviewed facility Administrator on [DATE] at 1:00 p.m. The Administrator told surveyor that the facility's Medical Director was aware of R#1's condition and was R#1's attending physician. Surveyor asked Administrator if she had ever spoken directly to R#1. The Administrator replied that she had not spoken directly to R#1, but that she got feedback from her staff on R#1 and also read psychiatric notes about R#1. The Administrator said the appropriateness of each resident's placement in the locked unit was reviewed at quarterly meetings. The family was asked if they still wanted the resident in the unit. If th