Every finding on record at Avir at Belton

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 had orders in place to treat his UTI from 06/27/26 to 07/04/26. Resident #1 went to the ED for UTI and returned to the facility the same day. Resident #1 was prescribed cefuroxime 500 MG every 12 hours for 7 days to treat UTI and the orders were not entered on the MAR upon readmission by the admitting nurse. Resident #1 was sent back to the ED on 07/23/26 and admitted due to green pus and foul smelling urine. This failure placed residents at risk for unassessed changes in conditions and for not receiving adequate care.Findings included: Record review of Resident #1's face sheet dated 08/22/26 revealed a [AGE] year-old male who was admitted to the facility 02/15/24 and diagnosed with acute kidney failure (inability to filter waste from the blood), disorders of kidney and ureter (body's filtration and drainage system gets blocked, damaged, or infected), urinary tract infection (infection caused by bacteria causing difficulty to no urinary void), retention of urine (blockage), and chronic pain syndrome. Record review of Resident #1's MAR dated 06/01/26 reflected no medication cefuroxime used to treat his UTI. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated moderate cognitive impairment. Record review of progress note dated 06/27/26 and time-stamped 02:16 AM by LVN A reflected, Resident stated that something was wrong with his catheter and wanted this nurse to change the catheter bag, Approx 200 mL of clear yellow urine noted in drainage bag at this time. Changed out drainage bag on catheter per pt request. Pt continued to complain that something is wrong with his catheter, deflated foley balloon and advanced catheter and reinflated balloon to ensure proper placement, then Flushed catheter with 30 mL of sterile water. Pt stated he hadnt [sic] consumed an adequate amount of fluids thatday [sic], encouraged him to drink more water and if no drainage noted in catheter bag after a few hours that we would change the catheter. Left pt room and he continues to put on hi scall [sic] light and complain that something is wrong with his catheter, pt does not have a distended bladder, shows no signs of distress, and scant amount of clear yellow urine noted in new drainage bag. Pt then called 911 and stated that there was something wrong with his catheter, EMS showed up at around 0215 (2:15 AM) and left the facility with resident at 0230 (2:30 AM). Record review of Resident #1's after visit summary dated 06/27/26 and time stamped 05:19 AM from (Local Hospital) reflected Instructions: Start taking cefuroxime (Ceftin); Today's Visit: Male GU Problem Diagnosis UTI. Procedures and tests performed during your visit: urinalysis with microscopy with reflect to culture. Culture, urine. Insert indwelling urinary catheter. Antibiotics: take antibiotics exactly as prescribed. Do not skip doses or stop taking antibiotics, even if you feel better. Discharge Instructions: Take your medicines only as told by your health care provider. If you were given antibiotics, take them as told by your provider. Do not stop taking them even if you start to feel better. Contact a health care provider if: your symptoms don't get better after 1-2 days of taking antibiotics, your symptoms go away and then come back, you have a fever or chills, you vomit. Get help right away if; you have very bad pain in your back or lower belly, you faint. Record review of Resident #1's ED to Hosp-admission dated 07/23/26 and time stamped 08:40 AM from (Local Hospital) reflected Date of Service: 7/22/2026 Chief Complaint: Tube Problem. HPI: (Resident #1) is a 68 y.o. male with history of HLD (too many fats in the blood), HTN (high blood pressure), chronic foley presenting for Tube Problem. Patient (Resident #1) initially had lower abdominal pain and a distended bladder, staff tried to flush Foley and was not able to. It appeared the Foley was clogged. Foley was replaced and upon removal there was green pus and foul-smelling discharge. Once new Foley was placed, patient's bladder drained 1100 mL of urine. Genitourinary Comments: Penis swollen. MDM: Differential diagnoses includes urinary tract infection, acute kidney injury, urosepsis (life-threatening medical emergency where a simple UTI spreads to the kidneys and triggers an extreme, harmful body-wide immune response). admit: Given the above findings, patient will require admission to the hospital for continued monitoring, further diagnostic evaluation and symptom management. Patient was admitted to the hospital in stable condition. Record review of Resident #1's progress note dated 07/28/26 and time stamped 08:30 PM reflected, Resident (#1) returned to the facility via EMS @ 1200 (12:00 PM) in stable condition following hospital evaluation. Resident (#1) had been transferred to the hospital due to Foley catheter obstruction and was dx with hyponatremia (too little sodium in blood) during hospitalization. Upon arrival, resident returned without incident, transferred safely, and appeared comfortable. Vital signs are as follows: BP 126/69, P 87, RR 18, T 98.1, O2 99% on room air. Resident A&O x4, with no changes in LOC noted from baseline. Speech clear and resident able to communicate needs appropriately. Mood remained pleasant and cooperative throughout the shift. Resident denied pain including urinary pain, burning, bladder discomfort. Catheter patent and intact, draining clear/yellow urine into the drainage bag without difficulty. No sediment, blood, or foul odor was noted. Resident tolerated oral fluids and medications as ordered. No s/s of acute distress were observed during the shift. Safety measures remain in place, call light in reach and bed in lowest position. Resident encouraged to report any pain, decreased urine output, catheter leakage, or any other changes in condition; Resident verbalized understanding. Plan of care remains ongoing. During an interview with LVN B on 08/22/26 at 11:39 AM, she stated Resident #1 was sent out to the ED on the 27th of June and returned same day. She stated she was not at work that day, but LVN A was on shift and should have entered the orders from the hospital as the admitting nurse. LVN B stated she heard through the grapevine Residnet #1's orders were not entered into his MAR. She stated Resident #1 did get sick and was sent back out about a month later, was admitted to the hospital and was treated for sepsis (life-threatening medical emergency where body overreacts to infection and starts damaging its own organs). During an interview with Resident #1 on 08/22/26 at 12:00 PM, he stated he was doing well. He stated a couple of months ago he was really sick and was hospitalized . Resident #1 stated he was not sure what happened, neither did he know about missing medication. He stated he thought he was going to have to get on a 'kidney machine'. Resident #1 added he had not been drinking enough water during the time he went to the hospital. He stated nothing like that had happened before or since. Resident #1 stated he was doing well, and added he had no concerns. During an interview with the MDS RN on 08/22/26 at 12:15 PM and 01:11 PM, she stated she had no knowledge that Resident #1's medication had not been entered into the computer following his ED visit. She stated the process was for the admitting nurse (whomever was on schedule) was responsible for inputting resident information into the system following admission or readmission. She stated the person on duty on 06/27/26 was LVN A. She stated LVN A was written up for a separate issue and quit without notice. She stated the DON was terminated Friday (08/21/26) for unrelated issues. Calls were placed to LVN A on 08/22/26 at 01:15 PM and 01:20 PM with no success. Neither was there an option to leave a voice message. During an interview with the ADM on 08/22/26 at 02:30 PM, she stated the process for readmission was the same as admission. She stated the hospital nurse contacted the admitting nurse with hospital discharge information. She stated once the resident returned to the facility, the admitting nurse reviewed and added orders, regardless of the admission time. She stated LVN A should have entered the orders into the MAR. During an interview with LVN A on 08/27/26 at 02:45 PM, she stated she was an LVN at (Facility Name) for about 2 1/2 to 3 months. She stated trainings at (Facility Name) included OJT for a few days, then she was alone. LVN A stated there was an in-service that covered resident transfers. She stated she received a packet of papers to read. When asked about resident readmission process, LVN A stated the orientation packet was on the desk and she was told to read it. LVN A stated she saw no information about readmissions. However, she stated just being a nurse, she knew if a resident discharged and returned within 24-48 hours, vitals and skin assessments were taken. She stated she received no training specifically, but she picked up what generally was done so she implemented that. LVN A stated Resident #1 went out to the ED and returned right at shift change. She said she was in the middle of doing stuff and was busy so she did not enter his orders into the system. She stated she did not send Resident #1 out, but rather, he called 911 and they brought him back. LVN A stated it was nearly time for her to get off. She stated technically, not entering the orders would be on her, but she had to get off to get her kids to school. She stated any time a resident did not take medication as prescribed placed them at risk of heightened illness, up to death. Record review of LVN A's personal personnel file reflected a start date of 06/18/26 and a final date of 08/19/26. Nurse Orientation/Competency Ckecklist reflected completions date of 06/23/26 and included the following topics:*Access to Systems*competency: Change of shift reporting process; Change of condition process; Assignment confirmation at start of shift process; CNA Assignment; Schedule break and lunch times; Prioritizes resident care activities with CNA; Resident Rounds; Resident Care Plan Review Process; Supervise CNAs*Facility Resources*Resident Care: Tube Feedings; Medical Emergency/Choking/Code Blue; Oxygen Set Up and Supplies; Respiratory Therapy; Glucometer Check/Quality Control; Admissions (Nursing admission Comprehensive Assessment; MD admission Orders; Discharges; Incident Reporting; Phone Usage; Intercom; Paging; Infection Control; Charting/POC/Dashboards: change of condition process: B&B, Wounds. Weights, Recap, Care Planning (Baseline); Lab & x-Ray (Lab Long, Ordering for Lab and Diagnostics, Lab Draws, Specimen Collection); Audits (Medical, In-House); Resident Identification; Pharmacy (Med Pass, Ordering Medications, In-House; Ordering Medications, Outside, Expiration of Medications, Date Open Stickers, House Stock, Documentation, PRN, Stop Orders, E-Kits/E-Carts, Out on Pass with Meds, Narcotic Counting at Shift Change Record review of facility policy entitled admission Notes dated 2001 reflected, Preliminary resident information shall be documented upon a resident's admission to the facility. Policy and Interpretation and Implementation: 1. When a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol: c. From where the resident was admitted (i.e., hospital, home, other faciltiy); d. Reason for the admission; e. The admitting diagnosis; f. The general condition of the resident upon admission; h. The time the physician's orders were received and verified; i. Description of any lab work completed or the time specimens were sent to the lab; j. The presence of a catheter, dressings, etc.; l. The time medications were ordered from the pharmacy. A statement indicating that the nursing history and preliminary assessment is completed o has been started; t. The signature and title of the person recording the data. 4. Should a resident be discharged from and readmitted to the facility, new admission data must be recorded. Record review of facility policy entitled Compliance Risks - Resident Quality of Care dated 2001 reflected, Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program. Medication management: 2. Procedures are in place to ensure accuracy and safety of administering, acquiring, receiving, storage, labeling, and dispensing of mediations. Resident Safety: 1. Residents are free from abuse, neglect, exploitation, and misappropriation of property. Record review of facility policy entitled Administering Medications dated 04/2019 reflected, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 29. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have oriented to the medication administration system used by the facility. Record review of facility incident report for 90 days reflected neither Resident #1's hospital visit on 06/27/26, nor on 06/23/26. Record review of LVN A's time card dated 06/27/26 reflected a clock-in time of 06:56 PM and a clock-out time of 07:07 AM.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and failed to properly transfer residents 3 (Resident # 2, # 3, 4) of 6 residents reviewed for transfer status. The facility failed to prevent Resident #1 from falling when CNA A transferred resident alone without using a mechanical lift (specialized device designed to safely transfer individuals with limited mobility ) resulting in Resident #1's fall and sustained a fractured right ankle on 05/01/26. Resident #1 stood and pivoted to the toilet and CNA A attempted to prevent resident from falling when resident slid to floor from toilet. The facility failed to properly transfer residents 3 (Resident # 2, # 3, 4) of 6 residents. This failure could place residents at risk for serious injury and accidents.Findings included: Record review of residents face sheet dated 05/02/26 reflected Resident #1 was a [AGE] year-old female, admitted [DATE], with diagnoses including congestive heart failure (a serious condition that occurs when the heart cannot pump enough blood to meet the body's needs), hypertensive heart disease with heart failure (when high blood pressure (hypertension) weakens the heart over time, leading to heart failure), anxiety (intense, excessive, and persistent worry and fear about everyday situations), diabetes (a group of diseases that result in too much sugar in the blood), and dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #1's admission MDS assessment, dated 04/06/26, reflected a BIMS score of 03 indicating severely impaired cognition. MDS reflected Resident #1 required setup or clean up assistance for eating, substantial or maximal assistance for toileting and showering, and partial to moderate assistance for personal hygiene. Record review of Resident #1's care plan, dated 04/21/26, reflected, Resident #1 had an ADL self-care performance deficit r/t terminal Dx (CHF - Congestive Heart Failure). Goal will maintain current level of function in ADLs within my [Resident #1's] functional limits through the review date. Interventions included: Toilet use: The resident requires substantial to maximal assist by one staff for toileting. Date Initiated: 04/21/2026. Revision on: 04/21/2026 - Transfer: The resident is totally dependent on two staff members for transferring using a mechanical lift. Record review of Resident #1's Care Profile Report, dated 05/02/26, reflected Resident #1 required a mechanical r lift for all transfers. Record review of Resident #2 admission face sheet dated 5/14/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2 had diagnosis of type 2 diabetes (a chronic condition where your body either doesn't produce enough insulin or resists it), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis or partial weakness on the right side of the body due to brain or spinal cord damage), seizures, muscle wasting and atrophy, vascular dementia, aphasia following cerebrovascular disease (a neurological language disorder caused by damage to the brains language centers), cerebral infarction (stroke), cognitive communication deficit (an impairment in communication caused by underlying cognitive difficulties rather than a primary language or speech issue), abnormalities of gait and mobility. Record review of Resident #2 EHR Kardex report dated 5/14/26 reflected under heading Transferring Resident #2 requires total assistance of 2 staff via mechanical lift with transfer. Record review of Resident #2 Care plan dated 10/20/25 reflected an ADL self-care performance deficit in bed mobility, transfers, eating, toileting, bathing, dressing, and personal hygiene r/t frequent incontinence, aphasia, seizures, CVA, hemiplegia/hemiparesis, anxiety, pain, dysphagia, reduced mobility and malaise. Interventions of locomotion on and off unit: Resident needs assistance of 2 staff to transfer with assistance of mechanical lift. Record review of Resident #3 admission face sheet dated 5/124/26 reflected a 71-year-olf female admitted to the facility on [DATE] and re-admitted on [DATE]. Resident # 3 had diagnosis of type 2 diabetes (a chronic condition where your body either doesn't produce enough insulin or resists it), spinal stenosis of lumbar region (the narrowing of the spinal canal in the lower back which puts pressure on the nerves running to your legs), osteoarthritis (a chronic degenerative joint disease where the protective cartilage that cushions the ends of your bones wears down over time) muscle weakness, lack of coordination, muscle wasting and atrophy (muscle shrinkage), cognitive communication deficit (an impairment in communication caused by underlying cognitive difficulties rather than a primary language or speech issue), sciatica left sided pain (a symptom of an underlying problem involving the sciatic nerve), chronic pain, need for assistance with personal care, and unsteadiness on feet. Record review of Resident #3 EHR Kardex report dated 5/14/26 reflected under heading Transferring Resident #3 requires total assistance for transfers and requires mechanical sling lift for transfers. Provide 2 person for transfer. Record review of Resident #3 Care plan dated 9/2/25 reflected an ADL self-care performance deficit in bed mobility, transfers, eating, bathing, toileting, dressing, and personal hygiene r/t CVA, anxiety, vision, diabetes, and arthritis. Interventions of mechanical sling lift is a total assist for transfers and requires mechanical sling lift for transfers. Provide 2 people for transfers. Record review of Resident #4 admission face sheet dated 5/14/26 reflected a 71-year-olf male admitted to the facility on [DATE]. Resident # 4 had diagnosis of cerebral infarction (stroke), type 2 diabetes (a chronic condition where your body either doesn't produce enough insulin or resists it), spastic hemiplegia affecting right dominant side (a common subtype of spastic cerebral palsy that causes muscle stiffness, weakness, and involuntary contractions on just the right side of the body), aphasia following cerebral infarction (a neurological language disorder caused by damage to the brains language centers), encephalopathy (a broad term for any disease, damage, or malfunction of the brain), CHF (a chronic progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently throughout the body), attention and concentration deficit following cerebral infarction. Record review of Resident #4 EHR Kardex report dated 5/14/26 reflected under heading Transferring Resident #4 is totally dependent on 1-2 staff for transferring Record review of Resident #4 Care plan dated 4/14/26 reflected ADL staff assist r/t hemiplegia affecting right dominant side, recent CVA, mood decline, encephalopathy, CHF, diabetes, A-fib, aphasias, swallowing disorder, and impaired mobility. Transfers: the resident is totally dependent on 1-2 staff for transferring. During an interview on 05/02/26 at 7:42 AM, RN A was notified of the investigation being conducted in the facility. She stated on 05/01/26, at approximately 4:40 p.m., Resident #1 arrived at the hospital emergency room for treatment via EMS. She stated EMS told her they were told Resident #1 was being transferred by a single CNA, when the resident required a two person assist and/or mechanical lift, and, as a result, Resident #1 suffered a fall in the bathroom. She stated EMS further stated they were told that Resident #1 slipped off the toilet. She stated EMS further stated that they were told that Resident #1 had an area of bleeding on her right foot that the staff had wrapped prior to their arrival. She stated during the triage nursing assessment, Resident #1's right foot was found to be discolored and cold to the touch. She stated when the dressing that was applied by the facility was removed, an obvious open fracture was identified, with a large area of bone exposed. She stated Resident #1 was only alerted to her name and location (hospital), otherwise she was only able to answer limited yes or no questions. She stated they were unable to obtain a clear history on how she was injured due to her altered mentation. She stated the orthopedic surgery team attempted to reduce Resident #1's open fracture but after approximately an hour of trying to repair her injury at the bedside, they were unable to and made the decision that she would need emergent surgery. During an interview on 05/02/26 at 10:13 AM, RN B, she stated she was made aware that Resident #1 had fallen and was sent to the hospital. She stated she was the weekend on-call nurse and she did not see the resident all the time but she had been to the facility about 3-4 times to see resident . She stated to her knowledge resident was walking with a walker on her own at home two months ago and when Resident #1 went to the facility, her walker was removed . She stated Resident #1's family member requested that the facility give Resident #1 back her walker so she could have tried to use it again. She stated the resident had gotten a little better and began using the walker. She stated Resident #1 fell trying to go to the bathroom and tripped when she was using her walker not long ago and they did x-rays at that time to rule out any fractures because Resident #1's ankle was swollen. RN D stated she believed that was 04/13/26. She stated there were no fractures when that fall occurred. She stated she was not sure what all happened with the fall that just occurred but the resident had swelling to both of her ankles on a regular basis. She stated she had only been out to the facility once before for a fall for Resident #1. During an interview on 05/02/26 at 10:22 AM, CNA G stated she took care of Resident #1. She stated the resident's normal CNA was out but so she was covering for her. She stated Resident #1 transferred with 1 person assist and could usually stand on her own. She stated if she ever needed extra help, she would just ask a staff member at the facility to come in and help her. She stated there was a time when the resident had gotten weak and they used the mechanical lift for her transfers but Resident #1 got better and no longer needed the lift. She stated Resident #1 was pleasantly confused at times but could recall some things. During an interview on 05/02/26 at 10:56 AM, RN C stated she had worked in the facility for about 6 years. She stated she was in-serviced on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, she would have first assessed the resident and checked for injuries or pain, gotten vital signs, and tried to find the safest way to get them up off the floor if possible. She stated she would have checked the resident's neurological status to make sure their cognitive level was ok. She stated she would have notified hospice if applicable, the family, the DON, administrator, and the doctor and if needed, and the family agreed, she would have sent the resident to the hospital. She stated some fall preventions they used in the facility were non-skid socks, grab bars in bathrooms, gait belts, and following the residents electronic record to know what kind of transfer the residents required. She stated she knew what type of assistance her residents needed by following the residents electronic record. She stated if a resident required a transfer with a mechanical lift there should always be 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never been transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift, it could have caused an injury to staff and or the resident. She stated in the incident that involved Resident #1, around 3:30 PM on 05/01/26, CNA H alerted her Resident #1 fell. She stated CNA H told her she had witnessed the fall happen. She stated CNA H told her that after she had gotten Resident #1 on the toilet, the resident slid off the toilet and sat herself down and then laid down on the floor. She stated when she entered the room she noticed there was feces and blood on the floor beside Resident #1's feet. She stated she assessed Resident #1 and got residents vital signs, checked her mental status, checked her range of motion, checked her breathing, and checked for any injures. She stated the only injuries she noted at that time was the bleeding from the resident's right foot and a small abrasion to the middle of the resident's left shin. She stated Resident #1's right foot was bleeding from the inner ankle. She stated the resident had a blister to the right ankle and had a kerlix wrapped on the ankle and she could not tell where the bleeding was coming from. She stated she tested Resident #1's full range of motion and the resident was able to move both of her feet and legs while still in the bathroom on the floor . She stated using the gait belt her and the CNA transferred resident from the floor to the wheelchair. She stated resident had not complained of any pain. She stated she asked CNA H to get her a towel because of the area that was actively bleeding and she wrapped the towel around the area and elevated Resident #1's leg. She stated Resident #1 was a 2 person transfer and mechanical lift transfer but resident was in the bathroom floor and they could not get the lift in the bathroom to get the resident out. She stated her and CNA H rolled resident out of the bathroom in her wheelchair and she looked at the area where the wound was and there was still a little bleeding. She stated she asked CNA H to get RN D, which was also the ADON, and treatment nurse, at that time, so RN D could have assisted with and looked at the wound. She stated she then grabbed her scissors and began to cut the bandage off the wound. She stated RN D arrived and they removed the bandage completely and she noticed the wound was more than just a skin tear. She stated the ADON stepped out to get more supplies and she noticed that residents foot was kind of sagging to the side and she knew that the area could have possibly been fractured. She stated her and RN D traded spaces and she stepped out to alert the DON, hospice, family, and the doctor. She stated she also called the on-call nurse practitioner and informed her. She stated hospice was made aware that Resident #1 needed to be sent to the hospital and had given the orders to do so. She stated the family agreed and she called 911 and the resident was sent to the hospital. She stated she did not see any bone protruding through the wound and there was only coagulated (a liquid that has changed into a thickened, curdled, or solid state) blood and flesh that she saw. During an interview on 05/02/26 at 11:24 AM, CNA H stated she had worked in the facility for about a year and a half. She stated she worked 7:00 AM - 7:00 PM shift. She stated she was in-serviced on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, she would have gotten help and informed the nurse immediately. She stated some fall preventions they used in the facility were gait belts, fall mats, float beds, and call lights in residents reach. She stated she knew what type of transfer assistance her residents needed by following the residents electronic record. She stated if a resident required a transfer with a mechanical lift there should have always been 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never been transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift or transferred without 2 people, it could have caused a fall or skin tear or broken bones. She stated in the incident involving Resident #1, she went to the resident's room and the resident was on her oxygen sitting in her wheel chair. She stated she told Resident #1 she was going to take her to the bathroom and get her changed. She stated she pushed Resident #1 to the bathroom in her wheelchair and asked Resident #1 if she could stand up. She stated the resident did not have a mechanical lift sling under her. She stated the resident told her she could stand up and Resident #1 grabbed the poles and stood up. She stated she pulled the resident's pants down and she told resident she was going to remove the brief. She stated resident had BM up her back and the wheel chair was still behind resident at this time. She stated she removed the wheelchair and got behind Resident #1 and removed the brief. She stated Resident #1 pivoted slightly and sat on the toilet. She stated she tried to clean the BM off of the resident's back and that was when Resident #1 started sliding off of the toilet. She stated she tried to help Resident #1 get back on the toilet and resident tightened up and then began to slide down again. She stated she knew she was not going to get resident back on the toilet safely, so she guided Resident #1 down to the floor. She stated at that time there was BM all over the toilet. She stated she made sure Resident #1 was in a safe place and called for RN C. CNA H stated she came back in and looked and saw Resident #1's foot was wrapped but there was some blood on the floor. She stated she ran and got RN C and informed her of the incident. She stated they went back to Resident #1's room and the resident was laying sideways on the floor and there was blood, BM, and urine on the floor. She stated Resident #1 was assessed by the nurse and her oxygen was put back on. She stated they had got the resident back into her wheelchair. She stated she was not aware that Resident #1 was a mechanical lift transfer and had a change in condition recently . She stated resident had recently been walking to the bathroom. She stated RN D came and RN D and RN C cut the bandage off of the resident's right ankle. She stated they could not tell what the wound was but the area was open and bleeding. She stated it looked like meat to her and there was gauze on the wound from the wound care that was previously done. She stated the wound appeared like something was sticking out but she could not tell if it was bone or the way resident was holding her foot. She stated Resident #1's foot was tilted to the side. CNA H stated Resident #1 was not reacting to the situation at all and never complained of pain. She stated the resident was sent out to the hospital. CNA H stated she was called to the office and told that resident was supposed to be a 2 person transfer and that she should have been transferred with the mechanical lift. She stated there was no sling on Resident #1 when she went in and assisted the resident to the bathroom and she told the ADM, DON, and RN D that. She stated they told her Resident #1's transfer status was in the Kardex and she was suspended pending investigation. She stated she did not know who had gotten the resident out of bed and up in the wheelchair that day. CNA H stated it was her first day back after being off. She stated she was surprised Resident #1 was up in the wheelchair to begin with because she was usually in the bed when she took care of her. She stated she usually looked at the residents Kardex's but she had not looked at it that day. In an interview on 05/02/26 at 12:01 PM, the FM stated Resident #1 was ambulatory when she admitted to the facility and walked at home with her walker. FM stated the resident was not allowed to use her walker after she was admitted to the facility. FM stated the facility staff was told that resident needed her walker back and they gave it back to her. FM stated resident had an immediate fall after getting her walker back. FM stated the hospice nurse had come out to see resident when that happened and they were not sure how the fall occurred. FM stated had not thought resident had access to the walker since then and the staff used a lift to transfer resident in and out of bed. FM stated they were not sure how resident was being transferred to the bathroom. FM stated they were notified that resident fell yesterday and initially the hospice nurse called and said resident slipped off the toilet and her foot was bleeding from the blister to her right lower leg so resident needed to be sent out to the hospital. They stated they were then told that residents foot was not stable and agreed for resident to be sent to the hospital. They stated resident was at the hospital and she had surgery last night on her ankle They stated resident was in ICU so the hospital could make sure residents toxicology report was stable and for close monitoring and she would be there for about 4-5 days. They stated resident had a compound fracture and could have possibly had to have a skin graft or amputation, but they had her in a wound vac and they would not know the extensiveness of the wound until a week from then when they removed the wound vac and got everything cleaned up. They stated the hospital said there would have likely been more than one surgical procedure that needed to be done. In an interview on 05/02/26 at 12:26 PM, the HPS stated resident was still in ICU and they had consulted plastic surgery for the wound to see if there were any recommendations for the care of the wound. She stated she had not seen the resident when she initially came to the hospital and she was not actively participating in residents care. In an interview on 05/02/26 at 12:32 PM, RN E stated she was not present when Resident #1 transferred into the hospital with EMS but she was caring for resident at that time. She stated Resident #1 had surgery overnight and the fractured area was now closed. She stated Resident #1 was in stable condition. She stated Resident #1 had a wound vac (a medical device that uses continuous or intermittent suction to accelerate healing in acute or chronic wounds) in place and she was not sure how the fracture occurred. In an interview on 05/02/26 at 12:52 PM, the MD stated she was not familiar with Resident #1, but she was the doctor on call for the weekend. She stated it was possible for a fracture to occur in a [AGE] year old resident that could have had osteoporosis in her bones. She stated Resident #1 would be a high risk for fractures. She stated it was hard to say how the actual fracture had occurred and it could have been that something happened prior to the incident. She stated it was hard to say. She stated resident could have gotten a fracture from pushing too hard on a wall or floor and it would not have taken a lot for residents brittle bones. In an interview on 05/02/26 at 12:48 PM, RN D stated she was in the process of being transitioned to ADON. She stated she had worked in the facility for about a month. She stated she was in-serviced on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, she would have made sure the resident was not injured, done a full assessment, gotten help if needed, and she would not have moved the resident if they were injured while waiting for EMS. She stated some fall preventions they used in the facility were mechanical lifts, 2 person assist, call lights in reach, rounding every 2 hours, toileting, and gait belts. She stated she knew what type of assistance her residents needed by looking at their care plans and Kardex. She stated if a resident required a transfer with a mechanical lift there should always have been 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never be transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift, it could have caused falls, major injuries, or possible death. She stated in regard to the incident that involved Resident #1, she and the DON were notified by CNA H that Resident #1 had fallen and was on the floor and that there was blood on the floor. She stated she went to Resident #1's room and RN C was holding residents foot. She stated Resident #1 had an open blister to her right ankle and the nurse had mostly removed the dressing. She stated the area was bleeding and the wound looked like their could have been an open fracture due to the position resident was holding the foot. She stated she could not see any bone or what the actual injury was due to the bleeding. She stated she stabilized residents foot and applied abdominal pads and kerlix to try to stop the bleeding. She stated by that time EMS had come in and she stepped out while the RN C and a few other CNA's came in and assisted EMS. In an interview on 05/02/26 at 3:05 PM, LVN F stated she had worked in the facility for about 13 years. She stated she was in-serviced on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, she would have assessed resident and made sure there were no injuries, sent resident to the hospital if needed, checked vital signs, checked neurological assessment, and if the resident was safe, she would have gotten them up. She stated some fall preventions they used in the facility were fall mats, residents were monitored and toileted often and they offered activities. She stated she knew what type of assistance her residents needed because she checked the Kardex. She stated if a resident required a transfer with a mechanical lift there should have always been 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never been transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift, it could have caused a severe injury. She stated when a resident was transferred that required maximum assistance x 1 staff that meant the staff should have done more than what the resident did but that the resident could still help and could bear weight if able. In an interview on 05/02/26 at 3:11 PM, CNA I stated she had worked in the facility for 2 years plus. She stated she was in-serviced on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, she would have yelled for help and asked who came to get the nurse. She stated some fall preventions they used in the facility are gait belts, check the Kardex to see how residents were transferred, residents were toileted often, and some residents were transferred with a mechanical lift. She stated she knew what type of assistance her residents needed because she looked at the Kardex as soon as a new resident arrived. She stated anytime there was an update for current residents, therapy or the nurse informed her. She stated if a resident required a transfer with a mechanical lift there should have always been 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never been transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift, it could have caused a fall or for the resident to have gotten hurt or it could have also caused the staff member to get hurt. She stated when residents were transferred that required maximum assistance x 1 staff that meant she should have checked the Kardex first to see what kind of transfer the resident required and then followed the Kardex. In an interview on 05/02/26 at 3:22 PM, CNA J stated he had worked in the facility for about 4 days. He stated he has been in-serviced on abuse and neglect, mechanical lift transfers, and falls/fall prevention. He stated if a resident fell, he would have notified the charge nurse or notify whoever he saw to get the charge nurse. He stated some fall preventions they used in the facility were keeping things out of the walk ways, non-slip socks, and call lights in reach. He stated he knew what type of assistance his residents needed by checking their Kardex in POC. He stated if a resident required a transfer with a mechanical lift there should always have been 2 staff present during the entire transfer. He stated a resident that required transfers with a mechanical lift should have never been transferred without the lift. He stated if a resident required to be transferred with a mechanical lift and the resident was transferred without the lift, it could have caused a fall or broken bone. He stated when transferring residents that required maximum assistance x 1 staff that meant he should have done whatever the resident needed to keep the resident safe, so if they could bear weight he would have stayed with the resident the entire time and helped them as much as needed. In an interview on 05/02/26 at 3:31 PM, the DON stated she had in-serviced staff regularly on mechanical lift transfers and falls/fall prevention. She stated if a resident fell, the CNA should have gotten the nurse and the nurse should have assessed the resident for any injuries or open skin wounds or bruises, conducted a neurological assessment, notified her, the ADON, the RP, and the provider. She stated if there was a serious injury the staff should have sent the resident to the hospital or if they suspected resident had hit their head and were acting different or if they were on blood thinners. She stated in that case she would also have informed the ADM. She stated some fall preventions they used in the facility were low beds, fall mats, increased monitoring, call lights in reach, signage to call for help, and trying to keep residents busy with activities. She stated staff knew what type of assistance their residents needed by checking the Kardex. She stated at any time the CNA's may to have been clear they should have asked the nurse. She stated staff should have checked the Kardex every day before taking care of residents because changes occurred. She stated some of the residents transferred with the mechanical lift PRN because they could have been frequent fallers or may have their ups and downs depending on their mood and the time of day. She stated if a resident required a transfer with a mechanical lift there should have always been 2 staff present during the entire transfer. She stated a resident that required transfers with a mechanical lift should have never be transferred without the lift. She stated if a resident required to be transferred with a mechanical lift and they were transferred without the lift, it could have caused serious injury or harm to the resident and staff could have also been hurt. She stated when residents that required maximum assistance x 1 staff were transferred, that meant staff should have transferred residents with a gait belt and staff should have been doing most of the work. She stated a resident could still have been able to bear weight with maximum assistance x 1 staff. She stated in the incident that involved Resident #1 she had not witnessed the incident but RN C told her resident had fallen. She stated RN D went to Resident #1's room because she was informed there was bleeding present. She stated she informed the ADM and CNA H was suspended pending investigation. She stated they got CNA H's statement and in-serviced her abuse and neglect prior to her leaving the facility. She stated RN D and the RN C unwrapped residents dressing and she walked into Resident #1's room and assessed the area. She stated she did not see any bone poking out and she only saw the area where the wound was and it appeared the existing wound had opened up around it. She stated the area was bleeding and she told the staff to send Resident #1 to the hospital. She stated RN D informed her that she thought residents foot may have been fractured and she informed the ADM. She stated they suspected a fracture to the area due to how the residents foot was moving. She stated resident never showed any sign of pain at all during the entire incident. She stated EMS transferred resident to the hospital. She stated she called the hospital and was informed that resident had a fractured right foot. She stated she and the ADM received statements from all staff who was had worked and found that none of the staff at the facility or

Based on observation, interview and record review the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated this was not possible or the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 6 of 6 Residents (Residents #4, Resident # 5, Resident # 6, Resident # 7, Resident # 8 and Resident # 9) reviewed for nutrition status maintenance. The facility failed to ensure Resident #4 weights were obtained and monitored and interventions were addressed or implemented for his weight lossThe facility failed to obtain and monitor new residents (Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) weights according to the facility policy to ensure weight loss and nutritional status were not compromised. These failures could place residents at risk of losing weight and result in unplanned weight loss and a decline in the residents' overall health.Findings include: Observation on 5/14/26 at 5:20 PM revealed Resident # 4 being weighed with a mechanical lift by MA M and AD/CNA L with Resident #4 weight of 136.6 lbs. displayed on the scale reading. 1. Record review of Resident #4 admission face sheet, dated 5/14/26, reflected a 71-year-olf male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included cerebral infarction (stroke), type 2 diabetes (a chronic condition where your body either doesn't produce enough insulin or resists it), spastic hemiplegia affecting right dominant side (a common subtype of spastic cerebral palsy that causes muscle stiffness, weakness, and involuntary contractions on just the right side of the body), aphasia following cerebral infarction (a neurological language disorder caused by damage to the brains language centers), encephalopathy (a broad term for any disease, damage, or malfunction of the brain), CHF (a chronic progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently throughout the body), and attention and concentration deficit following cerebral infarction. Record review of Resident #4's admission Comprehensive MDS, dated [DATE], section GG reflected under heading Eating, resident was dependent on staff for eating. Record review of Resident # 4 Baseline Care plan, dated 3/27/26, reflected Resident # 4 required substantial/maximal assistance for eating. Resident # 4 was cognitively impaired. Under dietary/nutritional status reflected the residents' dietary goal was to maintain current weight and prevent weight loss. Risks of weight loss, swallowing problems, and chewing problems Record review of Resident #4's Comprehensive Care plan, dated 4/14/26, reflected ADL staff assist r/t hemiplegia affecting right dominant side, recent CVA, mood decline, encephalopathy, CHF, diabetes, A-fib (rapid irregular heart rate), aphasias, swallowing disorder, and impaired mobility. Eating: The resident is dependent on 1 staff for eating. Further review reflected the resident has diabetes mellitus. Dietary consultation for nutritional regimen and ongoing monitoring. Record review of Nutrition Risk Assessment, dated 4/7/26, reflected the most recent weight documented was 154 lbs. Hospital records documented weight of 160 lbs. Resident has dysphagia (swallowing disorder) diagnosis on mechanical soft texture diet. Resident requiring assistance/supervision while eating per documentation. No significant weight changes currently. Record review of Resident #4's weights and vitals documentation reflected weight 154 lbs. dated 3/27/26. and weight of 154 lbs. dated 5/7/26. No other weights documented. Record review of Resident #4's Clinical physician orders, dated 5/14/26, reflected no orders for scheduled weights to be obtained or monitored. During an interview on 5/15/25 at 2:10 PM with the ADON revealed she was aware of Resident # 4's weight loss it had been brought up and the resolution was for the CNAs and therapy staff to sit and feed him. The ADON stated Resident #4 had been going to the dining room but had behaviors or exposing himself while in the dining room so he was now being fed in his room. ADON stated she did not think Resident #4's weight loss was expected. The ADON stated the facility had probably not been getting resident weights because of low staffing. The ADON stated it was her expectation that the nurse would obtain resident weights and would designate 1-2 people to complete all weights for consistency and accuracy. The ADON stated resident weights were supposed to be obtained and entered before the 7th day of the month. The ADON stated she would expect staff to track resident weights and make sure they were accurate. The ADON stated she would expect training to be completed to make sure staff knew what they were doing when it came to obtaining resident weights, so the results were consistent and there weren't any gaps. The ADON stated hospice services were discussed with the family previously, but the family had declined them at that time. The ADON stated hospice services would likely be discussed in the future due to disease process contributing to weight loss and refusal of food. The ADON stated resident documentation should be consistent and accurate because it triggered tasks and follow up actions. The ADON stated staff should stay on top of documentation and interventions by adding a house shake or additional supplement. The ADON stated she could not say for sure as to what documentation or tasks triggered Resident #4 currently had. The ADON stated if weight loss was noticed the next steps were to notify the dietician and get recommendations, notify the physician, notify the family to obtain preferences and cultural accommodations, request health shakes and preferred snacks from dietary, assistance with feeding consistently using the same staff, if possible, to maintain baseline knowledge of condition. The ADON stated she was not immediately familiar with the facility policy and procedures for obtaining/maintaining weights. The ADON stated she was told any orders would automatically populate to the EMAR when it was time for weights to be obtained. ADON stated she did not feel Resident # 4 weight loss has negatively impacted the resident's health status. The ADON stated Resident #4 was still up and with it, not in distress, appeared comfortable, with a little anxiety but nothing so alarming that she felt he needed to be sent out to the emergency room for evaluation. The ADON stated it could negatively impact a resident if weights were not obtained or monitored, because it could lead to serious injury or death. The ADON stated weights were consistently needed to correctly ascertain a resident's status and condition. During an interview on 5/15/26 at 3:37 PM with the MD revealed he was made aware of Resident #4's weight loss earlier this week while in the facility and had relayed to the NP to follow up. The MD stated he was unaware of Resident #4 weight loss prior to this week. The MD stated it was his expectation that resident weights be obtained once a week for new admissions and at regular intervals. During an interview on 5/15/26 at 3:41 PM with Resident # 4's RP revealed she was not aware of Resident # 4 significant weight loss The RP stated when she asked if Resident # 4 had eaten, she was always told yes. During an interview on 5/15/26 at 4:00 PM with NP revealed she had recently had discussion with Resident # 4's FM and the facility staff about the resident's decline. The NP stated Resident #4's weight loss was expected due to disease process. c During an interview on 5/15/26 at 5:45 PM with RNC revealed she was not aware of Resident #4's weight loss until yesterday (5/14/26) because both weights that were entered into the electronic health record were the same. The RNC stated she had already been made aware the weight system was broken and implemented action in April of 2026. The RNC stated Resident #4's weight loss was not expected but he did have dysphasia and had a stroke previously so it could have been possibly expected. The RNC stated she was not as familiar with this resident so after thinking about it with his diagnosis, the RNC stated she was changing her previous answer to reflect Resident #4's weight loss was probably expected. The RNC stated every resident should have weights obtained monthly unless there were special conditions or prior weight loss that indicated weights needed to be obtained more often but at a minimum, they should be obtained monthly. The RNC stated interventions should have been in place for Resident #4 if the facility was aware of the weight loss. The RNC stated the care plan was updated today and the RD had also seen the resident and ordered supplements. The RNC stated the only time there were physician orders for weights was if the weights were out of the ordinary scheduled monthly weights. The RNC stated if a resident had weight loss, the MD, RD, and DON should be notified to address the weight loss. The RNC stated monthly weights were completed by the 7th of the month and the DON should run a report and see who triggered for significant weight loss and the IDT team should be notified to address the weight loss. The RNC stated the staff were trained on facility systems and policy and procedures upon hire and the DON and ADON completed the training. The RNC stated it could negatively affect a resident if weights were not obtained timely and accurately because it was hard to look at someone and be able to tell if they lost weight. The RNC stated the negative impact could be malnutrition and overall systems effect. During an interview on 5/15/26 at 6:02 PM with the ADM revealed she was aware of Resident #4's weight loss. The ADM stated she was informed the resident was not eating. The ADM stated she had spoken with the ADON to ensure Resident #4 was being brought to the dining room for all meals after therapy brought the weight loss to her attention on Monday 5/11/26. The ADM stated it was her expectation the resident weights were obtained monthly and more if the RD or MD requested more often and the staff followed the facility policy regarding weights. The ADM stated she was not a clinical person, but she expected Resident #4 to have some weight loss because of his overall condition. The ADM stated there should be interventions for weight loss if the weight loss was known. The ADM stated the RD, MD, and DON should be notified of weight loss. The ADM stated obtaining weights was primarily delegated to the CNAs to obtain. The ADM stated she was unsure if the weight loss would negatively impact Resident #4 since she was not a clinical person but stated anytime someone was not eating there could be a negative impact. The ADM stated Resident #4's weight loss may have been expected due to diagnosis. The ADM stated not obtaining resident weights could negatively impact because residents could become ill and not get the nutrients needed for the body to be healthy. 2. Record review of Resident # 5 admission face sheet, dated 5/15/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included cerebral infarction (stroke), epilepsy (chronic neurological disorder characterized by recurrent unprovoked seizures), hypertension (elevated blood pressure), aphasia following cerebral infarction (a language disorder caused by damage to the brains language centers following a stroke), dysarthria (speech disorder), dysphagia (swallowing disorder), ataxia (lack of voluntary muscle coordination and control), cognitive communication deficit (an impairment in communication caused by a disrupted thinking process rather than a direct physical issue), emphysema (a progressive lung disease that damages the tiny air sacs in your lungs), atherosclerotic heart disease (a condition in which the arteries that supply blood to your heart become narrowed or blocked by plaque), and displaced fracture of right femur (right hip fracture). Record review of Resident #5's admission Comprehensive MDS, dated [DATE], reflected a BIMS score of 3, which indicated severe cognitive impairment. Resident # 5 required set up or clean up assistance for eating. Record review of Resident #5's Clinical physician orders, dated 5/15/26, reflected no orders for scheduled weights to be obtained or monitored. Record review of Resident #5's weights and vitals documentation reflected a weight of 102.4 lbs., dated 4/30/26 and weight of 105 lbs. dated 5/12/26. No other weights documented. 3. Record review of Resident # 6's admission face sheet, dated 5/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included cerebral infarction (stroke), unspecified dementia (when a patient has clear cognitive decline and memory loss but the exact underlying cause cannot be determined), sepsis (the body's extreme life-threatening response to an infection), thyrotoxicosis (a condition caused by excess thyroid hormones in the bloodstream), hyperlipidemia (fat particles in the blood), type 2 diabetes (a chronic metabolic condition where the body either resists the effects of insulin or doesn't produce enough insulin causing sugar to buildup in the bloodstream), depression (a serious mental health condition that causes a persistent feeling of sadness, loss of interest, and a wide range of emotional and physical symptoms), CHF (a chronic progressive condition where the heart muscle becomes to weak or stiff to pump blood efficiently), hypertension (elevated blood pressure), COPD (a progressive lung disease that causes obstructed airflow and makes breathing difficult), atrial fibrillation (a heart rhythm disorder), peripheral vascular disease (circulation disorder), and GERD (acid reflux). Record review of Resident #6's admission Comprehensive MDS, dated [DATE], reflected a BIMS score of 8, which indicated moderate cognitive impairment. Resident # 6 was independent for eating. Record review of Resident #6's Clinical physician orders, dated 5/15/26, reflected no orders for scheduled weights to be obtained or monitored. Record review of Resident #6's weights and vitals documentation reflected weight of 216 lbs., dated 4/29/26, and a weight of 179 lbs., dated 5/13/26. No other weights documented. 4. Record review of Resident #7's admission face sheet, dated 5/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included traumatic subdural hemorrhage with loss of consciousness (a life-threating brain injury where blood leaks and pols between the surface of the brain and the brains tough outer covering following a head impact), anemia (low blood iron), protein-calorie malnutrition, hyperlipidemia (fat particles in the blood), fluid overload, unspecified dementia (when a patient has clear cognitive decline and memory loss but the exact underlying cause cannot be determined), hypertension (elevated blood pressure), heart failure, COPD (a progressive lung disease that causes obstructed airflow and makes breathing difficult), chronic kidney disease stage 4, BPH (enlarged prostate), atrial fibrillation (a heart rhythm disorder), thrombocytosis (a condition where the blood produces to many platelets and is too thick), right hip pain, hypoxemia (low blood oxygen levels), abdominal aortic aneurysm without rupture (a [NAME] like bulge in the lower part of the aorta the body's main artery), and syncope with collapse (fainting with collapse). Record review of Resident #7's admission Comprehensive MDS, dated [DATE], reflected a BIMS score of 8, which indicated moderate cognitive impairment. Resident # 7 required setup or clean up assistance for eating. Record review of Resident #7's Clinical physician orders, dated 5/15/26, reflected no orders for scheduled weights to be obtained or monitored. Record review of Resident #7 weights and vitals documentation reflected weight of 145.2 lbs., dated 4/24/26, and weight of 143.6 lbs., dated 5/3/26. No other weights documented. 5. Record review of Resident #8's admission face sheet, dated 5/15/26, reflected an 84 -year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8 had diagnoses which included moderate protein calorie malnutrition, type 2 diabetes (a chronic metabolic condition where the body either resists the effects of insulin or doesn't produce enough insulin causing sugar to buildup in the bloodstream), hyperlipidemia (fat particles in the blood), dementia (a decline in mental ability severe enough to interfere with daily life), Alzheimer's disease (a progressive irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), hypertension (elevated blood pressure), GERD (acid reflux), history of falling, and neuromuscular bladder dysfunction (nerve damage that impairs bladder storage and emptying). Record review of Resident #8's Comprehensive care plan, dated 4/2/24, reflected the resident required assistance with ADLs. Record review of Resident #8's Clinical physician orders, dated 5/15/26, reflected no orders for scheduled weights to be obtained or monitored. Record review of Resident #8's weights and vitals documentation reflected weight of 126.2 lbs., dated 3/5/26, and weight of 130 lbs., dated 5/12/26. No other weights documented. 6. Record review of Resident #9's admission face sheet, dated 5/15/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included CHF (a chronic progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently), malignant neoplasm of brain (brain cancer), anemia (low blood iron), hypothyroidism (underactive thyroid), hyperlipidemia (elevated fat particles in the blood), depression (a serious mental health condition that causes a persistent feeling of sadness, loss of interest, and a wide range of emotional and physical symptoms), Alzheimer's disease (a progressive irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), meningitis (inflammation of the meninges which are protective membranes surrounding the brain and spinal column), hypertension (elevated blood pressure), GERD (acid reflux), chronic kidney disease stage 2, osteoarthritis (arthritis that occurs when the cartilage that cushions the ends of your bones gradually breaks downs causing movement to become painful), anxiety disorder, osteoporosis (brittle bones), and non- [NAME] lymphoma (lymphatic cancer). Record review of Resident #9's Comprehensive care plan, dated 3/29/26, reflected the resident required assist in all ADLs with eating requiring assistance by 1 staff. Resident #9 had impaired cognition r/t Alzheimer's with a BIMS score of 2, which indicated severe cognitive impairment. Record review of Resident #9's Clinical physician orders, dated 5/15/26, reflected no orders for scheduled weights to be obtained or monitored. Record review of Resident #9's weights and vitals documentation reflected weight of 147.6 lbs., dated 4/5/26 and weight of 150 lbs., dated 5/12/26. No other weights documented. Record review of Weight Assessment and Intervention policy, dated 3/2022 with a revision date of 5/12/25, reflected under heading policy statement: Resident weights are monitored for undesirable or unintended weight loss or gain.Under heading policy Interpretation and Implementation:Residents are weighed upon admission or readmission and weekly for four weeks, as determined by the Interdisciplinary Team (IDT) and monthly thereafter.Weights are recorded in the resident's electronic health record.Any weight change of 5 pounds or more since the last weight assessment will be reweighed for confirmation.Monthly weights will be obtained by the 7th of each month, reweighs within 48 hours. The dietitian will review monthly weights and will intervene as needed.The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]:1 month - 5% weight loss is significant; greater than 5% is severe.3 months - 7.5% weight loss is significant; greater than 7.5% is severe.6 months - 10% weight loss is significant; greater than 10% is severe.If the weight change is desirable, this is documented, and no change in the care plan will be necessary.If a resident has significant unplanned weight change, all pertinent members of the interdisciplinary team (IDT) are made aware with the month.Heights will be obtained on admission and annually.

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 3 residents (Resident #2, Resident #3 and Resident #4) reviewed for quality of life.The facility failed to ensure Resident #2, Resident #3 and Resident #4 received regular showers.This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes, and decreased self-esteem.Findings include:1. Record review of Resident #2's face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, respiratory failure, hypertension (high blood pressure), cognitive communication deficit (problems with communication), and difficulty in walking. Record review of Resident #2's admission MDS assessment, dated 03/02/2026, reflected Resident #2 had a BIMS score of 99, which indicated unable to complete the interview. The MDS also revealed Resident #2 required supervision or touching assistance for showers. Record review of Resident #2's Care Plan, dated 04/03/26, reflected [Resident #2] required assistance with ADLs related to traumatic brain injury, and chronic respiratory failure. Interventions were: Provide extensive assistance of one staff with bathing/showering. Provide showers/bathing per schedule and PRN. Record review of Resident #2's shower log, dated April 2026, reflected Resident #2 did not get her showers on 04/04/2026, 04/09/2026, 04/14/2026, 04/18/2026, 04/23/2026, 04/25/2026 and 04/28/2026. During an interview with Resident #2 on 04/30/2026 at 2:04 p.m., she said she still was not getting her showers regularly. She said she asked staff for her shower and she never got it. She said she wanted her showers regularly. She said she did not feel good when she could not take a shower. Resident #2 did not have an odor and appeared to be clean. 2. Record review of Resident #3's face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), obesity, heart failure, respiratory failure, depression (mood disorder that causes a persistent feeling of sadness), chronic pain, obstructive sleep apnea (breathing pauses while sleeping), and lack of coordination. Record review of Resident #3's admission MDS assessment, dated 04/04/2026, reflected Resident #3 had a BIMS score of 15, which indicated intact cognitive response. The MDS also revealed Resident #2 required supervision or touching assistance for showers. Record review of Resident #3's Care Plan, dated 04/03/26, reflected [Resident #3] is at risk for skin breakdown related to decreased mobility, incontinence, equipment, and nutritional status. The resident requires staff assistance with ADL's. Interventions were Provide shower/bed bath per schedule and PRN. [Resident #3] needs assist of (1 - 2) staff to transfer with assist of wheelchair, shower chair. Once resident is stable with wheelchair/shower chair resident needs assist of 1 to 2 staff for mobility out of the room. Record review of Resident #3's shower log, dated 04/2026, reflected Resident #3 did not get his showers on 04/02/2026, 04/04/2026, 04/09/2026, 04/11/2026, 04/14/2026, 04/18/2026, 04/21/2026, 04/23/2026, 04/25/2026 and 04/28/2026. During an interview with Resident #3 on 04/29/2026 at 04:00 p.m., he said he still had not gotten a shower. He said he was around a lot of ladies and did not want to smell bad. He said a man his size will smell if not cleaned. He said he felt like there was not enough staff for to give showers regularly. He did not have an odor however his shirt was dirty. 3. Record review of Resident #4's face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included Cardiomegaly (enlarged heart), hypomagnesemia (electrolyte disorder), muscle weakness, lack of coordination and heart failure. Record review of Resident #4's admission MDS assessment, dated 03/25/2026, reflected Resident #4 had a BIMS score of 15, which indicated intact cognitive response. The MDS also revealed Resident #2 required supervision or touching assistance for showers. Record review of Resident #4's Care Plan, dated 03/20/26, reflected [Resident #4] was wheelchair bound and did not have any information on showers. The care plan also said the resident required substantial to max assess of 1-2 staff with use of gate belt to move between surfaces when transferring. Record review of Resident #4's shower log reflected she did not get her showers on 04/02/2026, 04/04/2026, 04/07/2026, 04/09/2026, 04/11/2026, 04/14/2026, 04/16/2026, 04/18/2026, 04/21/2026, 04/23/2026 and 04/28/2026. During an interview with Resident #4 on 04/29/2026 at 04:24 p.m., she said she last got a shower on 04/25/2026. She said she had to wipe herself down to prevent herself from having skin issues. She said she wanted to take her showers regularly. She said it upset her because she could not get her showers. During an interview with CNA E on 04/29/2026 at 1:25 p.m., she said she had been trained on ADL care and resident rights. She said the policy for showers was that all residents were to get three showers a week and PRN. She said the CNAs were responsible for giving the residents their showers. She said if the residents did not get their showers regularly the resident may feel terrible. She said she got a lot of complaints from the residents about not getting their showers. She said the nurse and the DON monitored to ensure residents were getting their showers. She said the nurse and DON monitored through observations. She said some residents were not getting their showers because at one point there were only two CNA for 63 residents. She also added no residents refused their showers. She said she did not know why Resident #2, Resident #3 and Resident #4 did not get their showers regularly. During an interview with CNA G on 04/29/2026 at 1:39 p.m., she said she was trained on ADL care and resident rights. She said the policy for showers was that all residents were to get three showers a week. She said the CNAs were responsible for giving the residents their showers. She said if the residents did not get their showers regularly the resident may get a rash or infection. She said she got a lot of complaints from the residents about not getting their showers. She said if it was a resident who was assigned to her she would try to find a way to fit them in. She said the nurse and the DON monitored to ensure residents were getting their showers. She said the nurse and DON monitored through observations. She said Resident #2, Resident #3 and Resident #4 did not get their showers regularly due to the lack of staff. During an interview with CNA F on 04/29/2026 at 3:44 p.m., she said she was trained on ADL care and resident rights. She said the policy for showers was that all residents were to get three showers a week. She said the CNAs were responsible for giving the residents their showers. She said if the residents did not get their showers regularly the resident may feel awful because they could not take a shower. She said she got a lot of complaints from the residents about not getting their showers. She said she would tell the resident she would do her best to get them their shower. She said the nurse monitored to ensure residents were getting their showers. She said the nurse monitored through observations. She said Resident #2, Resident #3 and Resident #4 did not get their showers regularly because the facility did not have enough staff. During an interview with the DON on 05/01/2026 at 11:58 a.m., she said she was trained on ADLs. She said the policy was the staff should give the showers three times a week. She said depending on the resident's preference the shower should be given during the day or at night. She said it was the responsibility of the entire nursing team to ensure residents were getting their showers. She said the resident could have skin breakdown, increased wounds, or body odors if they did not get showers regularly. She said the nurse, ADON and DON monitored to ensure the staff gave the residents showers. She said the charge nurse, ADON and DON monitored by checking the residents' charts. She said she did not know why Resident #2, Resident #3 and Resident #4 were not getting their showers regularly. During an interview with the ADM on 05/01/2026 at 1:34 p.m., she said she was trained on ADLs and resident rights. She said the policy for showers was that the residents were to have showers according to their preference day; so, they had good grooming and hygiene. She said the direct care staff were responsible for providing the residents with showers. She said the residents should be getting showers three times a week. She said if the residents did not get their shower, they could become sick or not have good hygiene. She said the DON monitored to ensure residents got their showers. She said the DON monitored by documentation from the CNAs shower log and observations. She said she did not know why Resident #2,Resident #3 and Resident #4 were not getting their showers regularly. Record review of Activities of Daily Living, Supporting Policy, dated 2/2025, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs Independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Record review of Grievances for April 2026 reflected six grievances about nursing services. All six complaints were regarding medications being late and some had showers not being done on them. Record review of the Bath, Shower, Tub Policy, dated 2/2018, reflected The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The staff member will initial and date the shower/tub bath was performed. All evaluation data (any reddened areas, or sores, on the resident's skin) obtained during the shower/tub bath. If the resident refused the shower/tub bath, the reason(s).

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for pharmacy services. 1. The facility failed to ensure medications were administered in a timely manner to Resident #1. 2. The facility failed to ensure medications were administered in a timely manner to Resident #2. 3. The facility failed to ensure medications were administered in a timely manner to Resident #3. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. Findings include: 1. Record review of Resident #1's face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), type 2 diabetes mellitus with unspecified complications (high blood sugar), morbid obesity, Alzheimer's disease (progressive disease that destroys memory and other important mental function), and heart failure. Record review of Resident #1's admission MDS assessment, dated 03/01/2026, reflected Resident #1 had a BIMS score of 06, which indicated severe cognitive impairment. Record review of Resident #1's physician orders, dated 2/27/2026, Quetiapine Fumarate Oral Tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Sundowning. Record review of Resident #1's MAR reflected Quetiapine Fumarate Oral Tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Sundowning was scheduled to be given at 8:00 p.m. The MAR also revealed staff did not give Resident #1 her Quetiapine Fumarate Oral Tablet 25 mg until 10:03 p.m. on 2/27/2026. Record review of Resident #1's Care Plan, dated 03/08/26, reflected [Resident #1] had impaired cognitive function and impaired thought processes related to Alzheimer's, vascular dementia. Interventions were: Administer medications as ordered. Monitor/document for side effects and effectiveness. During an interview with FM of Resident #1 on 04/29/2026 at 2:45 p.m., revealed the facility was not giving Resident #1 her sundowning medication on time. He said there were times when Resident #1 would not get her medication until 10:00 p.m. or 11:00 p.m., and the medication would not be affected. 2. Record review of Resident #2's face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, respiratory failure, hypertension (high blood pressure), cognitive communication deficit (problems with communication), and difficulty in walking. Record review of Resident #2's admission MDS assessment, dated 03/02/2026, reflected Resident #2 had a BIMS score of 99, which indicated unable to complete the interview. Record review of Resident #2's Care Plan, dated 04/03/26, reflected [Resident #2] had a seizure disorder. Interventions were Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Record review of Resident #2's physician orders, dated 4/24/2026, levetiracetam oral tablet 2000 mg given by mouth twice a day. Record review of Resident #2's MAR revealed levetiracetam oral tablet 2000 mg given by mouth twice a day for seizures was scheduled to be given at 8:00 a.m. The MAR also revealed staff did not give Resident #2 her levetiracetam oral tablet 2000 mg until 12:56p.m. on 04/26/2026. During an interview with Resident #2 on 04/30/2026 at 2:04p.m., she said she was not getting her seizure medication on time. She said there were times she would not get her morning medication until the afternoon. She said the staff were always late giving her medication. 3. Record review of Resident #3 face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), obesity, heart failure, respiratory failure, depression (mood disorder causing a persistent feeling of sadness), chronic pain, obstructive sleep apnea (breathing pauses while sleeping), and lack of coordination. Record review of Resident #3's Care Plan, dated 04/03/26, reflected [Resident #3] is at risk for chest pains, irregular pulse, edema (swelling) and adverse reaction related to medication due to history of cardiovascular disease. Interventions were Provide medications as ordered. Check vital signs prior to giving as ordered. Record review of Resident #3's admission MDS assessment, dated 04/04/2026, reflected Resident #3 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #3's physician orders, dated 03/03/2025, apixaban oral tablet 5mg (Apixaban) give 1 tablet by mouth two times a day for paroxysmal atrial fibrillation. Record review of Resident #3's MAR revealed apixaban oral tablet 5mg (Apixaban) was scheduled to be given at 8:00 a.m. The MAR also revealed staff did not give Resident #3 his levetiracetam oral tablet 2000 mg until 01:03p.m. on 04/15/2026. Resident #3 was also scheduled to get apixaban oral tablet 5mg (Apixaban) was scheduled to be given at 4:00 p.m. Resident #3 did not get his apixaban oral tablet 5mg (Apixaban) was scheduled to be given at until 6:41 p.m. on 04/15/2026. During an interview with Resident #3 on 04/29/2026 at 10:59a.m., he said staff did not give him his mediations on time. He said he mentioned it to the administrator. He said the nurse did not have time to pull out the medications and take care of the resident because the facility did not have enough staff. During an observation and interview with LVN C administering medication on 4/30/2026 at 10:47 a.m., he said he was still passing 8:00a.m. medications. Observation of LVN C at the time revealed he was still giving medications to residents. During an interview with LVN C on 04/30/2026 at 9:14 a.m., revealed he was trained on medication administration. He said the policy was medications had to be given within one hour before and one hour after the scheduled time. He said the nurses were responsible for giving the medication to the residents on time. He said if medication was not given on time the resident may have an adverse effect. He said he did not think anyone monitored to ensure medication was given timely. He said he was late passing medications due to having to take care of residents. He said he did not feel like the facility had enough staff for him to get medications out on time. During an interview with RN D on 04/30/2026 at 8:24 a.m., she said she was trained on medication administration. She said the policy was medication was supposed to be given within an hour of the scheduled time. She said the nurse was responsible for giving medication to the residents on time. She said if medication was not given timely some medication may not be affective. She said she had gotten a lot of complaints about medications being late. She said the DON monitored to ensure medication was given timely. She said the DON monitored by checking the MARs. She said medications were late because she would come in because someone called in and she would get a late start passing medications. During an interview with the DON on 05/01/2026 at 12:07 p.m., she said she was trained on medication administration. She said the policy was to give medication as ordered, no pre-popping pills, medication was to be given an hour before and an hour after to be compliant. She said the charge nurses were responsible for ensuring the residents were getting their medication on time. She said if the resident was not given their medication on time; depending on what medication it was it could make the medication not affective. She said the ADON and DON monitored to ensure the residents were getting their medication on time. She said they monitored by checking the MAR and making sure medication was given on time. She said she did not know why LVN C and RN D were not giving medications on time to residents. During an interview with the ADM on 05/01/2026 at 1:42 p.m., she said she was trained on medication administration. She said the policy was to give medication to the right patient, the right dose, the right time, and staff were to make sure the resident took the medication and. She said the staff were to give the medication at the prescribed time and the staff had an hour before an hour after the scheduled time. She said the nurse was responsible for ensuring the residents got their medications on time. She said the DON and ADM monitored to ensure staff were giving medication on time. She said the DON and ADON monitored by checking documentation. She said if the residents did not get their medication on time they could become ill. She said she did not know why LVN C and RN D were not giving medication on time. Record review of the Administering Medications Policy, dated 04/2019, reflected Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frames. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on interview and record review the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for grievances.The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance.Findings Included:1. Record review of Resident #1 face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), type 2 diabetes mellitus with unspecified complications (high blood sugar), morbid obesity, Alzheimer's disease (progressive disease that destroys memory and other important mental function), and heart failure. Record review of Resident #1's admission MDS assessment, dated 03/01/2026, reflected Resident #1 had a BIMS score of 06, which indicated severe cognitive impairment. Record review of Resident #1's physician orders, dated 2/27/2026, reflected Quetiapine Fumarate Oral Tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Sundowning. Record review of Resident #1's MAR reflected Quetiapine Fumarate Oral Tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Sundowning (increased confusion, agitation and restlessness typically occurs in the afternoon) was scheduled to be given at 8:00p.m. The MAR also revealed staff did not give Resident #1 her Quetiapine Fumarate Oral Tablet 25mg until 10:03p.m. on 2/27/2026. Record review of Resident #1's Care Plan, dated 03/08/26, reflected [Resident #1] had impaired cognitive function and impaired thought processes related to Alzheimer's, vascular dementia. Interventions were: Administer medications as ordered. Monitor/document for side effects and effectiveness. During an interview with FM of Resident #1 on 04/29/2026 at 2:45 p.m., revealed the facility was not giving Resident #1 her sundowning medication on time. He said there were times when Resident #1 would not get her medication until 10:00 p.m. or 11:00 p.m., and the medication would not be affected. 2. Record review of Resident #2 face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, respiratory failure, hypertension (high blood pressure), cognitive communication deficit (problems with communication), and difficulty in walking. Record review of Resident #2's admission MDS assessment, dated 03/02/2026, reflected Resident #2 had a BIMS score of 99, which indicated unable to complete the interview. The MDS also reflected Resident #2 required supervision or touching assistance for showers. Record review of Resident #2's Care Plan, dated 04/03/26, reflected [Resident #2] had a seizure disorder. Interventions were Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. [Resident #2] required assistance with ADLs related to traumatic brain injury, and chronic respiratory failure. Interventions were: Provide extensive assistance of one staff with bathing/showering. Provide showers/bathing per schedule and PRN. Record review of Resident #2's MAR revealed levetiracetam oral tablet 2000 mg given by mouth twice a day for seizures was scheduled to be given at 8:00 a.m. The MAR also reflected staff did not give Resident #2 her levetiracetam oral tablet 2000 mg until 12:56 p.m. on 04/26/2026. Record review of Resident #2's shower log, dated April 2026, reflected Resident #2 did not get her showers on 04/04/2026, 04/09/2026, 04/14/2026, 04/18/2026, 04/23/2026, 04/25/2026 and 04/28/2026. During an interview with Resident #2 on 04/30/2026 at 2:04 p.m., she said she was not getting her seizure medication on time. she said there were times she would not get her morning medication until the afternoon. She said the staff were always late giving her medication. She said she still was not getting her showers regularly. She said she had asked staff for her shower and she never got it. She said she wanted her showers regularly. She said she did not feel good when she could not take a shower. 3. Record review of Resident #3 face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), obesity, heart failure, respiratory failure, depression (mood disorder causing a persistent feeling of sadness), chronic pain, obstructive sleep apnea (breathing pauses while sleeping), and lack of coordination. Record review of Resident #3's admission MDS assessment, dated 04/04/2026, reflected Resident #3 had a BIMS score of 15, which indicated intact cognitive response. The MDS also revealed Resident #2 required supervision or touching assistance for showers. Record review of Resident #3's Care Plan, dated 04/03/26, reflected [Resident #3] Resident is at risk for chest pains, irregular pulse, edema (Swelling) and adverse reaction related to medication due to history of cardiovascular disease. Interventions were Provide medications as ordered. Check vital signs prior to giving as ordered. [Resident #3] is at risk for skin breakdown related to decreased mobility, incontinence, equipment, and nutritional status. The resident requires staff assistance with ADL's. Interventions were Provide shower/bed bath per schedule and PRN. [Resident #3] needs assist of (1 - 2) staff to transfer with assist of wheelchair, shower chair. Once resident is stable with wheelchair/shower chair resident needs assist of 1 to 2 staff for mobility out of the room. Record review of Resident #3's MAR reflected apixaban oral tablet 5mg (Apixaban) was scheduled to be given at 8:00 a.m. The MAR also reflected that staff did not give Resident #3 his levetiracetam oral tablet 2000 mg until 01:03 p.m. on 04/15/2026. Resident #3 was also scheduled to get apixaban oral tablet 5mg (Apixaban) was scheduled to be given at 4:00 pm. Resident #3 did not get his apixaban oral tablet 5mg (Apixaban) was scheduled to be given at until 6:41 p.m. on 04/15/2026. Record review of Resident #3's shower log, dated 04/2026, reflected Resident #3 did not get his showers on 04/02/2026, 04/04/2026, 04/09/2026, 04/11/2026, 04/14/2026, 04/18/2026, 04/21/2026, 04/23/2026, 04/25/2026, and 04/28/2026. During an interview with Resident #3 on 04/29/2026 at 10:59a.m., he said staff did not give him his mediations on time. He said he mentioned it to the administrator. He said the nurse did not have time to pull out the medications and take care of the resident because the facility did not have enough staff. He said he still had not gotten a shower. He said he was around a lot of ladies and did not want to smell bad. He said a man his size would smell if not cleaned. He said he felt like there was not enough staff for to give showers regularly. 4. Record review of Resident #4 face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #4's diagnoses included Cardiomegaly (enlarged heart), hypomagnesemia (electrolyte disorder), muscle weakness, lack of coordination and heart failure. Record review of Resident #4's admission MDS assessment dated [DATE] revealed that Resident #4 had a BIMS score of 15 indicating intact cognitive response. The MDS also revealed that Resident #2 was supervision or touching assistance for showers. Record review of Resident #4's Care Plan dated 03/20/26 reflected that Resident #4 was wheelchair bound and did not have any information on showers. The care plan also said the resident required substantial to max assess of 1-2 staff with use of gate belt to move between surfaces when transferring. Record review of Resident #4's shower log revealed she did not get her showers on 04/02/2026, 04/04/2026, 04/07/2026, 04/09/2026, 04/11/2026, 04/14/2026, 04/16/2026, 04/18/2026, 04/21/2026, 04/23/2026, and 04/28/2026. During an interview with Resident #4 on 04/29/2026 at 04:24 p.m., she said she last got a shower on 04/25/2026. She said she had to wipe herself down to prevent herself from having skin issues. She said she wanted to take her showers regularly. She said it upset her because she could not get her showers. During an interview with CNA E on 04/29/2026 at 1:25 p.m., she said she did not feel like the facility had enough staff for the CNAs to do their job. She said the facility took away the MAs, so she had to go to CNA. She said residents complained about getting medications on time and not getting their showers. She said residents were complaining about a couple of weeks. She said she told the ADM and DON and was told to do the best they could. During an interview with LVN C on 04/29/2026 at 9:14a.m., he said he did not feel like the facility had enough staff. He said they took the MAs away and now the nurses passed medication. He said doing wound care treatments were out of the question now. He said the facility said they had someone for treatments, but he was not sure. He said he had gotten complaints about medications being late, and showers not being given. He said he told the ADM and that he was told to do the best he could. During an interview with the DON on 05/01/2026 at 11:31 a.m., she said she was trained on ADLs. She said if staff showed up for work the facility would have enough staff. She said staff would be able to get medications out on time and showers done. She said she did not have the staff willing to do the work. She said she got complaints about showers, and she handled the complaints at that time. She said residents complained with medication being late and she would try to help the nurse and see what was going on. She said they were not getting a lot of grievances on showers or medications because most of them went directly to her. She said the ADON and the DON monitored to ensure the staff were doing their job. She said they checked the MAR and shower logs and other reports. She said she did not know why residents were not getting their showers she said it was just the aides. She said she did not know why the nurses could not get medication to the residents on time. She said with two nurses and three CNA's for 60 residents was do-able. During an interview with the ADM on 05/01/2026 at 1:27 p.m., she said the policy was to have adequate staff to take care of the residents. She said the ADM was responsible for ensuring there were staff who could provide for the resident. She said she felt like the facility hired enough staff and the staff did not show up and administration had to step in. She said the facility had an increase in the last month in grievances. She said she had not received anything outside of showers on the grievances. She had not received anything as far as medication grievances, but residents told her their medications had been late. She said the facility was hiring more staff. She said the facility was going to bring back the MA position. She said the ADM and the DON monitored to ensure staff were showing up and doing their job through staffing sheet, and a chat group that was used when someone called in. She said she had let corporate know about the staffing issue. She said they were hiring but people were not coming back. She said residents were not getting showers and medication on time because everyone needed to be responsible and do their job. During an interview with the Corporate Nurse on 05/01/2026 at 12:42p.m., revealed she had been trained on ensuring the facility had enough staff. She said the policy was staffing was based on what the residents' needs were such as how many residents needed assistance with dinging, how many tracheostomy, gastrostomy tubes, and a resident's level of care. She said she felt like the facility had enough staff to provide for the needs of the residents. She said she knew the building had been experiencing an increase in problems. She said the administrator and the DON were responsible for ensuring the staff were getting the job done and there were enough staff for the residents to get the care they needed. She said if the staff were not doing their job or enough staff the residents needs will not be met. She said if the facility had staffing concerns the ADM and DON would reach out to corporate. She said the ADM and DON had not reached out to her personally. She was not sure if they had reached out to anyone in corporate office. The corporate monitored by observation and watching the labor in the building. She said they were aware of issues in the building. Record review of Grievances for April 2026 reflected six grievances about nursing services. All six complaints were regarding medications being late and some had showers not being done on them.Record review of Staffing, Sufficient and Competent Nursing Policy, dated 8/2022, reflected Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.

Based on interview 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 and accurately documented for 3 of 3 residents (Resident #2, Resident #3 and Resident #4) reviewed for complete and accurate records. The facility failed to ensure RN D documented medications at the time administered to Resident #2, Resident #3, and Resident #4. This failure could place residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings include: 1. Record review of Resident #2 face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, respiratory failure, hypertension (high blood pressure), cognitive communication deficit (problems with communication), and difficulty in walking. Record review of Resident #2's admission MDS assessment, dated 03/02/2026, reflected Resident #2 had a BIMS score of 99, which indicated unable to complete the interview. Record review of Resident #2's Care Plan, dated 04/03/26, reflected [Resident #2] had a seizure disorder. Interventions were Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. During an interview with Resident #2 on 04/30/2026 at 2:04 p.m., she said she was not getting her seizure medication on time. She said there were times she would not get her morning medication until the afternoon. She said the staff were always late giving her medication. 2. Record review of Resident #3 face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3had diagnoses which included paroxysmal atrial fibrillation (irregular heartbeat that comes and goes), obesity, heart failure, respiratory failure, depression (mood disorder causing a persistent feeling of sadness), chronic pain, obstructive sleep apnea (breathing pauses while sleeping), and lack of coordination. Record review of Resident #3's Care Plan, dated 04/03/26, reflected [Resident #3] Resident is at risk for chest pains, irregular pulse, edema and adverse reaction related to medication due to history of cardiovascular disease. Interventions were Provide medications as ordered. Check vital signs prior to giving as ordered. Record review of Resident #3's admission MDS assessment, dated 04/04/2026, reflected Resident #3 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #3's MAR reflected RN D gave Resident #3 furosemide oral tablet 40 mg Give 1 tablet by mouth one time a day for edema at 5:09 a.m. but did not document she gave the medication until 6:09a.m. on 4/24/2026. During an interview with Resident #3 on 04/29/2026 at 10:59 a.m., he said staff did not give him his mediations on time and did not documents giving the medication until hours. He said he mentioned it to the administrator. He said the nurse did not have time to pull out the medications and took care of the resident because the facility did not have enough staff. 3. Record review of Resident #4's face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Cardiomegaly (enlarged heart), hypomagnesemia (electrolyte disorder), muscle weakness, lack of coordination and heart failure. Record review of Resident #4's admission MDS assessment, dated 03/25/2026, reflected Resident #4 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #4's Care Plan, dated 03/20/26, reflected [Resident #4] uses psychotropic medications related to depression. [Resident #4] is at risk of mood decline. Interventions were Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #4's MAR reflected RN D gave Resident #4 fluoxetine HCI oral capsule 40 mg give 1 capsule by mouth two times a day for depression at 08:22 a.m. but did not document she give the medication until 10:24 a.m. on 4/29/2026. During an interview with Resident #4 on 04/29/2026 at 04:24 p.m., she said staff did not give her mediations on time. She said she asked a few times about her medications. She said she did not know why she could not get her medications on time. During an interview with RN D 04/30/2026 at 8:24a.m., she said she was trained on medication administration documentation. She said the policy was medication administration documentation was medication was to be documented at the time given. She said the nurse was responsible for documenting medication at the time given. She said if medication was not documented at the time given staff did not have a true picture of what was going on. She also said if she did not document at the time given the other shift might give the medication again and cause an issue with the resident. She said the DON monitored to ensure medication was documented when given. She said the DON monitored by checking the MARs. She said she was trying to get Resident # 2, Resident #3 and Resident #4 their medications on time. During an interview with the DON on 05/01/2026 at 12:15 p.m., she said she had been trained on medication administration documentation. She said the policy for medication documentation was that the staff should be documented in the MAR when the medication was given. She said the nurse was responsible for documenting the medication when given. She said if the nurse did not document at the time the medication was given it could cause a resident to be over medicated because someone may think the resident did not get the medication. She said the DON and ADON monitored to ensure they were documenting at the time the medication was given. She said the DON and ADON monitored by checking the MAR. She said she did not know why RN D was not documenting at the time medication was given. During an interview with the ADM on 05/01/2026 at 1:45 p.m., she said she was trained on medication administration documentation. She said the policy for medication documentation was to document all medication given at the time it was given. She said the nurse or MA who was giving the medication was responsible for documenting the medication at the time given. She said if staff did not document at the time medication was given the staff member may not remember and give the resident the medication twice. She said the DON and ADM monitored to ensure staff were documenting at the time medication was given. She said the DON and ADM checked the MAR documentation. She said she did not know why RN D was not documenting at the time given. Record review of the Documentation of Medication Administration dated 11/2022 reflected A medication administration record is used to document all medications administered. nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record. Administration of medication is documented immediately after it is given.

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (MC #1, and MC #3) reviewed for drug storage and labeling.1. The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors.2. The facility failed to ensure MC #2, was locked, medications secured, and not accessible to other staff, residents, or visitors.These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include:Observation of hall four on 04/28/2026 at 5:27a.m., revealed LVN B was in a residents room with the door cracked open and the medication cart was along the wall unattended and unlocked.During an observation on 04/30/2026 at 7:30 a.m., revealed MC #1 revealed against the hall two walls unattended and unlocked. LVN A went down the hall three to do something leaving the medication cart unlocked and unattended. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box. Residents were walking past the medication cart.During an interview with LVN A on 04/30/2026 at 07:45a.m., she said she was trained on medication storage. She said the policy was staff must lock the medication carts any time the nurse walked away from the medication cart or turned their back. She said the nurse was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident could get into the medication cart and take medication that did not belong to them. She said the nurses monitored to ensure the medication carts were locked. She said the nurses monitored the medication carts through observation. He said she had left the medication cart unlocked because she was trying to get ready for the day and was not mindful of the cart.During an observation of the nurses' station on 05/01/2026 at 7:15 a.m., revealed MC #2 was up against the hall-one wall unattended and unlocked. LVN B was sitting at the nurses' station with her back to the medication cart. MC #2 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box. Staff and residents were passing by the medication cart.During an interview with LVN B on 04/30/2026 at 7:24 a.m., she said he was trained on medication storage. She said the policy for medication storage was to immediately lock the medication cart when not in use. She said the nurse or MA who was assigned to the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked or unattended an unknown person or a resident could get into the medication cart. She said the DON, ADON, ADM and peers monitored to ensure staff were locking the medication carts. She said the DON, ADON, ADM and peers monitored through observation. She said she did not lock her medication cart because she went to answer the phone. She added there was not an excuse for leaving the medication cart unlocked. She said she did not notice the state surveyor took pictures or opened the drawers on the medication cart.During an interview with the DON on 05/01/2026 at 12:07 p.m., she said she was trained on medication storage. She said the policy was if the medication cart was locked when staff were not attended to or when staff walked away from the medication cart. She said the nurse who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended someone could get into the medication cart and take medications. She said management monitored to ensure staff locked the medication cart. She said management monitored by doing observations. She said she did not know why LVN A and LVN B left the medication carts unlocked.During an interview with the ADM on 05/01/2026 at 1:38 p.m., revealed she was trained on medication administration. She said the policy for medication storage was that the medication cart was to always be locked. She said no medication was to be left on the medication cart and no medication left in the resident's room. She said the nurse who was on the medication cart or the MA on the cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended anyone could enter the cart and take medication or the facility could have a drug diversion. She said the DON monitored to ensure the staff were locking the medication cart. She said the DON monitored by doing observations. She said she did not know why LVN A and LVN B left the medication cart unlocked.Record review of Storage of Medications Policy, dated February 2023, reflected The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available others.

Based on interviews and observations, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication for 2 of 6 (Resident #1 and Resident #2) residents reviewed for resident rights; in that:The facility failed to ensure that Resident #1 and Resident #2 received their showers as scheduled.This failure could place residents at risk for decreased quality of life, isolation, and skin breakdown.Findings Included: Resident #1RR of Resident #1 face sheet revealed a [AGE] year-old male resident who admitted to the facility on [DATE] with diagnoses of multiple fracture of the pelvis (severe injuries, often resulting from high-energy trauma, that create unstable rings, causing intense pain, bleeding, and potential damage to internal organs), insomnia (inability to sleep), unstable burst fracture of T9-T10 vertebrae (a severe, high-energy injury where the bone shatters in multiple directions, potentially compromising the spinal canal and causing neurological damage), fracture of rib, dislocation of left wrist and hand, and displaced trimalleolar fracture of both legs (a severe, highly unstable injury involving fractures of the medial malleolus, lateral malleolus (fibula), and posterior malleolus (tibia), usually requiring urgent bilateral surgical reduction).RR of Resident #1 MDS record dated 02/15/2026 revealed that Resident #1 had a BIMS of 12, which indicate minimal cognitive impairment. The MDS also revealed that Resident #1 required maximum assist for toileting and showering needs. Maximum assist meant helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort of the task. An observation and interview was conducted on 04/07/2026 at 11:01AM with Resident #1 who was laying in their bed. Resident #1 appeared disheveled and unkempt. Resident #1 stated he hated the being at the facility. Resident #1 stated the staff do not offer showers or bed baths for him. He stated he had not received a shower in almost 2 weeks. Resident #1 stated that the care he received regarding lack of showers made him feel dirty and want to leave the facility.Resident #2RR of Resident #2 face sheet revealed a [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses of anxiety disorder, muscle weakness, wedge compression fracture of lumbar vertebrae (a common spinal injury where the front (anterior) part of a vertebra collapses, forming a wedge shape due to excessive pressure, often caused by osteoporosis, trauma, or tumors), and reduced mobility.RR of Resident #2 MDS record dated 03/29/2026 revealed that Resident #2 had a BIMS of 08, which indicate moderate cognitive impairment. The MDS also revealed that Resident #2 required maximum assistance for toileting and showering needs. Maximum assist meant helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort of the task. RR of daily shower list provided by the facility revealed:It is reported in the report that Resident #1 and Resident #2 is to shower on the evening shift on MWFThis document states all refusals are to be reported to the nurse and documented in POC/PCC. Nobody is allowed to make changes other than the DON or ADON.An interview was conducted on 04/07/2026 at 11:20AM with Resident #2 who was laying in bed. Resident #2 stated she does not often receive showers. Resident #2 stated her last shower had been more than 5 days prior. Resident #2 stated she did not know how it made her feel to not receive her showers.An interview was conducted on 04/07/2026 at 1:17PM with CNA A revealed they had received training on ADL care which included CNA's are responsible for providing a shower to residents. CNA A stated residents are offered a shower every other day, and if the resident refused a shower, it would be documented. CNA A also stated there would be no reason a resident did not receive a shower in almost 2 weeks unless they refused the shower. CNA A stated if a resident was not offered showers, it could impact them negatively by getting sores.An interview was conducted on 04/07/2026 at 1:23PM with CNA B revealed they had received training on ADL care which included CNA's are responsible for providing the showers to the residents. CNA B stated that residents are offered a shower 3 times a week, and if the resident refuses, it should be documented somewhere. She stated that a resident should not have been unshowered in almost 2 weeks. She stated it could negatively impact the residents hygiene and health concerns.An interview was conducted on 04/07/2026 at 1:30PM with RN C which revealed they had received training on ADL care which included that the CNA and hospice are responsible for the showers at the facility. She stated that residents are offered a shower 3 days a week. It should pop up in the Kardex for the aids to shower the residents. RN C stated if residents did not receive their showers in almost 2 week it could be the result of the resident refusing the shower and/or staffing levels were low. She said that it should be documented if residents had refused. She stated that residents may feel unsocial as well as their health and skin are at risk they had not received showers.An interview was conducted on 04/07/2026 at 1:36PM with the ADM which revealed she had received training on resident rights which included the residents had the right to be treated with dignity and respect. The ADM stated her policy regarding showers was that resident should receive their shower. They have a shower schedule that should be followed by 3 times a week. The ADM stated the nursing care team was responsible for providing showers to the residents. She stated that residents should be offered a shower 3-4 times a week, or at their leisure. She stated there would be no reason for a resident to not have received a shower in about 2 weeks. She stated that the resident could get bed sores and basic hygiene not being met. She stated they could get sick.An interview was conducted on 04/07/2026 at 1:51PM with the DON who stated she had received training on resident rights which had included residents have the right to proper care, be treated with dignity and the right to be clean. The DON stated she had received training on ADL care which included her expectation for showers were that staff provide showers 3 times a week or PRN. The DON stated that the CNA are mainly responsible for providing the showers to the residents. She stated that the resident could be affected mentally, their dignity as well and affect them in a negative way if they had not received their showers.RR of grievances filed provided by the facility revealed:03/17/2026 Resident care grievance: resident not being changed timely, soaking in urine.03/17/2026 resident care grievance: resident said she is not getting care timely as she should because short staffed. RR indicated the facility had conducted inservice training on the following care areas in January:Resident RightsRR of the facility provided policy titled Shower/Tub Policy undated revealed the following:The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on interviews and observations, the facility failed to ensure 1 of 6 residents (Resident #1) received services in the facility with reasonable accommodation of resident needs and preferences.Resident #1 had to wait 30 minutes for the call light to be answered, and according to Resident #1 had not received a shower in almost 2 weeks.This failure could place residents at risk of harm and/or isolation.Findings included:RR of Resident #1 face sheet revealed a [AGE] year-old male resident who admitted to the facility on [DATE] with diagnoses of multiple fracture of the pelvis (severe injuries, often resulting from high-energy trauma, that create unstable rings, causing intense pain, bleeding, and potential damage to internal organs), insomnia (inability to sleep), unstable burst fracture of T9-T10 vertebrae (a severe, high-energy injury where the bone shatters in multiple directions, potentially compromising the spinal canal and causing neurological damage), fracture of rib, dislocation of left wrist and hand, and displaced trimalleolar fracture of both legs (a severe, highly unstable injury involving fractures of the medial malleolus, lateral malleolus (fibula), and posterior malleolus (tibia), usually requiring urgent bilateral surgical reduction).RR of Resident #1 MDS record dated 02/15/2026 revealed that Resident #1 had a BIMS of 12, which indicate minimal cognitive impairment. The MDS also revealed that Resident #1 required maximum assist for toileting and showering needs. Maximum assist meant helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort of the task. An observation conducted on 04/07/2026 at 11:00AM revealed Resident call light was lit above their door.An observation and interview was conducted on 04/07/2026 at 11:01AM with Resident #1 who was laying in their bed. Resident #1 appeared disheveled and unkempt. Resident #1 stated he hated the being at the facility. Resident #1 stated he felt like that because he had to wait multiple hours, approximately 3 hours, before he got assistance. Resident #1 stated often the staff would respond to his call light but would tell him someone will come and help you but staff do not return. Resident #1 stated he had pushed his call light about 10 minutes before INV conducted the interview.An observation was conducted on 04/07/2026 at 11:18AM of Resident #1's call light lit above his door. Further observation revealed there were two staff members that sat at the nurse's station whom were a nurse and respiratory therapistAn observation was conducted on 04/07/2026 at 11:25AM of two staff still at the nurse's station located in the middle of the facility. At the nurse's station was a equipment box attached to the wall, which had lights, room numbers and was beeping. This box was revealed to be a call light alert system.An interview was conducted on 04/07/2026 at 11:28AM with Resident #1 revealed that the staff had not responded to his call light at that time.An observation conducted on 04/07/2026 at 11:30AM revealed the same 2 staff members at the nurse's station, and the same 4 lights binging including Resident #1's on the call light alert system. An interview was conducted on 04/07/2026 at 11:32AM, INV requested assistance from the ADM regarding Resident #1 call light which had been on for approximately 45 minutes at that point.An interview was conducted on 04/07/2026 at 1:17PM with CNA A revealed they had received training on call light systems which included all floor staff are responsible to answer the call lights. CNA A stated she knows when a call light was on by a light that triggered on the hallway above the resident's doors as well as the nurse's station would alert staff as well. CNA A stated residents should not wait a long time to have their call lights answered. She stated that if the call light was not answered timely the resident could be in a hurting situation. An interview was conducted on 04/07/2026 at 1:23PM with CNA B revealed they had received training on call lights which included that call lights should be answered in a timely manner, and every staff would be responsible for answering the call lights. CNA B stated she knows when a call light was on because above the resident's doors was a light that is lit whenever the call light had been pushed. CNA B stated there was also a call light monitoring system at the nurse's station that would beep and light up. CNA B stated that a resident should wait no more than 10 minutes if you are able to get to it right then and there, then you should. She stated if a call light was not answered timely, it could affect a resident due to the resident could have fallen. An interview was conducted on 04/07/2026 at 1:30PM with RN C which revealed they had received training on call lights which included that the call lights should be answered in a timely manner and to notify the residents that help was on the way. She stated that everyone was responsible, as far as staff, to respond to call lights that are on. RN C stated outside the door there was a light that was turned on. She stated the front panel by the nurse station will let you know when there is a call light on as well. RN C stated that residents should only wait a couple of minutes for a response after they set off their call lights. RN C stated if staff did not answer call lights in a timely manner, the resident could be in an emergency situation, fall risk situation or even a fatal situation. An interview was conducted on 04/07/2026 at 1:36PM with the ADM which revealed she had received training on resident rights which included the residents had the right to be treated with dignity and respect. The ADM stated she had also received training on call lights which had included that everyone can answer the call lights however, type of direct care should be given by nursing staff. Call lights should be answered in a timely manner and assist the residents. The ADM stated the training covered the same information in the facility's policy. The ADM stated that staff would know that a call light was on because a light above the room will be lit, as well as the board near the nurse station will beep for the call light that is on. The ADM stated that the resident would not receive the care that they need, and there may be an incident if they are trying to assist themselves due to not getting the assistance in a timely manner. An interview was conducted on 04/07/2026 at 1:51PM with the DON who stated she had received training on resident rights which had included residents have the right to proper care, be treated with dignity and the right to be clean. The DON stated she had received training on call lights which included her expectation was that staff in the building should respond to the call lights. She stated staff would be aware of a call light that was on because a light would be lit above the resident's door, as well as notification at the call light system located at the nurse's station. The DON said that the residents should not wait 30-45 minutes to have their call light answered, and that it should be answered in a timely manner such as 10-15 minutes. She stated that if staff do not answer the call lights, the residents would not have their needs met. 03/17/2026 Call light grievance: Call light not answered in a timely manner. Family member noticed multiple call lights on but nobody assisting. RR indicated the facility had conducted inservice training on the following care areas in January:Resident RightsRR indicated the facility had conducted inservice training on the following care areas in March:Call lights - all staff is to answer the call lights but only direct care staff can provide care.Call lights - it is the responsibility of all staff, not just nursing department. Call light response time should not be 30+ minutes.RR of the facility provided policy titled Call System, Residents Policy dated January 2025 revealed the following:Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.Each resident is provided with a means to call staff directly for assistance from his/ her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered timely.

Based on interviews, observation and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, as identified in the comprehensive assessment, for 3 of 3 residents. reviewed for comprehensive care plans. The facility failed to adequately address fall/safety concerns specific for Residents #10. The facility failed to adequately address fall/safety concerns specific for Residents #12. The facility failed to adequately address fall/safety concerns specific for Residents #14. This failure could place residents of not receiving necessary care or proper care/treatment for falls.Findings included:Record review of Resident #10's Medical Diagnosis indicated a [AGE] year-old male admitted on [DATE], diagnoses included Alzheimer's disease with late onset, muscle weakness, and unsteadiness on feet. A record review of Resident #10's MDS assessment, completed on 11/11/2025, indicated Resident #10 had a BIMS score of 06, which indicated severely impaired cognition. The MDS indicated Resident #10 was at risk for falls.Record review of Resident #10's care plan with last revision date of 1/06/2026 indicated Resident #10 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. The care plan indicated Resident #10 used a mobility device and required assistance with transfers. Resident #10 was lacking the personnel center care for the falls the resident was having. Resident #10 had falls on 3-23-2024, 7-28-2024, and 1-13-2026. Record review of Resident #12's Medical Diagnosis indicated a [AGE] year-old female admitted on [DATE] and readmitted on [DATE], diagnoses included cellulitis of the abdominal wall (spreading bacterial infection), Alzheimer's disease with late onset, need for assistance with personal care, reduced mobility, and need for assistance with personal care.A record review of Resident #12's MDS assessment completed on 10/09/2025, indicated a BIMS score of 13, which indicated she was cognitively intact. A BIMS score of 13 indicates cognitive function is considered intact or within a normal range. Resident #12 was coded as a fall risk.Record review of Resident #12's care plan with last revision date of 1/06/2026, indicated Resident #12 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. The care plan indicated Resident #12 used a mobility device and required assistance with transfers. Resident #12 had 17 falls between 8-13-2025 and 12-27-2025. The care plan did not include a person-centered plan for Resident #12 to address falls.Record review of Resident #14's Medical Diagnosis indicated a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Sepsis (harmful microorganisms in the blood), repeated falls, obesity, and muscle weakness. A record review of Resident #14's MDS assessment, completed on 1/14/2026, revealed that Resident #14 had a BIMS score of 8, which indicated moderate cognitive impairment. Resident #14 was coded as a fall risk.Record review of Resident #14's care plan with last revision date of 1/06/2026, indicated Resident #14 was at risk for falls due to unsteady gait, decreased balance, medications, and poor safety awareness. The care plan indicated Resident #14 used a mobility device and required assistance with transfers. The care plan showed that Resident #14 had 45 falls over the past 12 months.

Based on interview and record review the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 4 medication carts (Medication Aide Cart for 100,300,500 Halls) reviewed for medication storage and labeling. The facility failed to ensure residents were free of any significant medication errors for one (Resident #54) of five residents reviewed for significant medication errors. The facility failed to record receipt and reconciliation of medication aide cart for 100,300,500 each shift change. The facility failed to ensure Resident #54 was administered her prescribed nighttime medications within the allotted time. This failure could place residents at risk of drug diversions and could result in diminished health and well-being. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings Include:Record review of the Change of Shift Narcotic Count Sheets on the Medication Aide Cart for 100,300,500 Halls revealed missing narcotic receipt and reconciliation documentation from MA A on 1/04/2026 for the 6am-6pm on-coming Shift.Review of Resident #54's face sheet dated 01/08/2026 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis of abdominal wall (a serious bacterial skin infection in the dermis and subcutaneous tissue of the belly), chronic kidney disease, stage 3 unspecified (your kidneys have moderate damage, filtering blood less effectively, spondylosis, unspecified (a general descriptive term for any age-related, degenerative wear and tear changes in the spine without specifying the exact location or underlying cause of symptoms), bradycardia, unspecified (an abnormally slow heart rate, generally fewer than 60 beats per minute (bpm) for adults at rest), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident#54's MDS Assessment, dated 10/09/2025, reflected Resident #54 had a BIMS score of 13, which indicated resident's cognition was intact. Review of Resident #54's care plan, on 02/03/2023, reflected that the resident was at risk for adverse reaction r/t polypharmacy, 9+ (when you take several medications each day, often defined as five or more.) Goal: Resident will be free of adverse drug reactions through next review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #54's Physician's orders and medication audit report reflected night-time medications were supposed to be administered at 8:00 PM daily. Medications can be administered an hour prior at 7:00 PM or an hour later at 9:00 PM. The following dates and times reflected when the medications were administered: 12/07/2025 at 9:21 PMLatanoprost 0.005% (for glaucoma) Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/08/2025 at 9:06 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/11/2025 at 10:56 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/12/2025 at 10:34 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/20/2025 at 9:16 PM Latanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/21/2025 at 9:24 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/22/2025 at 9:08 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/23/2025 at 9:11 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) 12/27/2025 at 10:04 PMLatanoprost 0.005% (for glaucoma)Fluticasone Propionate (for sinus drainage)Levocetirizine Dihydrochloride 5 MG (for allergies)Melatonin 3 MG (for insomnia)Prazosin HCI 1 MG (for nightmares) During an observation and interview on 01/06/2026 at 11:30 am, Resident #54 was in her room along with her family members. She was pleasant and communicative. She stated she has been receiving her night medication late. Resident #54 stated she received her 8 PM medications at 10:30 PM and it is happening often especially when the facility is short staff. She stated she thinks there is only one person giving medications at night. Resident #54 stated she stayed up until she received her medication. She wakes up at 5 AM every morning and she falls asleep at the breakfast table, but she must take a nap during the day to make up for the time. During an interview with MA A on 1/07/2026 at 8:30am, she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was the possibility of drug diversion. She states she forgot to sign off on the narcotic count sheet on 01/04/2026 for Medication Aide Cart 100,300,500 Halls. During an interview with LVN A on 1/07/2026 at 2:15pm, she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion. During an interview on 01/07/26 at 03:50 PM, the DON stated their medication administration policy on timeliness is to pass the medication as close to time as possible. One hour before or after the time when the medication should be administered. The DON stated they monitor MAR times to make sure they were not given out the scheduled time by looking at the MAR every morning to be sure there are not any missed medications. If there is an issue, they will contact the doctor to hold medications or if the medications are not available. She stated she was not aware night medications were being administered late. She stated there could be a negative outcome; it just depends on what medication it is. The DON denied any residents had complained to her regarding receiving their medication late. During an interview with DON on 1/8/2026 at 4:15pm, she stated that it was required for the off-going and on-coming staff to count the narcotic medications and sign the narcotic count sheet. She also stated that staff were trained in this expectation during new employee orientation. She stated that a negative outcome of not consistently following the narcotic count expectation was the possibility of drug diversion. Record review of the policy Dispensing and Reconciling Controlled Substances (not dated) reflected, Controlled substances inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The nurse coming on duty and the nurse going off duty making the count together and document and report any discrepancies to the director of nursing services. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following:Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for (Resident #9) reviewed for baseline care plans.The facility failed to complete a baseline care plan within 48 hours of admission for Resident #9. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #9's Face Sheet, dated 01/07/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of traumatic subdural hemorrhage with loss of consciousness status unknown, subsequent encounter (type of bleeding near your brain that can happen after a head injury), pressure-induced deep tissue damage of other site (localized damage to skin and underlying soft tissues from prolonged pressure, often over bony areas, appearing as deep red, purple, or maroon skin (intact or blistered) or a dark wound bed, indicating severe damage beneath the surface that can quickly worsen), other fracture of base of skull, subsequent encounter for fracture with routine healing (a patient receiving follow-up care for a non-specific skull base fracture, where the bone is progressing normally toward healing, indicating a normal recovery phase rather than an initial treatment or complication). Review of Resident#9's MDS Assessment, dated 12/18/2025, reflected Resident #9 had a BIMS score of 00, which indicated resident's cognition was severely impaired. The MDS assessment reflected Resident #9 was dependent on staff for toileting and bathing and personal hygiene. Record review of Resident #9's care plan dated 1/6/26 reflected Resident #9 had impaired cognitive function/dementia or impaired thought process r/t head injury, traumatic brain injury.Goal: Resident will maintain current level cognitive functions through next review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness, ask yes/no questions to determine the resident's needs. There was no baseline care plan. An observation on 01/06/26 at 11:07 AM revealed Resident #9 was observed lying in a hospital bed, in the lowest position, with a fall mat positioned next to the bedside. Resident#9 was lying flat on his back and appeared not to be in any distress. Resident #9 was not interview able as he has a communication deficit. In an interview on 01/06/26 at 03:20 PM, the DON stated the care plans are updated and communicated to direct care staff through reporting at shift changes. Also, it is put in their task list, so they are aware. The DON stated that helps with breakdown in communication. If the care plans are not followed bad outcomes can happen. The DON stated care plans are audited for accuracy and follow-ups are done by MDS Coordinator and she will remind the team, so they know it is correct. The DON stated the timeframe to complete a care plan is 21 days and it is updated quarterly. The DON stated she think Resident #9 baseline care plan was not done timely, because the baseline care plan must be initiated by an RN and she think she may have accidentally deleted it because she didn't initiate it. In an interview on 01/06/26 at 03:32 PM, ADON stated care plan updates are communicated to direct care staff in their electronic reporting system and in the Kardex (a desktop file system that gives a brief overview of each patient and is updated every shift). They also are advised verbally. The ADON stated to avoid a breakdown in communication between departments, changes are discussed in morning stand-up meetings. The MDS Coordinator is responsible for accuracy and follow-throughs of the changes of the care plans. The timeframe to complete a care plan is seven days and updated quarterly. She did not know the care plan was not completed timely. In an interview on 01/06/26 at 04:18 PM, the Administrator stated she is responsible for leading and documenting and changes in condition through communication in the IDT meetings. ADM stated care plan updates are communicated to direct care staff by the DON, adding the information to the Kardex, in-services, and one on one meetings. ADM stated to ensure consistency across shifts, they used PCC (their electronic system Point Click Care), dashboard, and feedback from nurses. They handle breakdowns in communications by providing in-services, meetings, and identifying problems. ADM stated care plans are audited for accuracy by the DON and herself. The regional nurse can also look at them. She stated the care plans are completed within 7 days after they are initiated, but she is unsure when they are updated. ADM stated Resident #9 admissions assessment would have given information from the paperwork that was given to complete the care plan. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered revised March 2022 reflected: Policy: A comprehensive. Person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for (Resident #2) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #2. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (post-traumatic stress disorder with an onset date of 02/16/23) was present upon Resident #2's admission date on 02/16/23. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #2's face sheet, dated 01/8/26, reflected she was a [AGE] year-old female, admitted to the facility initially on 2/16/2023 and readmitted on [DATE]. Her diagnoses included post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a type of dementia caused by reduced blood flow to the brain, often due to conditions affecting the blood vessels, such as strokes or chronic high blood pressure. This condition leads to cognitive decline, impacting memory, problem-solving, and other cognitive functions), and cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes rather than from primary language or speech disorders). Record review of Resident #2's quarterly MDS assessment, dated 10/13/25, reflected that she had a BIMS score of 09, which indicated resident's cognition was moderately impaired. The MDS assessment reflected Resident #2 was dependent on staff for toileting and bathing and required substantial/maximal assistance with personal hygiene. Record review of Resident #2's PASRR Level 1 Screening, dated 02/16/23, reflected that Section C Mental Illness was marked as no, which indicated Resident #2 did not have a mental illness. Record review of Resident #2's care plan dated 09/08/25 reflected Resident #2 was at risk for declining cognition, behavior, and physical condition due to PTSD. Goal: Resident will continue to participate with care as condition allows no complication due to medications, no injury to self or others due to behaviors, needs will be met by staff as needed through next review date.Intervention: Disregard inappropriate comments, provide redirection, verbal cue as needed. Encourage and allow residents to express/discuss concern about disease process. Encourage and assist with physical activities as able. Follow up with Neurologist as indicated. Observe for change in condition and notify Physician, and family. In an interview on 01/06/26 at 3:07 PM, Resident #2 stated she has lived there too damn long (she laughed). She feels safe living at the facility, and they come when her call light is active. Resident#2 had no concern with living at the facility. In an interview on 01/06/26 at 03:20 PM, the DON stated the PASSR list the resident's diagnosis is the facility process of identifying residents with a possible MD, ID, or a related condition prior to admission. Also, the facility identifies residents with newly evident or possible serious MD, ID or a related condition after admission to the facility if the residents are exhibiting behaviors, they will try to refer to psych. They can also reach out to the doctor. DON stated it is usually the social worker's or the MDS Coordinator's responsibility to make the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible MD, ID or related condition. The DON stated if the PASSR I is not completed accurately, the residents will not receive services due to them. In an interview on 01/06/26 at 03:32 PM, ADON stated the facility's process for identifying residents with a possible MD, ID or a related condition prior to admission, is to send over the PASSR before the residents are accepted into the facility. The facility identifies residents with newly evident or possible serious MD, ID or a related condition after admission. Once the nurses assessed the resident they would put in a referral to the psych or the physician. The SW is responsible for making the referral to the appropriate state-designated authority. The ADON stated if the resident had an identified MD, ID, or related condition and a referral was not made, it could be due to inaccurate assessment or no communication. ADON stated the residents can miss out on follow-up for medications and mental health treatments. In an interview on 01/06/26 at 03:41 PM, Social Worker stated the MDS Coordinator is responsible for completing the PASSR. She stated they identify residents with newly evident or possible ID, MD, or related conditions after admission by their history and diagnosis, along with interviews. If they suspect the residents need more, they will set up another interview to discuss services. The SW stated it is the MDS Coordinator's responsibility to make the referral to the appropriate state designated authority. SW stated if the referral is not made, it can be due to communication breakdown, or they just missed the diagnosis. She stated but it should not happen. In an interview on 01/06/26 at 03:58 PM, the MDS Coordinator stated the PASSR form is the facility process of identifying residents with a possible MD, ID, or a related condition prior to admission. The facility identifies residents with newly evident or possible serious MD, ID or a related condition after admission to the facility with updated progress notes. The MDS Coordinator stated it is the social worker's responsibility to make the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible MD, ID or related condition. The MDS Coordinator stated if PASSR is positive it alerts MHMR, and they are out within 72 hours and provide what follow up is needed. If the PASSR II is not completed, the residents will not receive the services they qualify for. MDS Coordinator stated she had not heard of PASSR II. Record review of the facility's policy, PASRR for Nursing Facility revised 07/29/25 reflected: Policy: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs.

Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents hazards and supervision, in that: The facility failed to ensure on 10/16/2025 Resident #1 was transferred by CNA A and RN A using standing pivot transfer x 2 staff without a gait belt. During transfer Resident #1 became too heavy for CNA A and RN A and Resident # 1 was lowered to the floor causing Resident # 1 knees to be in a bent position while sitting on the floor. Resident #1 was sent to the hospital and diagnosed with a displaced periprosthetic distal Femoral fracture (broken thigh bone near a hip implant that has shifted out of position) The non-compliance was identified as past noncompliance (PNC). The noncompliance began on 10/16/25 and ended on 10/27/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of falls with injuries. Findings include: Record review of Resident # 1's face sheet revealed a 91-year -old female admitted to the facility on [DATE] with readmission on [DATE]. Her diagnoses include Muscle Weakness (Generalized) (a lack of muscle strength or the inability to control voluntary muscle force), Lack of Coordination (condition that affects the ability to control and execute smooth, and precise movements), restless leg syndrome (disorder characterized by irresistible urge to move the legs), acute respiratory failure and mild cognitive impairment. Record review of Resident # 1's change of condition MDS assessment dated [DATE], reflected a BIMS of 11(moderate cognitive impairment). Section GG reflected Resident #1 required partial/moderate assistance with transfers. Record review of Resident #1's Care Plan dated 7/28/2025 reflected Resident #1 required staff assistance with transfers and staff to provide assistance using a gait belt, if physical assistance needed for transfers. Resident#1 was at risk for falls due to unsteady gait, lack of coordination, CVA, mood decline, restless leg syndrome, muscle weakness, altered respiratory status, decreased balance, medications, and poor safety awareness. Record review of Resident #1's Kardex on 10/28/2025 reflected Resident #1 required 2-person physical assistance using gait belt for transfers. Record review on 10/28/2025 of the administrator's investigation report (not dated) reflected on 10/16/2025 around 8:30PM RN A and CNA A assisted Resident #1 to the floor while attempting to transfer Resident #1 from bed to wheelchair. RN A noted Resident #1 knees were in a bend position while sitting on the floor and CNA A held her up while RN A went to get assistance from CNA B because the resident was too heavy for a 2-person transfer. CNA B stated he assisted RN A and CNA A in transferring Resident #1 from the floor into the wheelchair. CNA A and CNA B stated Resident #1 did not scream in pain. After the accident Resident #1 complained of knee pain and stated, knees are broken, and she can never walk around again due to her being placed on the ground. Record review of medication administration revealed Resident #1 was given Hydrocodone-Acetaminophen 7.5-325 mg tablet on 10/16/2025 for complaint of generalized pain of 7 out of 10. Record review of nurse note dated 10/17/2025 at 1:15PM from RN A revealed she called Resident #1's hospice care team to request an x-ray which was denied but stated they would notify her case manager. Nurse A notified the on-call physician and obtained an order for stat x-ray, which was done onsite at the facility. Nurse A contacted Resident #1's responsible party to inform them of the incident and the party responsible requested Resident #1 be sent to the Hospital Record review of the radiology report dated 10/17/2025 on 3:53AM confirmed the right knee had a displaced periprosthetic distal femoral fracture. Record review of hospital records revealed, Resident # 1 was admitted on [DATE] with displaced right periprosthetic distal femoral fracture. On 10/18/2025 Resident #1 received Intramedullary rod to right femur. Resident #1 was discharged home on [DATE]. Record review of CNA A's interview with the ADON and DON dated 10/17/2025 revealed CNA A and Nurse A each lifted Resident #1 under each arm to transfer Resident #1 from the bed to her wheelchair and then when they were unable to transfer Resident #1 they sat her back on the bed to regroup and try again. They again tried to transfer Resident #1 by standing her up and holding her brief with one hand and another arm under her arm. They were unable to turn her safely, so they sat her gently on the floor. In an interview with CNA B on 10/28/2025 at 12:11 PM, he stated that he walked into Resident #1's room to assist RN A and CNA A with transferring Resident #1 from the floor to the wheelchair. He and CNA A each lifted Resident #1 under the arm and RN A lifted her legs. They placed Resident #1 in the wheelchair, and she did not complain of pain at that time. He stated they did not use a gait belt. He stated that's where we messed up. We should have used a gait belt for her (Resident #1) transfer. He stated that it was documented in Resident #1 Kardex and care plan to use a gait belt for transfers, and they did not follow it. He stated that the gait belt is used to help transfer the resident safely. He stated after the incident he received in service training over abuse, neglect, identifying types of abuse and safe lifting and movement of residents. In an interview with CNA A on 10/28/2025 at 6:31 AM, she stated that her and RN A attempted to transfer Resident #1 from the bed to the wheelchair that resulted in placing Resident #1 on the floor. RN A requested additional help from CNA B to help transfer Resident #1 from the floor into the wheelchair. CNA A, RN A, and CNA B together transferred Resident #1 from the floor into the wheelchair. She denied using a gait belt for Resident #1's transfers. She stated after the incident she received a one-on-one in-service training on abuse, neglect, identifying types of abuse, and safe lifting and movements of residents. She stated that a gait belt is used to transfer residents safely and prevent falls. In an interview with the RNC on 10/28/2025 at 7:34 AM, she stated the staff should have used a gait belt during the transfer on 10/16/2025 with Resident #1. All staff have since received in-servicing over proper transfers, gait belt use, abuse, neglect, and using the Kardex to find residents transfer status. After the investigation was completed, an Ad Hoc QAPI Committee was convened, a Root Cause Analysis was completed. In an interview with RN A on 10/28/2025 at 1:15 PM, she stated her and CNA A attempted to transfer Resident #1 from the bed to wheelchair that resulted in slowly lowering Resident #1 to the ground due to Resident # 1 being too heavy to transfer. She denied using a gait belt for the transfer. She stated they did not use a gait belt to transfer Resident #1 because they did not need it due to them doing a lift and turn transfer. They would use a gait belt for the resident if she was walking a distance. She stated that she had been trained on abuse, neglect, and resident transfers during time of hire, but did not receive training on resident transfers after the incident because she resigned from the facility after the incident. Record review of facility policy undated titled Safe Lifting and Movement of Residents policy statement reads, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Record review of the facility in-service one on one training titled Abuse, neglect, identifying typed of abuse, safe lifting and movement of residents and dated 10/27/2025 reflected the signature of CNA A. Record review of facility staff in-services titled Safe lifting and movement of residents, abuse, neglect, exploitation and misappropriation prevent program and dated 10/17/2025 reflected the signatures of CNA B, Record review of facility in-service titled Abuse, neglect policy dated 10/20/2025 reflected the signatures of the DON, ADON, and administrator. The facility implemented interventions prior to the entrance of the investigation on 10/28/2025 to correct the non-compliance. Confirmed through a record review of the facility Investigation Report and confirmed during an interview with RNC, in-service training was implemented with all direct care staff on Safe Lifting and Movement of Residents and Abuse, Neglect. One on one training was conducted for CNA A over safe lifting and movement of residents policy. RN A after the incident. Other corrective actions included the implementation of the QAPI Ad Hoc Committee that included Root cause and corrected actions. Root cause indicated two staff members lacked knowledge of proper transfer techniques involving the use of a gait belt which contributed to an assisted fall. Corrected Actions included Interview with all staff involved to determine the root cause of the assisted fall. Inservice: Abuse/Neglect, Proper Transfer and Use of Gait belts, Assessment for suspected fracture, and how to find transfer status in PCC. Each team member is to be issued a gait belt and instructed on it's proper use. Care plan audit to ensure transfer status is accurate for all residents. Skills check- off for transfers for all direct care staff.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from physical abuse for 1 of 7 residents (Resident #4) reviewed for abuse. CNA A awakened Resident #4 abruptly, was rude and rough with her. The resident stated CNA A dug the comb in her scalp while combing her hair. Resident #4 was crying, shaking, and stated she did not feel safe. The non-compliance was identified as PNC. The noncompliance began on 12/03/2024 and ended on 12/5/2024. The facility had corrected the non-compliance before the investigation began. This failure placed residents at risk of fear and physical/psychosocial injury. Findings included: Review of the Face Sheet for Resident #4 dated 12/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills) and Need for Assistance with Personal Care. Review of the MDS assessment for Resident #4 dated 11/26/2024 reflected . Resident #4 required assistance in all activities of daily living. Review of the Care Plan for Resident #4 revised 01/22/2024 reflected the following: (Resident #4) has an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: Activity Intolerance, Disease Process (Post-Polio Syndrome), Depression, Fatigue, Impaired balance. The resident will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene over next 90 days. Locomotion on and off unit: Resident needs assist of 1 staff to transfer with assist of gait belt. Resident utilizes a wheelchair as adaptive device for mobility and require assist of 1 staff for mobility on and off unit. Resident is able to wheel self. Transfer: the resident is limited assistance for transfers. Provide 2 person for transfer. Encourage and remind resident to hold onto handles during transfer. Provide reassurance as needed. Observe extremities and devices during transfer and position for comfort. Ensure wheelchair is available to facilitate transfers. Personal Hygiene: the resident is limited assistance with personal hygiene. Ensure that hygiene items are available for use. Offer resident hygiene items and provide reminders, verbal cues and encouragement as needed. Do not rush, allow resident time to complete task. Provide assistance as needed to complete tasks. Check nail length and trim and clean per facility guidelines and as necessary. Report any changes to the nurse. Prior to trimming nail verify with Nurse for contraindications. Dressing: The resident requires limited assistance with dressing. Encourage and allow resident to choose weather appropriate clothing, non-slip/skid shoes/socks of choice. Provide encouragement, verbal cues and simple 1-2 step instruction as needed. Provide assistance with buttons, zippers, tying shoes etc. to compete tasks. Record review of the facility investigation report on 12/18/2024 reflected the following event: The administrator was notified by the DON on 12/3/2024 Resident #4 made an allegation of abuse against CNA A. Resident #4 informed CNA B and DON that CNA A grabbed her roughly out of bed and yanked and pulled her hair while combing it. At that time, continuous monitoring of the resident was implemented by CNA B. Record Review of the Facility Investigation and Follow Up Report and confirmed in interview with the Administrator immediate action to ensure the safety of the resident was implemented. The following observations, assessments, and interventions occurred on 12/3/24: CNA B observed Resident #4 crying and reporting abuse by CNA A. CNA B began continuous monitoring of Resident #4. The DON was notified, and she notified the Administrator that Resident #4 made an allegation of abuse against CNA A. The DON assessed Resident #4 for signs of trauma to the scalp or body. The assessment was reflected in the Record review of the documentation of the Facility Investigation, record review of the progress note submitted by the DON and confirmed per interview with the DON. There was no evidence of injury. The Administrator implemented an investigation beginning with an interview of Resident #4. Next, the Administrator interviewed CNA A and asked her to write a statement regarding the incident. Record review of the statement demonstrated that the resident was upset about getting hair combed and did not want to get up like ever morning. There was no admission/denial of abuse to the resident. Interview with the Administrator confirmed CNA A denied the allegation and responded by stating what else do you want me to write? when invited to add to her statement. The Administrator suspended CNA A immediately. The Administrator then administered the facility Resident Abuse/Neglect Questionnaire to Resident #4. Record review of the Questionnaire demonstrated that Resident #4 understood what it meant to be abused or neglected, a statement that this was the first time Resident #4 had been abused or neglected by a staff member, Resident #4 stated she would notify the Head Nurse if feeling she had been abused or neglected, and that she had nothing else she wanted to share. Per Record Review of the Facility Investigation report and confirmed by interview with the Administrator Safety Rounds were immediately implemented. Confirmed per Record review of the safety rounds and Administrator interview, all other residents assessed denied having been mistreated or harmed by any staff. Following this, the Administrator interviewed staff present to include the DON, other CNA's and the Social Worker. After the interviews were completed, the Administrator notified the Chief of Operations and Clinical Director. The DON notified the resident's responsible party and the physician. Inservice training on the following was implemented: Abuse Policy, Resident Rights, Code of Conduct/Code of Ethics, Standard of Conduct, and suspected Abuse Checklist. The Administrator performed safety rounds on residents who also resided on the same hallway where CNA A was assigned. The Social Worker performed an assessment to assess for negative emotional outcomes. She also notified the Resident's Representative of the event and notified him that CNA A will no longer be employed at the facility. On 12/5/2024, CNA A was terminated. Record review of the facility policy, Prevention and Reporting of Suspected Resident Abuse and Neglect stated Upon identification of suspected abuse and/or neglect, provide for the immediate safety of the resident. Means of providing protection may include but are not limited to: moving resident to another room or unit; provide one-on-one monitoring as appropriate; suspend suspected employee(s) pending outcome of the investigation. Based on record review of the facility investigation and confirmed in an interview with the Administrator, upon receiving notification of the allegation, the Administrator suspended CNA A. Record review of CNA A personnel file demonstrates documentation of the suspension dated 12/03/2024. The facility policy, 'Prevention and Reporting of suspected Resident Abuse and Neglect stated Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. Record review of the documentation of the facility investigation and confirmed during interview with the Administrator, an investigation was initiated immediately after the report was received. The investigation was completed on 12/03/2024. Record review of staff training records demonstrated the staff were inserviced on the Abuse Policy, Resident Rights, Code of Conduct/Code of Ethics, Standard of Conduct, Suspected Abuse/Neglect Checklist was completed on 12/03/2024. Record review of CNA A employee file contained documentation of termination dated 12/05/2024. This was confirmed in interview with Administrator. Record Review of Psychological Services progress note dated 12/04/2024 at 12:12pm revealed that Resident #4 did not express any particular complaints or ongoing concerns about the issue. A telephone interview was conducted on 12/18/2024 11:07AM with Resident #4's family member. The family member confirmed that he was notified of the event and the actions taken afterward. The family member stated he believed the incident was handled appropriately and Resident #4 was well taken care of. Resident #4 was observed in the Dining Room on 12/18/2024 11:12AM. Resident #4 was clean and dressed in clothing appropriate to the situation. Resident #4 did not have any signs of fear or abuse. In an interview of Resident #4 she stated she did not remember anyone ever being rough with her. A phone interview was conducted with CNA B 12/18/2024 at 3:53pm. She stated that she went into Resident #4's room to take her tray and noticed Resident #4 was crying and jumpy. CNA B stated that Resident #4 told her she was treated badly by another staff member. CNA B stated that she went and got the DON and went back to Resident #4's room. CNA B heard Resident #4 tell the DON that she was afraid to be left alone. Record Review of the DON's statement for the Facility Investigation report and confirmed per interview with the DON revealed Resident #4 was trembling and stated please don't hurt me. Additionally, Resident #4 reported the CNA A pulled her hair and shoved and jerked her out of the bed. CNA B stated she heard from other residents that they do not receive abuse from CNA A; however, they state that sometimes she does not get them to the shower when they ask. A phone interview was conducted with CNA D 12/18/2024 at 3:58 PM. CNA D stated she walked to Resident #4's room to pick up a tray, but the door was closed. CNA D opened the door and noticed CNA B was present. CNA D stated Resident #4 was hysterical and kept asking why she did this to me. CNA D stated Resident #4 said that she was pushed in the restroom forcefully and that her hair was combed roughly by the other lady. CNA D stated she sat with Resident #4 for a while, until she calmed down. CNA D confirmed record review of inservice documentation of inservice training received on Abuse and Neglect. Interview with LVN F was conducted at 12/18/2024 4:30 PM . LVN F verbally confirmed she received training regarding Abuse Policy, Resident Rights, code of Conduct/Code of Ethics, Standards of Conduct, and Education on Suspected Abuse and Neglect Checklist on 12/3/2024 as documented on the Inservice Sheet for that date. Interview with LVN G was conducted at 12/18/2024 4:40 PM. LVN G verbally confirmed she received training regarding Abuse Policy, Resident Rights, code of Conduct/Code of Ethics, Standards of Conduct, and Education on Suspected Abuse and Neglect Checklist on 12/3/2024 as documented on the Inservice Sheet for that date. Record Review of in-service for 12/03/2024 revealed training on Abuse Policy, Resident Rights, Code of Conduct/Code of Ethics, Standards of Conduct, and Education on Suspected Abuse and Neglect Checklist received by direct care staff, housekeeping, dietary, and nonclinical staff . There were a total of 41 signatures on the inservice record. Review of personnel file for CNA A, reflected required background checks, and orientation/training on abuse/neglect/exploitation, resident rights, and dementia care. Observed 2 different individual in-services dated 4/19/24 and 7/11/24 for Standard of Conduct, Code of Ethics, Patient Care, Resident rights. The file also contained the Verbal Warning disciplinary notice of suspension dated 12/03/2024 and the Termination Notice dated 12/05/2024. Review of facility policy titled Prevention and Reporting of Suspected Resident Abuse and Neglect on 12/18/2024 11:07 AM reflected the following: this facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the follow processes in an effort to provide resident and staff a comfortable and safe environment. The administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation and Reporting.

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 7 residents (Resident #4) reviewed for Resident Rights. The facility failed to ensure Resident #4 was treated with respect, dignity, and care while CNA A was assisting her to attend to grooming and dressing for breakfast in the dining room. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. The non-compliance was identified as PNC. The noncompliance began on 12/03/2024 and ended on 12/5/2024. The facility had corrected the non-compliance before the investigation began. Finding included: Review of the Face Sheet for Resident #4 dated 12/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills) and Need for Assistance with Personal Care. Review of the MDS assessment for Resident #4 dated 11/26/2024 reflected Resident #4 required assistance in all activities of daily living. Review of the Care Plan for Resident #4 revised 01/22/2024 reflected the following: (Resident #4) has an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: Activity Intolerance, Disease Process (Post-Polio Syndrome), Depression, Fatigue, Impaired balance. The resident will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene over next 90 days. Locomotion on and off unit: Resident needs assist of 1 staff to transfer with assist of gait belt. Resident utilizes a wheelchair as adaptive device for mobility and require assist of 1 staff for mobility on and off unit. Resident is able to wheel self. Transfer: the resident is limited assistance for transfers. Provide 2 person for transfer. Encourage and remind resident to hold onto handles during transfer. Provide reassurance as needed. Observe extremities and devices during transfer and position for comfort. Ensure wheelchair is available to facilitate transfers. Personal Hygiene: the resident is limited assistance with personal hygiene. Ensure that hygiene items are available for use. Offer resident hygiene items and provide reminders, verbal cues and encouragement as needed. Do not rush, allow resident time to complete task. Provide assistance as needed to complete tasks. Check nail length and trim and clean per facility guidelines and as necessary. Report any changes to the nurse. Prior to trimming nail verify with Nurse for contraindications. Dressing: The resident requires limited assistance with dressing. Encourage and allow resident to choose weather appropriate clothing, non-slip/skid shoes/socks of choice. Provide encouragement, verbal cues and simple 1-2 step instruction as needed. Provide assistance with buttons, zippers, tying shoes etc. to compete tasks. Record review of the facility investigation report on 12/18/2024 reflected the following event: The administrator was notified by the DON on 12/3/2024 Resident #4 made an allegation of abuse against CNA A. Resident #4 informed CNA B and DON that CNA A grabbed her roughly out of bed and yanked and pulled her hair while combing it. At that time, continuous monitoring of the resident was implemented by CNA B. Record review of the Facility Investigation Reports and interviews of CNA B and DON confirmed that Resident #4 reported she was rudely awakened and treated rudely and roughly by CNA A. Record Review of the Facility Investigation and Follow Up Report and confirmed in interview with the Administrator immediate action to ensure the safety of the resident was implemented. The following observations, assessments, and interventions occurred on 12/3/24: CNA B observed Resident #4 crying and reporting abuse by CNA A. CNA B began continuous monitoring of Resident #4. The DON was notified, and she notified the Administrator that Resident #4 made an allegation of abuse against CNA A. The DON assessed Resident #4 for signs of trauma to the scalp or body. The assessment was reflected in the Record review of the documentation of the Facility Investigation, record review of the progress note submitted by the DON and confirmed per interview with the DON. There was no evidence of injury. Record review of the documentation included in the Facility Investigation Report contained a statement submitted by the SW on 12/3/24. The documentation revealed that Resident #4 stated she did not feel safe due to the treatment she received from CNA A. Record review of the facility policy, Prevention and Reporting of Suspected Resident Abuse and Neglect stated Upon identification of suspected abuse and/or neglect, provide for the immediate safety of the resident. Means of providing protection may include but are not limited to moving resident to another room or unit; provide one-on-one monitoring as appropriate; suspend suspected employee(s) pending outcome of the investigation. Based on record review of the facility investigation and confirmed in an interview with the Administrator, upon receiving notification of the allegation, the Administrator suspended CNA A. Record review of CNA A personnel file demonstrates documentation of the suspension dated 12/03/2024. The facility policy, 'Prevention and Reporting of suspected Resident Abuse and Neglect stated Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. Record review of the documentation of the facility investigation and confirmed during interview with the Administrator, an investigation was initiated immediately after the report was received. The investigation was completed on 12/03/2024. Record review of staff training records demonstrated the staff were inserviced on the Abuse Policy, Resident Rights, Code of Conduct/Code of Ethics, Standard of Conduct, Suspected Abuse/Neglect Checklist was completed on 12/03/2024. Record review of CNA A employee file contained documentation of termination dated 12/05/2024. This was confirmed in interview with Administrator. A telephone interview was conducted on 12/18/2024 11:07 AM with Resident #4's family member. The family member confirmed that he was notified of the event and the actions taken afterward. The family member stated he believed the incident was handled appropriately and Resident #4 was well taken care of. Observation of Resident #4 was conducted in the Dining Room on 12/18/2024 11:12 AM. Resident #4 was clean and dressed in clothing appropriate to the situation. Resident #4 did not have any signs of fear or abuse. In an interview of Resident #4 she stated she did not remember anyone ever being rough with her. A phone interview was conducted with CNA B 12/18/2024 at 3:53pm. She stated that she went into Resident #4's room to take her tray and noticed Resident #4 was crying and jumpy. CNA B stated that Resident #4 told her she was treated badly by another staff member. CNA B stated that she went and got the DON and went back to Resident #4's room. CNA B heard Resident #4 tell the DON that she was afraid to be left alone. Record Review of the DON's statement for the Facility Investigation report and confirmed per interview with the DON revealed Resident #4 was trembling and stated please don't hurt me. Additionally, Resident #4 reported the CNA A pulled her hair and shoved and jerked her out of the bed. CNA B stated she heard from other residents that they do not receive abuse from CNA A; however, they state that sometimes she does not get them to the shower when they ask. A phone interview was conducted with CNA D 12/18/2024 at 3:58 PM. CNA D stated she walked to Resident #4's room to pick up a tray, but the door was closed. CNA D opened the door and noticed CNA B was present. CNA D stated Resident #4 was hysterical and kept asking why she did this to me. CNA D stated Resident #4 said that she was pushed in the restroom forcefully and that her hair was combed roughly by the other lady. CNA D stated she sat with Resident #4 for a while, until she calmed down. CNA D confirmed record review of inservice documentation of inservice training received on Abuse and Neglect. Record review of personnel file for CNA A, reflected required background checks, and orientation/training on abuse/neglect/exploitation, resident rights, and dementia care. Observed 2 different individual in-services dated 4/19/24 and 7/11/24 for Standard of Conduct, Code of Ethics, Patient Care, Resident rights. The file also contained the Verbal Warning disciplinary notice of suspension dated 12/03/2024 and the Termination Notice dated 12/05/2024. Record review of the Texas Health and Human Services/ Texas Long-Term Care Ombudsman Nursing Facility Residents [NAME] of Rights dated November 2021 revealed: Residents Rights Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Dignity and Respect You have a right to be treated with dignity, courtesy, consideration, and respect.

Based on observations, interviews, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the tea was covered with a lid. 2. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 3. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 4. The facility failed to ensure hairnets were worn while in the kitchen, while breakfast was being prepared and served, in the kitchen area. 5. The facility failed to clean the food storage bins in the dry food storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on [DATE] from 8:39 AM to 9:00 AM in the facility's main kitchen reflected: Cook A was observed in the kitchen area during breakfast service, not wearing a hairnet covering. One large tea dispenser filled with tea, located in the kitchen area near the entry into the kitchen, was uncovered and exposed to air-borne contaminants. The findings in the kitchen freezer included the following: One large bag of frozen chicken patties was not dated, and no visible expiration date was observed. One large tray of oatmeal and sugar cookies was not sealed, undated, and exposed to air-borne contaminants. One large bag of meat (roast) with no expiration date and covered in frost. One large bag of frozen chicken unlabeled and undated. One large bag of corn empanadas unlabeled and undated. One large box of premade hamburger patties, not properly sealed, and exposed to air contaminants. One large bag containing Black beans covered in frost. One large bag of sliced seasoned potatoes not properly sealed and exposed to air contaminants. One large bag of tater tots not properly sealed and exposed to air contaminants. One large bag of French fries covered in frost, was not dated, and no visible expiration date was observed. One large bag of whole celery, located in the freezer, was not sealed, and was exposed to air-borne contaminants. The findings in the dry food storage area included the following: Three large bins containing sugar, flour, and powdered onion, had one lid cracked, covered in a brownish and blackish dirt stains on the top portion of the bins. One large bag of chips, not properly sealed, and exposed to air contaminants. In an interview with Dietary Manager on [DATE] at 8:55 AM, was advised of the concerns observed in the kitchen area. The DM stated the expectation of the kitchen staff was to make tea an hour before the meal service and the tea dispenser was supposed to be covered during and after the brewing process. The DM stated the tea was prepared by her staff that day around 6:30 AM, and it was not covered. The DM agreed regarding the concerns observed in the kitchen and stated preparing tea and not covering the tea dispenser may cause cross contamination and could lead to sickness among residents. In a follow up interview with Dietary Manager on [DATE] at 10:00 AM, she stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. She was shown images of all the concerns observed in the kitchen. The DM advised she spoke with staff about ensuring the tea was covered once it was prepared. The DM was advised of a staff member being observed not wearing the proper head covering. The DM advised this has been an ongoing issue and it has been addressed but that she will address it again. She did a full in-service of food rotation and storage pertaining to what the proper procedures were dealing with food rotation, storage. Further they completed a customer satisfaction training in reference to resident rights, and options on the food items. The DM advised a full in-service was done regarding proper labeling and cleaning logs, of food items. The DM stated the proper procedure would be to make sure the facility stores, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DM stated these failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. In an interview on [DATE] at 12:50 PM, the Administrator was advised there were concerns observed in the kitchen. She was advised of these concerns and has spoken with the DM. She advised that the issues could cause food contamination and this matter would be resolved. She stated the risk of all these concerns observed in the kitchen could result in residents getting sick. Follow up interview with the DM on [DATE] at 10:00 AM she stated everyone in the kitchen, including herself, were responsible for dating and labeling items in the kitchen. Record Review of the Facility'sundated policy, titled Dietary/Food Services undated, revealed: Policy: Storage of Food in Refrigeration Procedure: - all containers must be labeled with the contents and date food item was placed in storage. Review of the facility's undated policy titled Employee Hygiene , revealed: Procedure: -Employees must keep hair from contacting exposed food, clean equipment, utensils, and linens. All food handling and safety must comply with the Texas Food Establishment Rules (TFER ) and the CMS and Texas Health and Human Services Commission (HHSC ). Review of the U.S. Food and Drug Administration (FDA ) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE]. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD (6) Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice for 7 (Resident #24, Resident #25, Resident #12, Resident #31, Resident #54, Resident #17, and Resident #16) of 10 residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #24's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #25's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) face mask was properly stored. 3. The facility failed to ensure that Resident #12's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 4. The facility failed to ensure that Resident #31's nebulizer face mask was properly stored. 5. The facility failed to ensure resident #54's nebulizer face mask was properly stored. 6. The facility failed to ensure that Resident #17's CPAP was properly stored. 7. The facility failed to ensure that Resident #16's nebulizer face mask was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #24 Review of Resident #24's Face Sheet, dated 09/16/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #24 was diagnosed with COPD (Chronic Obstructive Pulmonary Disease: lung disease that blocks airflow and makes it difficult to breathe). Review of Resident #24's Quarterly MDS Assessment, dated 08/28/2024, reflected that Resident #24 had an intact cognition with a BIMS (Brief Interview for Mental Status: test used to measure cognitive decline) score of 15. Resident #24 was administered oxygen therapy. Review of Resident #24's Comprehensive Care Plan, dated 08/05/2024, reflected that Resident #24 was at risk for shortness of breath, respiratory distress, increased anxiety due to DX COPD . An intervention was to observe for shortness of breath, respiratory distress, increased anxiety and implement appropriate ordered interventions. Notify medical doctor if interventions were not effective. An observation 09/10/24 at 08:49 AM revealed Resident #24's nasal cannula was hanging over the back of Resident #24's wheelchair. The nasal cannula was not stored properly. Resident #25 Review of Resident #25's Face Sheet, dated 09/16/2024, reflected that Resident #25 was an [AGE] year-old female admitted on [DATE]. Resident #25 was diagnosed with Asthma (chronic lung disease) and OSA (Obstructive Sleep Apnea: sleep-related breathing disorder). Resident #25 had severe cognitive impairment with a BIMS score of 04. Resident #25 was treated for chronic respiratory failure. Review of Resident #25's Comprehensive Care Plan, dated 07/01/2024, reflected that Resident #25 had altered respiratory status and difficulty breathing related to Asthma and OSA. An intervention was to educate resident/family/caregivers regarding side effects and overuse of inhalers and nebulizers. An observation on 09/10/24 at 08:56 AM revealed that Resident #25's nebulizer mask was hanging from the bed controller that was on Resident #25's bedside table. The nebulizer mask was not stored properly. Resident #12 Review of Resident #12's Face Sheet, dated 09/11/2024, reflected that Resident #12 was a [AGE] year-old female admitted on [DATE]. Resident #12 was diagnosed with Asthma and OSA. Review of Resident #12's Quarterly MDS Assessment, dated 08/29/2024, reflected that Resident #12 was cognitively intact with a BIMS score of 15. Resident #12 used a non-invasive mechanical ventilator (delivers oxygen to lungs). Review of Resident #12's Comprehensive Care Plan, dated 08/26/2024, reflected that Resident #12 was at risk for complications of Asthma. One intervention was monitor vital signs, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia. An observation on 09/10/24 at 08:59 AM revealed Resident #12's CPAP face mask was on Resident #12's bedside table and was not stored properly. Resident #31 Review of Resident #31's Face Sheet, dated 09/16/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #31 was diagnosed with COPD. Review of Resident #31's Quarterly MDS Assessment, dated 07/22/2024, reflected that Resident #31 was cognitively intact with a BIMS score of 15. Resident #31 had shortness of breath when lying flat. Review of Resident #31's Comprehensive Care Plan, dated 08/08/2024, reflected that Resident #31 was at increased risk for shortness of breath, respiratory distress and increased anxiety related to COPD. The interventions were to educate resident/family/caregivers regarding side effects and overuse of inhalers and nebulizers and to monitor vital signs, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia. An observation on 09/10/24 at 09:02 AM revealed that Resident #31's nebulizer mask was on the table next to Resident #31's bed and was not stored properly. Resident #54 Review of Resident #54's Face Sheet, dated 09/16/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #54 was diagnosed with cerebral infarction (also known as a stroke: a serious condition that occurs when blood flow to the brain is blocked), dysphagia (difficulty swallowing), and spastic hemiplegia (muscles on one side of the body are in a constant state of contraction) affecting the left non-dominant side. Review of Resident #54's Order Summary Report, dated 09/12/24, reflected an order on 09/03/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 inhalation inhale orally every 6 hours for cough/congestion. Review of Resident #54's Quarterly MDS Assessment, dated 08/15/2024, reflected that Resident #54 was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicates that Resident #54 did not experience shortness of breath or symptoms of a swallowing disorder. Review of Resident #54's Comprehensive Care Plan, dated 05/16/2024, reflected that Resident #54 required a pureed diet and thickened liquids related to cerebral infarction and dysphagia. One intervention was to observe for signs of aspiration to include but not limited to: choking, gagging, sinus drainage, gurgling, wet vocal quality. An observation on 09/10/24 at 09:07 AM revealed Resident #54's nebulizer mask was on the table next to Resident #54's bed and not stored properly. Resident #17 Review of Resident #17's Face Sheet, dated 09/16/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #17 was diagnosed with Sleep Apnea (interrupted breathing during sleep). Review of Resident #17's Quarterly MDS Assessment, dated 08/21/2024, reflected that Resident #17 was cognitively intact with a BIMS score of 15 and used a CPAP at bedtime. Review of Resident #17's Comprehensive Care Plan, dated 05/16/2024, reflected that Resident #17 had altered respiratory status/Difficulty Breathing r/t related to chronic respiratory failure and wears a CPAP at bedtime. One intervention was to monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea An observation 09/10/24 at 09:15 AM revealed Resident #17's CPAP tubing was draped over the side of the bed rail and the mask was lying on the resident's bed. It was not stored in a bag. Resident #16 Review of Resident #16's Face Sheet, dated 09/11/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #16 was diagnosed with myocardial infarction (heart attack: blockage of blood flow to the heart) and combined systolic and diastolic heart failure (types of heart failure that affect the heart's ability to pump blood). Review of Resident #16's Quarterly MDS Assessment, dated 08/21/2024, reflected that Resident #16 had moderate cognitive impairment with a BIMS score of 08. Resident #16 was administered oxygen therapy. Review of Resident #16's Comprehensive Care Plan, dated 05/16/2024, reflected that Resident #16 had oxygen therapy related to shortness of breath. One intervention was to monitor for signs of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate, Restlessness, Diaphoresis. An observation on 09/10/24 at 10:56 AM revealed Resident #16's nebulizer mask was on the table next to Resident #16's bed and not stored properly. During an interview with the Staffing Coordinator on 09/10/24 at 11:04 AM, he stated that he was a CNA. The Staffing Coordinator stated that the residents' nasal cannulas should have been bagged, when not used, to prevent contamination. The Staffing Coordinator stated that the nebulizers and CPAP machines should have also been stored in bags, when not in use, so they do not get contaminated. During an interview with LVN B on 09/10/24 at 11:38 AM, he stated that the nebulizer masks and oxygen tubing should have been in a bag unless the resident was using them. LVN B stated it was important to keep these items clean and prevent infection. During an interview with the DON, on 09/11/24 at 08:17 AM, she stated when not in use, oxygen tubing, nebulizer masks, and CPAP masks should have been placed in bags. The DON stated it was important to prevent infection and that she would not want to put a nasal cannula in her nose that was not covered. The DON stated that the staff member who had removed the resident's nasal cannula should have placed it in a bag. Review of the facility's policy Breathing Therapy Devices, undated, reflected to wash with soap and water, rinse, and air-dry all reusable equipment and store in a clean plastic bag for future use.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (room [ROOM NUMBER], #2, #3, #4, and #5) of 12 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 09/10/24 at 10:33 AM of Resident room [ROOM NUMBER] reflected the floor in the resident's bathroom had dark orange stains circling the toilet and on the bottom of the toilet. An observation on 09/10/24 at 10:36 AM of Resident room [ROOM NUMBER] reflected the floor in the resident's bathroom had dark orange stains circling the toilet. The inside of the toilet had a long dark rust in color stain (approximately 3 inches in length). An observation on 09/10/24 at 10:42 AM of Resident room [ROOM NUMBER] reflected the floor in the resident's bathroom had dark orange stains circling the toilet and on the bottom of the toilet. An observation on 09/10/24 at 10:54 AM of Resident room [ROOM NUMBER] reflected the floor in the resident's bathroom had dark orange stains circling the toilet and on the bottom of the toilet. An observation on 09/10/24 at 11:24 AM of Resident room [ROOM NUMBER] reflected the floor in the resident's bathroom had dark orange stains circling the toilet and in the corners of the floor. In an interview on 09/12/24 at 11:00 AM, the Housekeeping Supervisor stated she had been at the facility for [AGE] years. She stated the staff were to clean the entire room, including the resident bathroom. She was shown the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, and #5. She stated housekeeping were to clean the areas observed and they just hired a floor tech to assist in cleaning the bathroom floors around the toilets, which were heavily stained. She stated the risk of the areas not being cleaned would not be good for the resident and she would not like the stains in her bathroom. In an interview on 09/12/24 at 11:08 AM, Housekeeping J stated she had been at the facility for over [AGE] years. She stated she cleaned rooms on hall 100 and 600. She stated she deeps cleans the room once a day, including the bathroom. She was shown pictures of the concerns observed in the Resident room [ROOM NUMBER], #2, #3, #4, and #5, and she stated they were responsible for cleaning the areas mentioned. She stated they had tried to scrub the areas in the bathroom around the toilet but had been unable to get it cleaned. She stated the risk to the resident was that they would not like it. In an interview on 09/12/24 at 11:20 AM, the Administrator stated she had not been made fully aware of the concerns observed in the resident rooms. She was shown pictures of the concerns observed in resident room [ROOM NUMBER], #2, #3, #4, and #5. She stated that she would follow-up with the housekeeping supervisor to ensure these concerns were addressed. She stated her expectation was for housekeeping to ensure they were thoroughly cleaning resident rooms. She stated the risk of not thoroughly cleaning resident rooms could result in infections and it was not good for their dignity. Review of the facility's policy on Internal Environmental Services (undated) reflected: Assure that the resident remains a pleasant, clean, and safe place to live. Procedure: The residence will be kept clean and well maintained. This will be accomplished through a regular cleaning schedule, a preventive maintenance program, and repair the or enhancement of existing structures, systems, equipment, and fixtures.

Based on interviews and record reviews, the facility failed to notify the physician and the resident's responsible party for 1 (Resident #18) of 3 residents reviewed for resident rights. The facility failed to notify Resident #18's physician and RP that the resident did not receive 12 doses of Torsemide between 08/01/23 and 08/07/23 as ordered.) This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of complications from deterioration in health, worsening of conditions, extended recoveries, and hospitalization s. Findings included: Record review of Resident #18's admission record dated 08/15/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included, acute on chronic systolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic respiratory failure with hypercapnia (result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #18's quarterly MDS assessment, dated 06/08/23, revealed a BIMS of 15, which indicated she was cognitively intact. Resident #18 required supervision and one-person physical assistance with bed mobility and eating, and extensive assist with one-person physical assistance for transfers, dressing, toilet use, and personal hygiene. Record review of Resident #1's Nursing Progress Note, dated 08/07/23 at 13:36 (1:36 PM) by the ADON revealed the following: While assessing resident this morning, resident stated she had not received her torsemide since last Tuesday. Upon looking into her medication administration, I noticed the med had been ordered but had not been delivered. I contacted Pharmacy and they stated it would not be refillable until 8/11 and I stated she needed it now since she had already been without it. Pharmacy information was incorrect in regard to her order. They were showing it was to be given once a day and our order shows twice a day. I faxed them the order and they stated they would send out today. I requested her weight, and it reflected a gain of 14 pounds since Friday, August 4th. On-call was paged. Doctor on-call asked to give IM of Lasix, but resident refused and requested to go to [NAME] and [NAME] so they could take the fluid off quickly. Son was on phone with her at the time and was requesting she be sent out as well. Vital signs WNL: Bp 134/62,T 97.7, P 62, Resp 20. Resident was not having any signs of distress and denied having any pain. Weight on Friday was 314 and today was 328. On-call doctor was made aware she was sent out and [family member], was contacted as well. Record Review of Resident #18's progress notes revealed facility did not contact MD or on call doctors during time between 08/01/23 and 08/07/23 in regard to missing diuretic medication. MD was contacted in regard to another issue but still was not informed of missing medication. Record review of Resident #18's physician orders dated 08/15/23 revealed Torsemide Oral Tablet 20 mg give 4 tablets by mouth two times a day. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was ordered from 07/23/23 to 08/10/2023 and changed to Torsemide 20 mg give 4 tablets by mouth two times daily on 08/10/23. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was given on 08/01/23 as ordered and the 8:00 AM dose on 08/02/23 and the 13:00 (1:00 pm) dose of Torsemide 100 mg by mouth two times a day was not given from 08/02/23 to 08/07/23 when medication error was discovered at 13:36 (1:36 pm) by the ADON. Torsemide 100 mg 1 tablet by mouth two times a day. This medication can treat fluid retention(edema) caused by congestive heart failure, kidney disease, or liver disease. It can also treat high blood pressure alone or in combination with other medications per Google. Record review of residents care plan dated 08/15/23 revealed: Resident #18 has renal insufficiency r/t chronic severe stage 4 kidney disease. Goals: I will be free from infection through the review date, I will have no s/s of complications r/t fluid deficit through the review date., and I will be able to resume normal daily activities of daily living through the review date. Interventions: Monitor/document/report for s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out, and Monitor/document/report to MD PRN the following s/sx: Edema; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness ; Monitor breath sounds for crackles. During an interview on 08/15/23 at 2:27 PM with Resident #18, she stated she received her last dose of diuretic medication on the morning of August 1st, 2023, and she had not received or refused it since. She stated she did not refuse the medication at all during the time of the last dose of medication and until the problem was discovered as to why her medication was not being delivered to the facility by the pharmacy, which was Monday, August 7th. She stated she went to the hospital on that day because she had gained 14 pounds over the weekend. She stated she received a huge dose of IV Lasix and she immediately lost 7 pounds. She stated she had received the medication since she returned to the facility from the emergency room with no problems. She stated she had refused the diuretic medication at times due to it causing her to urinate so much during the day and night and it kept her up at night. She stated she communicated with her doctor regarding the diuretic medication and the doctor made changes as needed. During an interview on 08/15/23 at 10:05 AM with the ADON, she stated if a resident was out of a medication that was ordered to be given, staff should have ordered the medication immediately, called the physician, and called the pharmacy and found out why the medication had not been sent. She stated the pharmacy could also call another local pharmacy to supply the medication if needed. She stated the staff should also have checked the E-kit to ensure residents did not miss any doses of medication. She stated there are possible risks involved if a resident missed doses of a medication, such as a high blood pressure medication missed could have caused a residents blood pressure to go up. She stated if medications were missed for a long period of time, it could possibly have caused harm to a resident. She stated she considered a couple of days a long period of time and that if a resident had an order for a medication to be given daily, it should have been given as ordered. She stated if the medication missed was a diuretic medication, it could cause fluid to build up on a resident. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication aide had told the nurse that the resident was out of the medication. She stated the nurse called the pharmacy, and the pharmacy told the nurse the medication had been ordered. She stated when the medications were delivered that night to the facility, the medication still did not come in. She stated the next day the medication aide asked the nurse to get the medication out of the E-kit and when the nurse went to get the medication, there was none of that kind of medication in the E-kit. She stated the nurse called the pharmacy again and the pharmacy told the nurse again they were sorry they didn't send the medication and they would send it that night. She stated that Monday, she had worked the floor and had took care of Resident #18. She stated Resident #18 told her that she hadn't gotten her diuretic in a few days. She stated she told Resident #18 that she was going to check into it and that is when she found out the medication was not in the facility. She stated she called the pharmacy, and they told her it was on order, and she told them the facility had been getting told that. She stated the pharmacy then told her the medication was not fillable until the 11th. She stated she told the pharmacy the medication was needed then, and resident had been out and had not received it in 4 days. She stated pharmacy told her the order they had an order that the medication was to be given once a day and the order the facility had was for resident to get the medication twice a day and that is why it was not able to be filled. She stated she had already paged the on-call doctor to inform of incident, she faxed the correct order to the pharmacy and called to ensure the order was received and the medication would be sent that day. She stated she was not sure why the pharmacy did not update the order when the order was changed because the pharmacy pulled it straight from the system in which the facility put orders in. She stated she had staff weigh Resident #18 and Resident #18 had gained 14 pounds from Friday to Monday. She stated the on-call doctor called her back and she informed doctor of the incident. She stated the doctor ordered an IM injection of Lasix (another diuretic medication), but Resident #18 refused the medication and requested to be sent to the emergency room for the hospital to give her the medication IV. She stated she notified the doctor that Resident #18 refused the medication and wanted to be sent to the hospital and the resident's family wanted Resident #18 to go to the emergency room as well. She stated the doctor gave orders for Resident #18 to be sent to the hospital and she arranged transportation for Resident #18 to be transported to hospital. She stated Resident #18 went to hospital and returned the same evening. She stated the hospital had given Resident #18 80 mg of Lasix IV and had gotten 2 liters of fluid off of Resident #18. She stated Resident #18 was very non-complaint with her diet and asked for things such as bacon, even though she was on a low sodium diet. She stated Resident #18's family brought her pizzas and things that were not on Resident #18's diet as well and she did not think all that weight was just from fluid buildup. She stated she was not sure of what Resident #18's weight was upon return from hospital. She stated Resident #18's routinely ordered medication, did come in from the pharmacy that day and Resident #18 had been on her routinely scheduled medication since returning from the hospital with no interruption due to medication not being in facility. She stated Resident #18 had a history of refusing medications and had refused the diuretic medication about 2 or 3 times since returned from emergency room visit. She stated Resident #18 said she refused the medication at times because she did not want to urinate so much. She stated she in-serviced staff on reordering medications and medication errors. She stated the staff were also in-serviced on the 8 rights of medications and medication administration. She stated if staff were checking the medication card with the medication order in the system the error may not have occurred because it would have been noticed earlier. She stated anytime a resident was out of their medication, the staff should be ordering a week prior to the resident running out of the medication. She stated if it was not received, they should inform the nurse. She stated the nurse should follow up with the pharmacy and find out if there was an issue with the medication and what needs to be done to ensure a resident did not miss any doses. She stated the nurse should also inform management for follow up and if there were any issues. During an interview on 08/15/23 at 10:48 AM with the DON, she stated if a resident was out of a medication that was ordered to be given, staff should call the pharmacy to see if medication can be expedited over, and if not, they should contact a local pharmacy where medication could be picked up. She stated if an ordered medication was missed, lab values could be affected or fluid levels could fluctuate, or mood could be affected, it just depended on the medication. She stated if the medication missed was a diuretic medication, it could possibly cause fluid level to fluctuate, swelling or edema, and respiratory distress. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication was not in the facility. She stated the pharmacy had been reached out to a few times and told the facility the medication was being sent those days, but medication was not received. She stated the staff were in-serviced on if they contacted the pharmacy and still didn't receive the medications, they should notify the ADONs and herself and they can call the pharmacy and find the issue and get it fixed so that resident doesn't miss any medication. She stated if they cannot get the medication that day, the staff should call the physician to get a hold order for that medication until medication can be provided, or to get a substitution until medication can be provided. She stated Resident #18 had a history of refusing the medication on some days due to going out on pass because Resident #18 did not want to urinate a lot. She stated she in-serviced staff on reordering medications and medication errors, the 8 rights of medications and medication administration. She stated she also did 1 on 1 in-servicing as needed with staff if there was disciplinary action needed or check off's with staff. She stated, medication aides should notify the nurse immediately and nurses should contact the pharmacy right away and notify the ADONs anytime a resident was out of their medication. During an interview on 08/15/23 at 12:03 PM with the MD, she stated if a resident missed one dose of a medication, it could potentially cause harm, depending on the medication. She stated if a resident missed multiple doses of a diuretic specifically, depending on residents clinical standpoint, if it was a onetime dose, it may not cause any harm, but if it was multiple doses, it could potentially cause fluid overload, and that could cause symptoms such as shortness of breath, pain if there is a significant amount of edema, and heart or kidney failure exacerbation if resident was diagnosed with heart or kidney failure. She stated it is very individualized for each person, so the potential outcomes vary. She stated the medical team was made aware of the incident regarding Resident #18, and they were informed as soon as the facility realized Resident #18 did not have the medication available. She stated the medical team gave a dose of medication as an alternative, but Resident #18 declined and wanted to go to the emergency room at that time. During an interview on 08/15/23 at 12:22 PM with the ADM and DON, they stated they had not had any QAPI meetings since 07/28/2023 and they did not discuss any concerns with medications during that meeting. They stated they had a policy that was in place for receiving medications and ensuring residents do not go without their medications. They stated the failure in the incident with Resident #18 not having medication in the facility, was a failure to follow policy; not that there was not a policy developed. During an interview on 08/15/23 at 2:46 PM with the DON, she stated Resident #18 refused the diuretic on 08/04/23 due to going out on pass with family. She stated it was documented on the MAR by the medication aide that the medication was not given on the 4th of August, but the medication aide had put NA for the reason why. She stated this medication aide was educated on not documenting NA but to document a description of what happened. She stated the nurse working that day later went in and documented that the resident refused the medication that day due to going out on pass. She stated she believed Resident #18 was not offered the medication when she refused it, but that Resident #18 told staff earlier in the day that she did not want her diuretic medication because she was going out on pass with family, and she did not want to be urinating the whole time. During an interview on 08/15/23 at 4:47 PM with ADON, she stated she does not believe Resident#18's doctor was notified during the time Resident #18 was missing her medication. She stated she believes the doctor was not notified until she did on 08/07/23. She stated staff should have notified the doctor as soon as the Resident #18 missed the first dose. During an interview on 08/15/23 at 4:49 PM with ADM, she stated she is not aware if Resident #18's doctor was notified during the time when Resident #18 was missing her diuretic medication. During an interview on 08/15/23 at 4:52 PM with DON, she stated she had nothing to show that staff informed the doctor of Resident #18's diuretic medication being missed. She stated she knew the staff notified the doctor about another issue going on with Resident #18, but not concerning the missed medication. During an interview on 08/15/23 at 4:56 PM with LVN B, he stated medications should be administered as ordered by physician. He stated he administered medication as a part of his job description. He stated if a resident was out of a medication that was ordered to be given, he would look for the medication, contact the pharmacy to find out what is going on, and if there were missed doses, he would contact the on-call doctor and notify them as well. He stated he would try to find out how long the resident had been out of the medication and why it was not brought to anyone's attention in a timely manner. He stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. He stated if the medication missed was a diuretic medication, it could cause harm in the long run, and depending on how long, it could cause acute problems such as swelling and shortness of breath as well. He stated he was in-serviced on 08/10/23 on reordering medications and medication errors. He stated the in-services covered the steps on what to take on missed medications. During an interview on 08/15/23 at 5:07 PM with LVN C, she stated medications should be administered as ordered by physician. She stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of a medication, she would look into the E-kit to see if the med was available and contact the pharmacy to see if she could get an order sent STAT. She stated if a resident missed doses, she would report it to the ADON and DON so they could follow up on it. She stated she would also inform the physician if a resident missed doses of a medication. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated there is a reason why medication is prescribed. She stated if the medication missed was a diuretic medication, it could cause urinary retention, increased edema, and it could affect the heart in a negative way. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, and contacting the provider, ADON, Administrator, and family to inform them if resident missed a dose of medications. During an interview on 08/15/23 at 5:24 PM, MA D stated medications should be administered as ordered by physician. She stated she administered medication is a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would inform her nurse. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause weight gain or it could affect the heart. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, she let her nurse know that the medication was missing, and she was told by the nurse that the medication was not in the E-kit. She stated she documented it each day the medication was not given. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, abuse and neglect and resident rights. She stated she will now let the nurse know the next steps that need to be done if they did not know and she would also inform the DON anytime a resident is out of their medication. During an interview on 08/15/23 at 5:35 PM with LVN A, she stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would check to see if it is in the E-kit to be given and order it from the pharmacy as well. She stated if a resident actually missed doses of a medication, she would contact the pharmacy and she would inform whoever is on-call and the doctor. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause shortness of breath and increased edema. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of an ordered diuretic medication, she worked the weekend of the 4th, 5th, and 6th of August 2023. She stated on the 4th she was told Resident #18 refused the diuretic medication because resident was going out on pass that day, which was normal for Resident #18 to do. She stated on Saturday, the 5th, her medication aide told her that Resident #18 did not have the medication. She stated the medication was not in their E-kit and it was not carried in the E-kit here in the facility. She stated she then ordered the medication to be delivered that evening. She stated on Sunday, the following day, the medication aide informed her the medication had not came in on the previous day when she ordered it and so she looked into the system, and it showed the medication had been ordered. She stated she did not call the physician regarding Resident #18 missing the diuretic medication. She stated Resident #18 did not voice any concerns or complaints to her and it was her understanding that the medication would be delivered that Saturday, and that was why she didn't inform the physician about Resident #18 missing doses of the medication. She stated she did not call the pharmacy again on that Sunday because it was to her understanding that the pharmacy did not deliver medications on Sundays. She stated she was in-serviced on reordering medications and medication errors on 08/10/23. She stated the in-services covered missed doses of medication and explained what to do in the future and how to handle it if a resident missed a dose of medications. She stated she would call the emergency pharmacy number and see if the medication could be delivered and if medication was still unavailable, she would contact the physician and see what the physician wanted her to do and follow those orders anytime a resident was out of their medication. During an interview on 08/15/23 at 5:53 PM with the ADM, she stated medications should be administered to residents as ordered by physician. She stated she did not administer medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of medication, staff should contact the charge nurse and DON, contact the pharmacy to order the medication, and contact the medical director to inform of the situation. She stated if a medication is missed there is a risk for potential harm. She stated if the medication missed was a diuretic medication, it could cause possible heart issues if a resident had a diagnosis of congestive heart failure. She stated regarding the incident involving Resident #18 , where resident missed 12 doses of ordered diuretic medication, the missed medication was discovered, and she was informed. She stated she alerted her chief officer of operations of the facility, Resident #18's responsible party, and HHSC. She stated the Medical Director was notified upon discovery of missed medications. She stated the nurse should have notified the doctor with the first dose of medication. She stated she in-serviced staff on reordering medications and medication errors. She stated the in-services covered missing medications and what to do in the case of a resident missing a medication. She stated staff should now be notifying the medical director and following orders, notifying the pharmacy and using the emergency protocol to get the medication here to the facility STAT anytime a resident is out of their medication. 08/15/23 Record review of facility policy titled Administering Medications - Oral which was undated revealed: To ensure that medications are administered within the restrictions of employee licensure and per regulation and best practice in the industry. Procedure: Administering Oral Medications: General guidelines and precautions: 5. Follow the six rights of medication administration. - Right patient, right drug, right dose, right route, right time, right documentation. 6. Read the label 3 times as you prepare medication, carefully checking the drug label against the medication administration record (MAR), med card or physicians orders, according to facility policy: check #1 as you take the medicine from the storage area, check #2 as you pour the medicine, check #3: for multi-dose drugs - as you replace the label container into storage area. For unit-dose drugs - at the bedside, before opening the unit-dose medicine package.7. If a medication is unavailable or missing, notify the charge nurse. a. unavailable medication: charge nurse will check the E-kit to see if the dose is available. If not in the E-kit, the charge nurse will reach out to the facility pharmacy to initiate emergency refill if the cutoff time has already passed for the next scheduled delivery. b. Missing medication: charge nurse will begin search for missing medication. If the medication cannot be located, the charge nurse will notify the Director of Nursing and facility administration to initiate an investigation and proceed with the steps listed under bullet point a above. Assessments (Activities to be completed prior to preparing medications) 1. Check medication card or MAR against physician's orders medication Kardex, according to facility policy. 2. Check for the six rights. 4. Review resident data and observe and assess residents as an on-going basis to determine therapeutic effects, side effects, drug allergies, contraindications, and nursing implications. Administration: 11. Give ordered medication(s) to resident by cup or gently place medicine in residents mouth if indicated. (Follow the six rights). Policy has no clear guidance on physician notification regarding missed medication doses. 08/15/23 Record review of facility policy titled: Receiving medications from the pharmacy which is undated revealed: It is the policy of this facility to assure all medications are correctly delivered and errors rectified as soon as possible, to assure proper handling of all medications and to assure a system is adhered to at all times. On 08/15/23 at 3:22 PM, an Immediate Jeopardy (IJ) was identified. The ADM and DON was notified on 08/15/23 at 6:57 PM. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. 08/17/23 Record review of facility plan of removal for pharmacy services revealed: Facility Policy on and Notifications to Physicians, Family, and others - In-services on the topic Notification to Physician, Family and Others began on 8/16/23 and were completed with current nursing staff on 8/16/23 by the DON and nurse educators. The RN, LVN, and Medication Aides were taught that the facility will inform the resident; consult with resident's physician; medical director, and notify, consistent with his or her authority, the resident representative and document in the resident's medical record. The nurses and medication aides currently on shift will pass a post-test of 5 questions pertaining to the Notification to Physician, Family and Others policy to demonstrate competency/understanding and a required grade of 100%. If they fail they will be immediately reeducated and required to retake the post-test and achieve 100%. The RN, LVN, and Medication Aides not currently on shift will be in-serviced before taking any assignment in the facility by 8/17/2023. The nurse educators will be in-serviced by the Director of Nursing on the notifying the medical provider and medical; director on 8/16/2023, and then the DON/RN, and both ADON's will educate the nursing staff on 8/16/2023-8/17/2023. Nurses and Medication Aides will receive training on the same topics during new employee orientation. The DON, ADON, and Administrator performed an audit from the 24-hour report on 8/08/2023 to ensure no other residents had missing or unavailable medication, and there were no other discrepancies. All remaining Nurses and Medication Aides not present will be required to be in-service on the above topics and pass the post-test for prior taking any assignment in the facility. A Quality Assurance Performance Improvement meeting was held on 8/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified on 8/15/23 of the Immediate Jeopardy For the next 30 days, the Director of Nursing will monitor three (3) nurses per week on the listed educational topics and the post-test given to determine retention of knowledge. Should one of the nurses fail the post-test immediate re-education will be provided and the post-test administered again until a 100% score is achieved. For the next 30 days, the Director of Nursing will monitor three (1) medication aide per week on Administering Medication and the post-test given to determine retention of knowledge. Should one of the Medication Aides fail the post-test immediate re-education will be provided and the post-test administered again until a 100% score is achieved. The Director of Nursing and the Administrator will review the 24-hour report Monday-Friday and the weekend report will be reviewed on Monday, promulgated by Point Click Care to review any medications listed as not given, NA, or medication on order and will follow-up immediately with the pharmacy and/or physician or other mid-level practitioner assigned to the residents care to ensure appropriate follow through. The following was monitoring of the facility's corrective actions between 08/16/23 and 8/18/23: During an interview on 08/16/23 at 9:03 AM with the MD, she stated if she was made aware that Resident #18 was missing doses of medication, she would have substituted the medication for something else or arranged for the medication to be picked up by family or staff at a local pharmacy. She stated she was not made aware of the medication not being administered until 08/07/23. During an interview on 08/16/2023 at 1:32 PM with MA E, she stated she was in-serviced on 08/16/23 regarding policy for passing medications correctly and it incorporated who to notify in different instances. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the Administrator. She stated anytime a resident missed a dose of medication, she would notify her charge nurse. During an interview on 08/16/2023 at 1:58 P [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #18) reviewed for pharmacy services. The facility failed to ensure Resident #18 received 12 doses (08/01/23 to 08/07/23) of Torsemide (for the treatment of fluid retention (edema) caused by congestive heart failure, kidney disease, or liver disease due to its unavailability in facility. This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of complications from deterioration in health, worsening of conditions, extended recoveries, and hospitalization s. Findings included: Record review of Resident #18's admission record dated 08/15/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included, acute on chronic systolic (congestive) heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic respiratory failure with hypercapnia (result of mechanical defects, central nervous system depression, imbalance of energy demands and supplies and/or adaptation of central controllers ), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #18's quarterly MDS assessment, dated 06/08/23, revealed a BIMS of 15, which indicated she was cognitively intact. Resident #18 required supervision and one-person physical assistance with bed mobility and eating, and extensive assist with one-person physical assistancefor transfers, dressing, toilet use, and personal hygiene. Record review of residents care plan dated 08/15/23 revealed: Resident #18 has renal insufficiency r/t chronic severe stage 4 kidney disease. Goals: I will be free from infection through the review date, I will have no s/s of complications r/t fluid deficit through the review date., and I will be able to resume normal daily activities of daily living through the review date. Interventions: Monitor/document/report for s/sx of acute renal failure: Oliguria (urine output <400ml per 24 hr.); Increased BUN and Creatinine; In the Diuretic phase, (output >500 ml/24 hr) the BUN and Creatinine level out, and Monitor/document/report to MD PRN the following s/sx: Edema; weight gain of over 2 lbs a day; neck vein distension; difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness ; Monitor breath sounds for crackles. Record review of Resident #18's physician orders dated 08/15/23 revealed Torsemide Oral Tablet 20 mg give 4 tablets by mouth two times a day. Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was ordered from 07/23/23 to 08/10/2023 and changed to Torsemide 20 mg give 4 tablets by mouth two times daily on 08/10/23 Record review of Resident #18's MAR for June 2023 revealed Torsemide 100 mg by mouth two times a day was given on 08/01/23 as ordered and the 8:00 AM dose on 08/02/23 and the 13:00 (1:00 pm) dose of Torsemide 100 mg by mouth two times a day was not given from 08/02/23 to 08/07/23 when medication error was discovered at 13:36 (1:36 pm) by the ADON. Record review of Resident #1's Nursing Progress Note , dated 08/07/23 at 13:36 (1:36 PM) by the ADON revealed the following: While assessing resident this morning, resident stated she had not received her torsemide since last Tuesday. Upon looking into her medication administration, I noticed the med had been ordered but had not been delivered. I contacted Pharmacy and they stated it would not be refillable until 8/11 and I stated she needed it now since she had already been without it. Pharmacy information was incorrect in regard to her order. They were showing it was to be given once a day and our order shows twice a day. I faxed them the order and they stated they would send out today. I requested her weight, and it reflected a gain of 14 pounds since Friday, August 4th. On-call was paged. Doctor on-call asked to give IM of Lasix, but resident refused and requested to go to [NAME] and [NAME] so they could take the fluid off quickly. Son was on phone with her at the time and was requesting she be sent out as well. Vital signs WNL: Bp 134/62,T 97.7, P 62, Resp 20. Resident was not having any signs of distress and denied having any pain. Weight on Friday was 314 and today was 328. On-call doctor was made aware she was sent out and family member , was contacted as well. During an interview on 08/15/23 at 2:27 PM with Resident #18, she stated she received her last dose of diuretic medication on the morning of August 1st, 2023, and she had not received or refused it since. She stated she did not refuse the medication at all during the time of the last dose of medication and until the problem was discovered as to why her medication was not being delivered to the facility by the pharmacy, which was Monday, August 7th. She stated she went to the hospital on that day because she had gained 14 pounds over the weekend. She stated she received a huge dose of IV Lasix and she immediately lost 7 pounds. She stated she had received the medication since she returned to the facility from the emergency room with no problems. She stated she had refused the diuretic medication at times due to it causing her to urinate so much during the day and night and it kept her up at night. She stated she communicated with her doctor regarding the diuretic medication and the doctor made changes as needed. During an interview on 08/15/23 at 10:05 AM with the ADON , she stated if a resident was out of a medication that was ordered to be given, staff should have ordered the medication immediately, called the physician, and called the pharmacy and found out why the medication had not been sent. She stated the pharmacy could also call another local pharmacy to supply the medication if needed. She stated the staff should also have checked the E-kit to ensure residents did not miss any doses of medication. She stated there are possible risks involved if a resident missed doses of a medication, such as a high blood pressure medication missed could have caused a residents blood pressure to go up. She stated if medications were missed for a long period of time, it could possibly have caused harm to a resident. She stated she considered a couple of days a long period of time and that if a resident had an order for a medication to be given daily, it should have been given as ordered. She stated if the medication missed was a diuretic medication, it could cause fluid to build up on a resident. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication aide had told the nurse that the resident was out of the medication. She stated the nurse called the pharmacy, and the pharmacy told the nurse the medication had been ordered. She stated when the medications were delivered that night to the facility, the medication still did not come in. She stated the next day the medication aide asked the nurse to get the medication out of the E-kit and when the nurse went to get the medication, there was none of that kind of medication in the E-kit. She stated the nurse called the pharmacy again and the pharmacy told the nurse again they were sorry they didn't send the medication and they would send it that night. She stated that Monday, she had worked the floor and had took care of Resident #18. She stated Resident #18 told her that she hadn't gotten her diuretic in a few days. She stated she told Resident #18 that she was going to check into it and that is when she found out the medication was not in the facility. She stated she called the pharmacy, and they told her it was on order, and she told them the facility had been getting told that. She stated the pharmacy then told her the medication was not fillable until the 11th. She stated she told the pharmacy the medication was needed then, and resident had been out and had not received it in 4 days. She stated pharmacy told her the order they had an order that the medication was to be given once a day and the order the facility had was for resident to get the medication twice a day and that is why it was not able to be filled. She stated she had already paged the on-call doctor to inform of incident. She faxed the correct order to the pharmacy and called to ensure the order was received and the medication would be sent that day. She stated she was not sure why the pharmacy did not update the order when the order was changed because the pharmacy pulled it straight from the system in which the facility put orders in. She stated she had staff weigh Resident #18 and Resident #18 had gained 14 pounds from Friday to Monday. She stated the on-call doctor called her back and she informed doctor of the incident. She stated the doctor ordered an IM injection of Lasix (another diuretic medication), but Resident #18 refused the medication and requested to be sent to the emergency room for the hospital to give her the medication IV. She stated she notified the doctor that Resident #18 refused the medication and wanted to be sent to the hospital and the resident's family wanted Resident #18 to go to the emergency room as well. She stated the doctor gave orders for Resident #18 to be sent to the hospital and she arranged transportation for Resident #18 to be transported to hospital. She stated Resident #18 went to hospital and returned the same evening. She stated the hospital had given Resident #18 80 mg of Lasix IV and had gotten 2 liters of fluid off of Resident #18. She stated Resident #18 was very non-complaint with her diet and asked for things such as bacon, even though she was on a low sodium diet. She stated Resident #18's family brought her pizzas and things that were not on Resident #18's diet as well and she did not think all that weight was just from fluid buildup. She stated she was not sure of what Resident #18's weight was upon return from hospital. She stated Resident #18's routinely ordered medication, did come in from the pharmacy that day and Resident #18 had been on her routinely scheduled medication since returning from the hospital with no interruption due to medication not being in facility. She stated Resident #18 had a history of refusing medications and had refused the diuretic medication about 2 or 3 times since returned from emergency room visit. She stated Resident #18 said she refused the medication at times because she did not want to urinate so much. She stated she in-serviced staff on reordering medications and medication errors. She stated the staff were also in-serviced on the 8 rights of medications and medication administration. She stated if staff were checking the medication card with the medication order in the system the error may not have occurred because it would have been noticed earlier. She stated anytime a resident was out of their medication, the staff should be ordering a week prior to the resident running out of the medication. She stated if it was not received, they should inform the nurse. She stated the nurse should follow up with the pharmacy and find out if there was an issue with the medication and what needs to be done to ensure a resident did not miss any doses. She stated the nurse should also inform management for follow up and if there were any issues. During an interview on 08/15/23 at 10:48 AM with the DON, she stated if a resident was out of a medication that was ordered to be given, staff should call the pharmacy to see if medication can be expedited over, and if not, they should contact a local pharmacy where medication could be picked up. She stated if an ordered medication was missed, lab values could be affected or fluid levels could fluctuate, or mood could be affected, it just depended on the medication. She stated if the medication missed was a diuretic medication, it could possibly cause fluid level to fluctuate, swelling or edema, and respiratory distress. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, the medication was not in the facility. She stated the pharmacy had been reached out to a few times and told the facility the medication was being sent those days, but medication was not received. She stated the staff were in-serviced on if they contacted the pharmacy and still didn't receive the medications, they should notify the ADONs and herself and they can call the pharmacy and find the issue and get it fixed so that resident doesn't miss any medication. She stated if they cannot get the medication that day, the staff should call the physician to get a hold order for that medication until medication can be provided, or to get a substitution until medication can be provided. She stated Resident #18 had a history of refusing the medication on some days due to going out on pass because Resident #18 did not want to urinate a lot. She stated she in-serviced staff on reordering medications and medication errors, the 8 rights of medications and medication administration. She stated she also did 1 on 1 in-servicing as needed with staff if there was disciplinary action needed or check off's with staff. She stated, medication aides should notify the nurse immediately and nurses should contact the pharmacy right away and notify the ADONs anytime a resident was out of their medication. During an interview on 08/15/23 at 12:03 PM with the MD, she stated if a resident missed one dose of a medication, it could potentially cause harm, depending on the medication. She stated if a resident missed multiple doses of a diuretic specifically, depending on residents clinical standpoint, if it was a onetime dose, it may not cause any harm, but if it was multiple doses, it could potentially cause fluid overload, and that could cause symptoms such as shortness of breath, pain if there is a significant amount of edema, and heart or kidney failure exacerbation if resident was diagnosed with heart or kidney failure. She stated it is very individualized for each person, so the potential outcomes vary. She stated the medical team was made aware of the incident regarding Resident #18, and they were informed as soon as the facility realized Resident #18 did not have the medication available. She stated the medical team gave a dose of medication as an alternative, but Resident #18 declined and wanted to go to the emergency room at that time. During an interview on 08/15/23 at 12:22 PM with the ADM and DON, they stated they had not had any QAPI meetings since 07/28/2023 and they did not discuss any concerns with medications during that meeting. They stated they had a policy that was in place for receiving medications and ensuring residents do not go without their medications. They stated the failure in the incident with Resident #18 not having medication in the facility, was a failure to follow policy; not that there was not a policy developed. During an interview on 08/15/23 at 2:46 PM with the DON, she stated Resident #18 refused the diuretic on 08/04/23 due to going out on pass with family. She stated it was documented on the MAR by the medication aide that the medication was not given on the 4th of August, but the medication aide had put NA for the reason why. She stated this medication aide was educated on not documenting NA but to document a description of what happened. She stated the nurse working that day later went in and documented that the resident refused the medication that day due to going out on pass. She stated she believed Resident #18 was not offered the medication when she refused it, but that Resident #18 told staff earlier in the day that she did not want her diuretic medication because she was going out on pass with family, and she did not want to be urinating the whole time. During an interview on 08/15/23 at 4:56 PM with LVN B, he stated medications should be administered as ordered by physician. He stated he administered medication as a part of his job description. He stated if a resident was out of a medication that was ordered to be given, he would look for the medication, contact the pharmacy to find out what is going on, and if there were missed doses, he would contact the on-call doctor and notify them as well. He stated he would try to find out how long the resident had been out of the medication and why it was not brought to anyone's attention in a timely manner. He stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. He stated if the medication missed was a diuretic medication, it could cause harm in the long run, and depending on how long, it could cause acute problems such as swelling and shortness of breath as well. He stated he was in-serviced on 08/10/23 on reordering medications and medication errors. He stated the in-services covered the steps on what to take on missed medications. During an interview on 08/15/23 at 5:07 PM with LVN C, she stated medications should be administered as ordered by physician. She stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of a medication, she would look into the E-kit to see if the med was available and contact the pharmacy to see if she could get an order sent STAT. She stated if a resident missed doses, she would report it to the ADON and DON so they could follow up on it. She stated she would also inform the physician if a resident missed doses of a medication. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated there is a reason why medication is prescribed. She stated if the medication missed was a diuretic medication, it could cause urinary retention, increased edema, and it could affect the heart in a negative way. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, and contacting the provider, ADON, Administrator, and family to inform them if resident missed a dose of medications. During an interview on 08/15/23 at 5:24 PM,MD stated medications should be administered as ordered by physician. She stated she administered medication is a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would inform her nurse. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause weight gain or it could affect the heart. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of ordered diuretic medication, she let her nurse know that the medication was missing, and she was told by the nurse that the medication was not in the E-kit. She stated she documented it each day the medication was not given. She stated she was in-serviced on 08/10/23 on reordering medications and medication errors, abuse and neglect and resident rights. She stated she will now let the nurse know the next steps that need to be done if they did not know and she would also inform the DON anytime a resident is out of their medication. During an interview on 08/15/23 at 5:35 PM with LVN A, she stated she administered medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given, she would check to see if it is in the E-kit to be given and order it from the pharmacy as well. She stated if a resident actually missed doses of a medication, she would contact the pharmacy and she would inform whoever is on-call and the doctor. She stated if a resident missed doses of a medication, it could potentially cause harm, depending on the medication. She stated if the medication missed was a diuretic medication, it could cause shortness of breath and increased edema. She stated regarding the incident involving Resident #18, where Resident #18 missed 12 doses of an ordered diuretic medication, she worked the weekend of the 4th, 5th, and 6th of August 2023. She stated on the 4th she was told Resident #18 refused the diuretic medication because resident was going out on pass that day, which was normal for Resident #18 to do. She stated on Saturday, the 5th, her medication aide told her that Resident #18 did not have the medication. She stated the medication was not in their E-kit and it was not carried in the E-kit here in the facility. She stated she then ordered the medication to be delivered that evening. She stated on Sunday, the following day, the medication aide informed her the medication had not came in on the previous day when she ordered it and so she looked into the system, and it showed the medication had been ordered. She stated she did not call the physician regarding Resident #18 missing the diuretic medication. She stated Resident #18 did not voice any concerns or complaints to her and it was her understanding that the medication would be delivered that Saturday, and that was why she didn't inform the physician about Resident #18 missing doses of the medication. She stated she did not call the pharmacy again on that Sunday because it was to her understanding that the pharmacy did not deliver medications on Sundays. She stated she was in-serviced on reordering medications and medication errors on 08/10/23. She stated the in-services covered missed doses of medication and explained what to do in the future and how to handle it if a resident missed a dose of medications. She stated she would call the emergency pharmacy number and see if the medication could be delivered and if medication was still unavailable, she would contact the physician and see what the physician wanted her to do and follow those orders anytime a resident was out of their medication. During an interview on 08/15/23 at 5:53 PM with the ADM, she stated medications should be administered to residents as ordered by physician. She stated she did not administer medication as a part of her job description. She stated if a resident was out of a medication that was ordered to be given or missed doses of medication, staff should contact the charge nurse and DON, contact the pharmacy to order the medication, and contact the medical director to inform of the situation. She stated if a medication is missed there is a risk for potential harm. She stated if the medication missed was a diuretic medication, it could cause possible heart issues if a resident had a diagnosis of congestive heart failure. She stated regarding the incident involving Resident #18 , where resident missed 12 doses of ordered diuretic medication, the missed medication was discovered, and she was informed. She stated she alerted her chief officer of operations of the facility, Resident #18's responsible party, and HHSC. She stated the Medical Director was notified upon discovery of missed medications. She stated the nurse should have notified the doctor with the first dose of medication. She stated she in-serviced staff on reordering medications and medication errors. She stated the in-services covered missing medications and what to do in the case of a resident missing a medication. She stated staff should now be notifying the medical director and following orders, notifying the pharmacy and using the emergency protocol to get the medication here to the facility STAT anytime a resident is out of their medication. Record review of facility's undated policy titled Administering Medications - Oral revealed: To ensure that medications are administered within the restrictions of employee licensure and per regulation and best practice in the industry. Procedure: Administering Oral Medications: General guidelines and precautions: 5. Follow the six rights of medication administration. - Right patient, right drug, right dose, right route, right time, right documentation. 7. If a medication is unavailable or missing, notify the charge nurse. a. unavailable medication: charge nurse will check the E-kit to see if the dose is available. If not in the E-kit, the charge nurse will reach out to the facility pharmacy to initiate emergency refill if the cutoff time has already passed for the next scheduled delivery. Record review of facility's undated policy titled Receiving medications from the pharmacy revealed: It is the policy of this facility to assure all medications are correctly delivered and errors rectified as soon as possible, to assure proper handling of all medications and to assure a system is adhered to at all times. On 08/15/23 at 3:22 PM, an Immediate Jeopardy (IJ) was identified. The ADM and DON was notified on 08/15/23 at 6:57 PM. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. Record review of facility plan of removal for pharmacy services revealed: Facility Policy on Administering Medication - Oral - In-services on the following topic Administering Medication Policy began on 8/16/23 and were completed with current RN, LVN, and Medication Aides on 8/16/23. The Administering Medication policy was revised by the Chief Operations Officer on 8/15/2023 to instruct the RN, LVN, and Medication Aides what actions to take if a medication is unavailable or missing. If medication is unavailable or missing the charge nurse will be notified by the Medication Aide. If unavailable the charge nurse will check the eKit, and if not in the eKit the charge nurse will contact the pharmacy for emergency refill immediately. If medication is missing the charge nurse will search for the medication. If the medication is not located, the charge nurse will notify the Director of Nursing and facility administration immediately to initiate an investigation. RN, LVN and Medication Aides currently on shift will pass a post-test of 5 questions to demonstrate competency/understanding of what to do when medication is unavailable or missing and a required grade of 100%. If they fail, they will be immediately reeducated by the DON and/or nurse educators and required to retake the post-test and achieve 100%. RN, LVN and Medication Aides not currently on shift will be in-serviced before taking any assignment in the facility by 8/17/2023. The DON was in-service by the Director of Clinical service on 8/16/20203. The nurse educators will be in-service by the Director of Nursing on the Administering Medication-Oral Policy and Physician Notification by 8/16/2023 and then the DON/RN, and both ADON's will educate the RN, LVN and Medication Aides from 8/16/2023-8/172023. All new hires that are Med Aides or Nurses will receive training on the same topics during new employee orientation. The DON, ADON, and Administrator performed an audit from the 24-hour report on 8/08/2023 to ensure no other residents had missing or unavailable medication, and there were no other discrepancies. All remaining Nurses and Medication Aides not present will be required to be in-serviced on the above topics and pass the post-test for prior taking any assignment in the facility. The Director of Nursing and Administrator will monitor the 24-hour report to ensure all medications have arrived from the pharmacy and administered to residents as prescribed. The medical provider, and medical director will be notified by the charge nurse immediately of any medication pending delivery from pharmacy and request for alternative order if unable to be filled. The nursing staff was in service on notifying the medical director from 8/16/2023-8/17/2023. A Quality Assurance Performance Improvement meeting was held on 8/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified on 8/15/23 of the Immediate Jeopardy The Director of Nursing and the Administrator will review the 24-hour report Monday-Friday and the weekend report will be reviewed on Monday, promulgated by electronic records system to review any medications listed as not given, NA, or medication on order and will follow-up immediately with the pharmacy and/or physician or other mid-level practitioner assigned to the residents care to ensure appropriate follow through. The following was monitoring of the facility's corrective actions between 08/16/23 and 08/18/23: During an interview on 08/16/23 at 9:03 AM with the MD, she stated if she was made aware that Resident #18 was missing doses of medication, she would have substituted the medication for something else or arranged for the medication to be picked up by family or staff at a local pharmacy. She stated she was not made aware of the medication not being administered until 08/07/23. During an interview on 08/16/2023 at 1:32 PM with MA E, she stated she was in-serviced on 08/16/23 regarding policy for passing medications correctly and it incorporated who to notify in different instances. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the Administrator. She stated anytime a resident missed a dose of medication, she would notify her charge nurse. During an interview on 08/16/2023 at 1:58 PM with LVN F, she stated she was in-serviced 08/16/23 regarding medication administration and what to do if they do not have a medication available. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would call the pharmacy and call the provider to get any new orders, or for a local pharmacy to send out within 24 hours so that she could give the medication. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify the residents provider to see if provider wanted to put it on hold or whatever next steps to follow and contact the pharmacy to get the medication in the facility. She stated anytime a resident missed a dose of medication, she would notify the provider. During an interview on 08/16/2023 at 2:38 PM with MA G, she stated she was in-serviced 08/16/23 regarding policies about administering medications and notification to physician and family. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would notify her charge nurse. She stated if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would notify her charge nurse. She stated anytime a resident missed a dose of medication, she would notify the charge nurse. During an interview on 08/16/2023 at 2:59 PM with LVN H, she stated she was in-serviced 08/16/23 regarding medication administration and what to do if medications were not in the facility. She stated they went over when to notify physicians and responsible parties as well. She stated she took a post-test after her in-servicing was complete. She stated if a medication was unavailable on the medication cart, she would look for the medication, call the pharmacy to try to get the medication here in the facility, if they could not get it when needed, she would call the doctor to get a hold order for the medication. She stated it was true that if a medication was unavailable, it could potentially cause a clinical issue. She stated anytime a medication was not in the facility, she would call the doctor and pharmacy. She stated anytime a resident missed a dose of medication, she would inform the doc [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident # 1) reviewed for accident hazards and supervision. The facility failed to ensure CNA A used a gait belt while ambulating Resident #1 to the dining hall on 04/30/2023, Resident #1 fell and sustained a fracture of the right distal radial. An Immediate Jeopardy (IJ) situation was identified on 05/16/2023 at 3:19 p.m. While the IJ was removed on 05/18/2023 at 8:57 a.m., the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for accidents, falls, fractures, and a diminished quality of life. Findings include: Record review of Resident #1's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, Parkinson disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), displaced fracture of right ulna styloid process (the styloid process of the ulna is a bony prominence found at distal end of the ulna in the forearm.), subsequent encounter for closed fracture with routine healing; other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing dated 04/30/2023. Record review or Resident #1's fall risk assessment, dated 1/19/2023, reflected a score 12, with 10 or greater being high risk for fall. Review of document presented by the therapy department titled Walking: to dine/around the facility/wherever you would like to walk Resident indicated Resident #1 was placed on the list as of 02/17/2023. Record review of Resident #1's POC for CNAs, dated 02/20/2023, reflected: Walk-to-dining program: assist resident to walk to and from dining room for all meals with RW SBA and gait belt donned. Record review of Resident #1's quarterly MDS assessment, dated 03/11/2023, revealed a BIMS score of 11, which indicated moderate impaired cognition. It was also revealed Resident #1 required 1-person physical assist with walking in the corridor. Record review of Resident #1's Care Plan, dated 03/25/2023, revealed Resident #1 was at risk for falls due to Parkinson's, Syncope/collapse, unsteady gait, decreased balance, medications, and poor safety awareness. Resident #1 used a mobility device, required assistance with transfers- observe resident when ambulating for unsteady gait, dizziness, decreased balance, weakness and provide assist as needed, provide assistance to keep area of ambulation free from cluster, trip, spill hazards. Record review of Resident #1's incident report, dated 04/30/2023, reflected Resident #1 had a fall while going to the dining hall for lunch. It was also indicated the corner of Resident #1's walker got stuck by the wall and the resident complained her arm hurt after the fall. Record review of Resident #1's progress notes, dated 04/30/2023, at 12:42 p.m., written by LVN A, reflected the following: Resident was taken to the emergency department after sustaining injuries from a fall. Incident took place around 11:30 AM and picked up by ambulance around 11:52 (a.m). Doctor, DON, and family notified. Incident report completed. Record review or Resident #1's fall risk assessment, dated 04/30/2023, reflected a score 14, with 10 or greater being high risk for fall. Record review of Resident #1's local hospital record, dated 04/30/2023, reflected an X-ray result, with 2 views of the right wrist: Findings: Interval reduction of acute, obliquely oriented fracture of the distal radial metaphyseal region with improved alignment. Displaced ulnar styloid avulsion (caused by traction from ligamentous structures, often from a fall onto an outstretched hand, and typically results in a stable styloid tip fracture) fracture is again noted. Scattered osteoarthritis of the right wrist. (Radial fracture is a break in the radius bone. The radius is a bone in the forearm, on the same side as the thumb. The forearm is the part of the arm that is between the elbow and the wrist. A radial fracture near the wrist (distal radio/fracture) is the most common type of broken arm.) In an interview on 05/16/2023 at 12:09 p.m., CNA A stated she was the staff who assisted Resident #1 with ambulation to the dining hall on 04/30/2023 when she fell . CNA A stated she and Resident #1 were walking, she (CNA A) was halfway side and halfway back of Resident #1 while they were walking. CNA A stated she and Resident #1 were rounding the corner to the dining hall when Resident #1' s walker remained standing while Resident #1 fell . CNA A stated she grabbed Resident #1 by the back of her pants for balance, but she still fell . CNA A stated she was supposed to apply a gait belt on Resident #1, but she (CNA A) was in a hurry, so she did not apply the gait belt. CNA A stated she was trained on how to transfer a resident with a gait belt from the bed to the chair and vice versa but not on ambulation. In an interview on 05/16/2023 at 11:42 p.m., the DOR stated Resident #1 was on a walk to dine program prior to her fall on 04/30/2023. The DOR stated the CNAs were supposed to have a walker, a wheelchair and a gait belt when assisting a resident to ambulate to the dining hall. She stated the therapy department communicated with the nursing department before Resident #1 was transferred to the CNAs for the walk to dine program that Resident #1 required standby assist with a gait belt for ambulation. In an interview on 05/16/2023 at 12:42 p.m., the DON stated she was aware of Resident #1's fall on 04/30/2023. The DON stated Resident #1 was ambulating to the dining hall while assisted by CNA A, Resident #1's walker hit the wall and she fell . The DON stated the therapy department usually communicate with nursing department when a resident is being put on the walk to dine program by indicating how much assistance was needed. She stated the communication from the therapy department was put in the POC for the CNAs to know how much assistance Resident #1 needed for mobility/ambulation. The DON stated, while she looked at the POC for Resident #1's mobility, the POC was printed directly from the CNAs POC for Resident #1 and CNA A should have known to apply a gait belt while she assisted Resident #1. The DON stated a gait belt should be in place when transferring and ambulating a resident. In an interview on 05/17/2023 at 10:05 a.m., the PTA D stated she worked with Resident #1 prior to her fall on 04/30/2023. She stated she communicated with nursing about Resident #1's walk to dine program and how much assistance was needed. PTA D stated she specifically spoke with CNA A on how to ambulate Resident #1 to the dining hall. The PTA D stated when a Resident #1 was stand-by assist, the staff still had to don a gait belt for safety. The PTA D stated, depending on what the resident was wearing, you could not hold the balance by grabbing their clothes, so it was advisable to use a gait belt. She also stated, if someone fell and there was no gait belt to hold, that's liability issue. In an interview on 05/16/2023 at 11:25 p.m., the Medical Director stated the nursing staff were supposed to get approval from the family and medical team for therapy recommendations. She stated the CNAs were expected to follow the POC entered into PCC for any given resident. She stated if the POC for Resident #1 indicated CNAs had to don a gait belt when ambulating, the CNAs were expected to don gait belt. In an interview on 05/17/2023 at 3:23 p.m., LVN C stated he was the nurse in charge of Resident #1 on 04/30/2023 when she fell . He stated he heard a commotion from the hall close to the entrance of the dining hall like someone had fallen. He stated CNA A stated the fall happened so fast and she was not able to catch Resident #1. He stated CNA A would have used the gait belt to catch Resident #1. He also stated, after the fall, he did not look to ensure the gait belt was on Resident #1 while she was on the floor. LVN C stated Resident #1 required a gait belt, walker and wheelchair while being ambulated. He stated Resident #1 had history of falls and fracture and required cautions during ambulation. Interview on 05/17/2023 at 3:40 p.m., the DON stated she did not know CNA A did not use a gait belt while ambulating Resident #1 on 04/30/2023 until the State Surveyor began asking questions. She also stated she is not sure if Resident #1's fall would have been prevented if a gait belt was applied. Record review of the facility's, undated, policy titled General Safety Policy reflected the following: In general, all employees will maintain a safe environment and report any issues immediately . Employees should be cautious when walking or pushing carts around [NAME] corner Record review of the facility's, undated, policy titled Fall and Post-Fall Management reflected the following: Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Discussions regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or Substitute Decision Maker (SDM) and interdisciplinary team with these notes documented in the resident medical chart and care plan. .Identify residents at risk for falls during ADL execution by resident individually or with staff assistance .Initiate preventative approaches where appropriate. Provide appropriate strategies and interventions directed to resident, environmental factors and staff. Record review of the facility's, undated, policy titled Ambulation with or without gait belt reflected the following: Licensed Nurse and Nursing Assistant, Restorative Nursing Assistant, Physical Therapist and Occupational Therapist . ? To assist resident to achieve maximum function. ? To provide assistance to resident that is identified as requiring such assistance. ? To supervise and assess resident function in order to plan care to maintain optimum ambulation function as long as possible. ? To re-educate resident in ambulation techniques. ? To teach resident use of assistive devices (where necessary) tco maintain optimum ambulation function as long as possible. ? To reduce risk of falls and injury. Procedure: The following is suggested for those residents that require assistance with ambulation . Review the KARDEX in Point Click Care for the MOBILITY STATUS (example: their level of required assistance such as . use of gait belt per their required level of assistant to include Stand-by-Assist and Contact Guard assist or greater.) 3. Move behind and slightly to one side of the resident. 4. Encourage resident to stand until good balance 1st established. 5. During ambulation, position yourself on the resident's strong side. 6. Walk with the resident with your gait matching the resident's gait. This was determined to be an Immediate Jeopardy (IJ) on 05/16/2023 at 3:19 p.m. The Chief Operational Officer, DON and the Administrator in Training were notified. The Chief Operational Officer, DON and the Administrator were provided with the IJ template on 05/16/2023 at 3:19 p.m. The following Plan of Removal submitted by the facility was accepted on 05/18//2023 at 8:57 a.m.: Plan of Removal - 5.16.23 SUBMISSION #5 Events Leading to the Deficient Practice: Due to the resident not wearing the gait belt as recommended by therapy, during a survey visit for a self-report and complaint, and Immediate Jeopardy was called on 5/16/2023 and the official l IJ Template was received by this facility at 3:19pm on the same day. Other residents affected Three (3) current residents on the Walk-to-Dine designation as recommended by the therapy department have the potential to be affected by the deficient practice. The failure is as follows: The CNA walking with the resident did not don the gait belt on the resident per therapy recommendation. fll-ser vici 11g/education provided in response: I. Facility Policy on Ambulation - In- services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All employees currently on shift will pass a post-test of 5 questions pertaining to the policy to demonstrate competency/understanding and a required grade of 100 %. If they fail, they will be immediately reeducated and required to retake the post-test and achieve 100%. All other nursing staff not currently on shift will be in-serviced before taking any assignment in the facility. The nurse educators will be in-serviced by the Director of Rehab on the Ambulation Policy and then the DON/RN, and both ADON' s will educate the nursing staff on the Ambulation Policy. All new-hire s will receive training g on the same topics during new employee orientation and prior to providing resident care. 2. Facility Policy on Gait Belt usage - In-services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All nursing employees currently on shift will pass a post-test 5 questions pertaining to the policy to demonstrate competency/understanding. If they fail, they will be immediately reeducated and required to retake the post-test and achieve I 00 %. All other nursing staff not currently on shift will be in-serviced and a post-test administered before taking any assignment in the facility. The nurse educators will be in-serviced by the Director of Rehab on the Gait Belt Policy and then the DON/RN, and both ADON's will educate the nursing staff on the Gait Belt Policy. All new- hires wi ll receive training on the same topics during new employee orientation and prior to providing resident care. 3. Facility process on how to access the KARDEX in Point Click Care - In-services began on 5/16/23 and were completed with current nursing staff on 5/17/23. All other nursing staff not currently on shift will be in-serviced and a post-test administered before taking any assignment in the facility. The DON/RN, and both ADON' s will educate the nursing staff on accessing the KARDEX. All new hires will receive training on the same topics during new employee orientation and prior to providing resident care. NOTE: all remaining nursing staff not present will be required to be in-serviced on the above topics and pass the post-test for #1/#2 combined, and #3 prior taking any assignment in the facility. Staff Reprimands 1. CNA will be terminated from employment on 5/17/2023 prior to clocking in for her regular shift A Quality Assurance Performance Improvement meeting was held on 5/16/2023 to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. All Walk-to-Dine recommendations for Residents #2, #3, and #4 were notated and communicated by the Director of Therapy to the Director of Nursing and care plans were updated by the MDS nurse to reflect the therapy recommendations for the Walk-to-Dine designation and was confirmed to be in place by the Director of Nursing. Monitoring For the next 30 days, the Director of Nursing will monitor three (3) nursing staff per week on the above listed educational topics and the post-test given (those with such a created post-test) to determine retention of knowledge. Should a staff member fail the post-test immediate reeducation will be provided, and the post-test administered again until 100%. For the next 30 days, the Director of Nursing will monitor the three (3) residents with a Walk-to-Dine designation to ensure that they are being appropriately ambulated with as recommended by therapy and that a gait belt is present. Preventing Reoccurrence The facility will utilize the Point Click Care KARDEX section to communicate with nursing staff related to the MOBILITY STATUS of the residents. Therapy recommendations specific to MOBILITY STATUS surrounding Walk-to Dine designations will be reviewed weekly in the Standards of Care Meeting and the KARDEX updated accordingly when someone is added or removed from such a program. Monitoring of the plan of removal was completed on 05/18/2023 through 01/13/2023 and revealed the following: During an observation on 05/18/2023 at 11:36 a.m., Resident #2 was observed being ambulated to the dining hall for lunch by CNA B. Resident #2 was noted with his walker and gait belt around his waist while CNA B was observed holding the gait belt attached to Resident #2's waist, a wheelchair, walking behind Resident #2. During an interview on 05/18/2023 at 11:05 a.m., the Chief Operational Officer stated he filled in for the Administrator position. He stated the staff were expected to present therapy recommendations to the IDT for discussion and approval. He stated the CNAs were expected to follow Resident's task in the Kardex that were communicated to them. He stated Resident #1 was stand by assist and not contact guard, meaning the staff did not have to touch Resident #1, and was not sure if the gait belt would have prevented the fall from occurring. He stated QAPI had a meeting on 05/16/2023 after the IJ was called to discuss the POR. He stated the facility-initiated trainings for staff on 05/17/2023, Ambulation with or without gait belt. Accessing the Kardex from PCC to verify walk to dine, and they were being trained before working the floor. In an interview on 05/18/2023 at 11:30 a.m., CNA G stated he was trained on 05/16/2023 on how to pull resident's information for care in PCC on the kiosk. He stated each hall had a kiosk, CNAs were trained to log onto PPC, find the resident, go to Kardex, and look for mobility or any other care are. He also stated he was trained on the proper use of gait belt. He stated there were 3 residents in the facility that were on the walk to dine program, he listed the 3 residents and stated gait belt was required for ambulation with those residents. In an interview on 05/18/2023 at 11:40 a.m. CNA B stated she was trained/in-serviced on 05/17/2023 and 05/18/2023 on how to use the kiosk to log into PCC, select a resident, select Kardex and check the mobility status. She stated after the training, she took a test, made 100 percent in the result. She stated she was also trained on how to walk Residents to the dining hall. She stated there were 2 residents on her assigned hall that were on the walk to dine program. In an interview on 05/18/2023 at 11:56 a.m. CNA H stated she was trained on 05/17/2023 and 05/18/2023 on how to use the kiosk to log into PCC, select a resident, select Kardex and check the mobility status. She stated she took a test after the training and had to get a 100 percent result. She stated she was trained on how to ambulate a resident to the dining hall who was on the walk to dine program. She stated she had 1 resident who was on the walk to dine program on her assigned hall Interview with the DON, ADON E, the MDS nurse, 2 LVNs and 3 CNAs all reflected they were trained and in serviced on ambulating a resident with or without gait belt, how to access the Kardex through PCC to verify walk-to-dine at the beginning of their shifts. They all were able to state the process of verifying resident's mobility needs and how ambulate a resident. They were all aware of Residents that were on the walk to dine program in the facility. In an interview on 05/18/2023 at 12:46 p.m., the DON stated she and the 2 ADONs were trained by the DOR, and they were responsible to train other staff. She stated the ADONs were focused on training the staff while she was focused on monitoring staff to ensure the trainings were effective. The DON also stated there were 3 residents in the facility who were on the walk to dine program. Record review of the facility's POR documentations reflected the QAPI team met on 05/16/2023 and the MD attended via phone. Record review of facility's Inservice, dated 05/17/2023, reflected the following trainings were instructed by the DOR and participants were the DON, ADON E and ADON F, post test results were attached: Ambulation with or without gait belt. Accessing the Kardex from PCC to verify walk to dine. Record review of facility's Inservice, dated 05/17/2023, reflected the following conducted by ADON E, ADON F and participants were other CNAs and nurses: It was also reflected that there was a checklist to indicate staff that had been trained along with post test results with passing mark of 100 percent. Ambulation with or without gait belt. Accessing the Kardex from PCC to verify walk to dine. The DON and the Administrator in Training were informed the Immediate Jeopardy was removed on 05/18/2023 at 1:14 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for residents #11-36 (36 residents) reviewed for infection control. A.) The facility failed to cohort residents that were COVID positive and COVID negative. Observed resident that tested positive for COVID and was left in a room with COVID negative resident. B.) The facility failed to use designated staff for residents located in COVID positive zones. The following staff designations were allowed to work in the COVID positive zone and the rest of the facility: licensed nurses and CNA's were working in positive COVID 19 areas to COVID 19 negative areas without changing PPE. These failures resulted in an Immediate Jeopardy situation on 1/26/2021. While the IJ was removed on 1/30/21 at 6:00 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. These deficient practices could place residents at risk for extended discomfort, physical and psychosocial decline, illness, and death. Findings include: A.) Observed on 1/26/21 at 10:05 am, room [ROOM NUMBER] with resident #12 and #13 are roommates. Resident #12 is COVID-19 negative and #13 is COVID-19 positive. Observed both in the room watching TV with the door open. During an interview on 1/26/21 at 10:00 am, DON stated resident #13 COVID-19 positive resident is cohorting in the same room resident #12 COVID-19 negative resident. Asked DON why she kept the two in the same room if one was negative and the other is positive and she said since the negative has been exposed then she could remain there. Observed on 1/26/21 at 10:05 am, with resident #12 and #13 are roommates. Resident #12 is COVID-19 negative and #13 is COVID-19 positive. Observed both in the room watching TV with the door open. During an interview on 1/26/21 at 10:10 am, with DON, she stated one COVID-19 positive resident #13 is cohorting in the same room with a COVID-19 negative resident #12. DON stated she kept the 2 in the same room because resident #12 had already been exposed to resident #13. Resident #13 tested positive for COVID-19 on 1/18/21. During an interview with DON, provided with COVID 19 policy for Outbreak Management and was not using this policy since they placed the entire facility on COVID 19 positive status. Review of facility policy on COVID-19 policy Outbreak Management. -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. -Identify HCP who will be assigned to work only on the COVID-19 care until when it is in use. -Identify a space in the facility that can be dedicated to care for new admissions or suspected COVID-19 for quarantine. -These residents should not be placed in a room with new admissions or other residents with COVID-19 signs or symptoms. While awaiting results, employees should wear full PPE when caring for these residents. -Roommates or other residents and employees exposed to a resident with confirmed COVID-19 will be closely monitored for 14 days. -Once staff are designated to work with a given cohort, staff should not change designation from one day to another, unless requires in order to maintain adequate staffing for a cohort. Consider designating entire units within the facility, with dedicated HCW, to care for known or probable COVID-19 cases. These HCW should be appropriately trained and fit-tested for N95 masks if at all possible. Review of COVID-19 Response for Nursing Facilities: o Review resident isolation and quarantine plans with staff. o To avoid transmission within facilities, NFs should use separate staffing teams for COVID-19-positive residents to the best of their ability, and designate separate facilities or units within a facility to separate residents into three categories: those who are COVID-19-negative, those who are COVID-19-positive, and those with unknown COVID-19 status. o Quarantine residents with exposure or symptoms. Note: All residents with unknown COVID-19 status must be quarantined for 14 days. According to the CDC guidance regarding COVID-19 outbreaks in a facility recommends that signage should be present at the entrance of the COVID-19 unit which informs staff they must wear eye protection, and an N95 mask when entering the COVID-19 unit. Gowns and gloves should be added when entering residents' rooms. B.) Record review of facility census report dated 1/26/21 revealed 36 positive residents and 50 negative residents. During an interview on 1/26/21 at 9:45 am ADM stated the entire building was put on COVID positive status on 1/22/21. ADM stated the facility had 36 positive residents, and all were on halls #100, #200 and #400. ADM stated two residents (husband and wife) that tested negative for COVID 19 are on the same hall as COVID 19 positive residents. She also stated resident #31 is on this hall and he is negative for COVID-19. ADM stated 50 residents were COVID-19 negative today. During an interview on 1/26/21 at 10:00 am, DON, I asked her why resident #13 who is COVID-19 positive resident is cohorting in the same room with a COVID-19 negative resident #12. DON stated she kept the two in the same room since they had already been exposed to each other. During an interview on 1/26/21 at 2:52 pm, CNA A, stated she worked the #600 hallway that is COVID negative and #100 hallway was a COVID positive. CNA A stated she is caring for COVID-19 positive residents and COVID-19 negative residents. Said she was instructed by her DON that she would do this as long as she is wearing full PPE. CNA A said the whole facility was placed on COVID-19 positive status last week. CNA stated she wears the same PPE all day and goes from COVID 19 positive residents room to COVID 19 negative room. Observation and interview on 1/26/21 at 3:10 pm, RN A said she works the hall #100 and #200 halls medication administration/blood sugar treatment. Said she has enough PPE. She was wearing full PPE and wears the same PPE all day and goes into COVID positive hall to COVID negative rooms to care for residents. RN A said she administers medication to positive and negative residents. Observation on 1/26/21 at 3:15 pm, revealed on hallway #400, CNA B and CNA G walk into room resident #50 and #51 that are COVID-19 positive wearing PPE and then entered room [ROOM NUMBER] and #66 that are negative for COVID-19 wearing the same PPE. In an interview 1/26/21 at 3:20 pm, HSC/Infection Preventionist stated ADM and DON placed the building on COVID positive status. She stated everyone in the facility had tested positive for COVID 19 except 7 residents. Observation on 1/26/21 at 3:54 pm, LVN A entered resident #48 (COVID-19 positive) to help resident to the restroom wearing full PPE and touched resident came out of the room and did not change PPE. Then entered room of resident #59 (COVID-19 negative) and fill her water cup. LVN A did not change her PPE and was wearing the same gloves. Observation on 1/26/21 at 4:27 pm, revealed staff CNA B entered resident room [ROOM NUMBER] (COVID positive) and was carrying laundry wearing full PPE and dropped off laundry. She then entered resident #78 (COVID-19 negative) and did not change PPE to drop off laundry to that resident. On 1/26/21 at 9:00 pm ADM, DON and HSC were notified of IJ. The IJ template was emailed at 9:02 pm to ADM. A Plan of Removal was submitted by the ADM on 1/29/21 at 5:41 pm and the following POR was accepted on 1/30/21 at 6:00 pm. Facility Park Place Manor Plan of Removal: 1. On 1/26/21, the facility received an IJ after 9:00 PM. By 9:00 AM on 1/27/21, the Director of Nurses, DON, updated all nursing staff regarding the need to designate hall 600 as a COVID-19 care area. Area was completed, and COVID positive residents were relocated to that are. -1/26/21 The DON planned out the relocation of current residents to other areas and planned room allocation for COVID positive residents on 600 hall. -1/26/21 The DON and Staff Development Nurse contacted nursing staff to work the COVID care area (License nurses and nursing assistants) -The hallway was prepared by the environmental and nursing departments, and residents that were not COVID positive were relocated per plan off of 600 hall. -The DON and licensed management staff donned PPE and relocated residents who were COVID positive to 600 hall. -100% of Nursing Assistants and License Nurses on duty were provided an in-service on 1/27/21 on good infection control, PPE use, and COVID care protocols by the Staff Development Nurse, 80% of staff completed in-service by 1/29/21 remaining 20% includes PRN and COVID positive staff who will receive training by 2/12/21. -COVID area nurse was in-serviced by DON prior to taking COVID care position on 600 hall (Has COVID care experience). -100% of the COVID area staff were in-serviced prior to working, by the COVID nurse. -Staff who are or absent due to illness or on vacation will also receive training/info regarding infection control, PPE use, and protocols by 2/12/21 and all future staff will receive this training. -Staff Development Nurse will review to be sure every nursing employee has received the training and signed the in-service by 2/12/21. -Any new positive COVID residents will be relocated to COVID care area. -COVID positive residents will remain on COVID care area for 10 days from positive result. 2. Medical Director immediately provided guidance and education to administrator and DON concerning changes needed for COVID positive care on hall 600 so as to prevent further spread of COVID-19. She instructed us to resume previous COVID-19 positive plan of action protocol which was previous COVID-19 positive plan of action protocol which was successfully used prior to 1/22/21. -Administrator and DON informed by surveyor on 1/26/21 of current CDC/CMS guidelines, and we will follow those guidelines. -Administrator and DON immediately reviewed guidelines by CDC/CMS so as to prevent further spread of COVID-19 and resumed prior procedures that facility used successfully in this past (4 infection control surveys with no deficiencies) See synopsis below: -Synopsis of COVID-19 positive plan of action -COVID area is set up with all supplies needed to maintain barrier/isolation of COVID are staff/residents away from general population of staff and residents. -Adequate staff will be provided and staff are trained on COVID-19 and prevention of spread prior to working in COVID area. -Staff maintain PPE use and universal precautions, and enter/exit through exterior door. -Residents are monitored by license nurse to include V/S, O2 sat, and lung sounds at least once each shift for at least 10 days, then move off COVID care area and continue routine monitoring for COVID symptoms. -Nursing assistants provide resident care. -Licensed nurses provide meds, treatments, documentation, and physician/RP notification of changes in resident condition. -DON, management nurses, Weekend RN to get report from nurse on all COVID area residents daily and PRN. -On 1/27/21, Administrator and DON provided re-education to all department heads regarding CMS guidelines to prevent further spread of COVID-10 and directed that all of their staff be in-serviced starting on (1/27/21) and all completed prior to working by 2/12/21, have been offering in-service on drive though basis for staff daily, Monday through Friday, and weekend RN will monitor staff on weekends. 3. The one resident who was negative and was residing with resident who was positive was immediately relocated from hall 100 to hall 200, in a room [ROOM NUMBER] full private (The resident who was negative was COVID-19 tested before relocated and is still negative). -She will be screened/monitored daily on all 3 shifts by the license nurses for any signs and symptoms of COVID-19 (Cough, fever, shortness of breath). -The DON, the Assistant DON, or the Weekend RN will be checking with resident daily to ensure she has not developed any symptoms of COVID-19 (Cough, fever, shortness of breath, nausea, sore throat). 4. To ensure Health and Safety of all residents: -All residents will continue to be monitored every shift by their assigned nurses for COVID symptoms (Cough, fever, shortness of breath) -Temperatures will continue to be taken 3 times a day. -The ADON and Weekend RN will do additional daily non COVID positive residents monitoring for signs and symptoms of COVID-19. -The residents who were previously positive (more than 90 days ago) and all negative residents, were retested as scheduled on 11/27/21. All residents were negative. -The facility Health Services Coordinator/Infection Preventionist will be reviewing any/all resident infections on an ongoing basis. -Residents who have not had COVID in the last 90 days will be tested per CDC guidelines currently weekly and PRN. -Staff will be COVID tested by CDC/CMS guidelines currently twice weekly and PRN. 5. Facility Administrator and Director of Nurses are working with TMF, Texas Medical Foundation, regarding in-service material (Infection Control Provider Safety of the Environment Patient Care) that can and will be used to assist out facility in the prevention of the spread of COVID-19 in our building. The Staff Development Nurse and/or DON provided small group and 1:1 in-services to all departments and in-service completed this on 1/27/21 for staff working. Department supervisors will continue doing 1:1 in-servicing of their staff until everyone is trained (by 2/26/21). The DON will re-educate license nurses and certified nurse assistants, therapist, housekeeping department, and interdisciplinary team regarding the following beginning on 1/27/21. -Transmission-based precautions are to be initiated on residents with suspected or known exposure to COVID-10 communicated by the DON and will be documented in the progress notes and added to the 24-hour report by DON. -Residents with suspected or known exposure to COVID-19 are to be screened using the resident screening tool 3 times a daily to monitor for signs and symptoms of COVID-19 and the MD contacted if any signs and symptoms are identified. -Resident room doors on the quarantine unit are to be closed as much as possible. -The COVID care hall/Hot zone will have proper signage related to isolation (Do not enter) -PPE will be available to all staff, and used by COVID care area staff routinely. Supplies are located on COVID area and on hall 400 storage room. 6. The QAPI Committee and Safety Committee met on 1/26/21. Decision was made to resume facility COVID-19 plan of action protocol which was in use prior to 1/22/21. -Reviewed, discussed and evaluated the present processes and action plans that are now in place regarding infection control on hall 600 and all areas of building. -QAPI committee evaluated infection control procedure for hall 600. -Safety Committee reviewed equipment required for hall 600. -QAPI committee members are meeting daily to re-evaluate infection control processes and root cause analysis (Monday through Friday). -Staff Development nurse and Weekend RN will monitor the nursing staff on competency check list to be completed on each nursing staff member by 2/26/21. The survey team monitored the plan of removal from 1/27/21 through 1/30/21 as follows: During an interview on 1/27/21 at 12:35 pm, CNA F stated he is only working hallway #100. During an interview on 1/27/21 at 12:45 pm, staff PTD said since she started work today and are not considered a positive facility, she can have her staff conduct PT on residents in the PT room. PTD said before this they were doing PT in the resident's room. During an interview on 1/27/21 at 1:00 pm, staff HK stated all residents that are positive are now on hall #600. Observation and interview on 1/27/21 at 1:35 pm, resident #12 was relocated to her own room. Observation on 1/27/21 at 1:40 pm, revealed hallway #100 with all residents that were negative (residents #2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13,14 and 15). All residents were in their rooms. Observation on 1/27/21 at 1:44 pm, hallway #200 with all residents that were negative (residents #17, 18, 21, 22, 23, 27 and 28). All residents were in their rooms. Record review of In services for all staff dated 1/27/21: Laundry and pickup for COVID 19 positive hallway, Using Paper good for COVID 19 positive residents, New COVID 19 positive area #600 hall, Designated staff to work COVID 19 positive hallway and How to use PPE. Observed on 1/28/21 at 2:15 pm, HKS going to the COVID-19 unit (#600 hall) from the outside collecting soiled linens. Staff was gowned and wearing mask and gloves. The staff collected the barrel and took to laundry through the back. Interview on 1/30/21 at 5:40 pm, with RN B, said she has been in-serviced on hand washing, staying 6 feet apart, designated COVID-19 hall is #600, testing twice a week and staying home when you are sick. RN B also said they are taking residents temperatures every shift and assessing for changes. She said if the resident is positive they will move the resident to the #600 hall for isolation. There are assigned nurses and CNA on the COVID-19 positive hall and they wear gown, mask, and work 12 hours shift. If they need something, they will call, and we drop it off at the table next to the door and they pick it up. RN B said the laundry is put in a yellow bag and it is taken to the end of the hall and laundry staff will pick it up. These failures resulted in an Immediate Jeopardy situation on 1/26/2021. While the IJ was removed on 1/30/21 at 6:00 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions.

Based on interview and record review the facility failed to provide necessary treatment and services to promote wound healing of a pressure ulcer for (1) one (Resident # 1) of (10) ten Residents reviewed for pressure ulcers when: 1. The facility interdisciplinary team failed to adequately assess, identify, and monitor Resident # 1 for pressure areas and develop relevant care plan goals and interventions to treat and prevent or minimize the risk of complications of Resident # 1 ' s pressure ulcer. 2. The facility failed to implement the facility skin care system and protocols to consistently treat or promote wound healing for Resident # 1 ' s pressure ulcer from 5/26/15 through 6/15/15. This deficient practice caused actual harm to Resident # 1 which resulted in deterioration of Resident# 1 ' s pressure ulcer to her sacrum as it regressed from a Stage 2 to a Stage 3 ulcer. This deficient practice could affect 4 Residents with pressure ulcers by placing them at risk for receiving inaccurate care and services by not allowing them attain or maintain the highest practicable physical, mental and psychosocial health. Findings included: Review of Resident # 1 ' s face sheet with an admission date of [DATE] reflected a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the facility ' s policy and procedure for pressure ulcer treatment dated October 2010 reflected: Definitions and Descriptions Stage 2 Pressure Ulcer- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Ulcer presents as a shiny or dry hollow ulcer without slough or bruising. Stage 3 Pressure Ulcer- Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present, but does not obscure the depth of tissue loss. Stage 3 ulcers can be shallow. Review of Resident # 1 ' s skin report by LVN A dated 5/26/15 reflected Resident # 1 had a pressure ulcer to her coccyx/sacral area. LVN A did not perform a nurse assessment with measurements, notify the physician, responsible party, and she did not initiate a facility treatment protocol. These sections of the form were left blank. Review of Resident # 1 ' s skin report by LVN B dated 6/3/15 reflected Resident # 1 had a pressure ulcer to her coccyx and that a treatment for [REDACTED]. Review of Resident # 1 ' s nurses notes dated 6/8/15 reflected: Duoderm to coccyx soiled with stool. Replaced with new duoderm and signed by LVN A. (Treatment protocol for Stage 2 ulcers). Review of Resident # 1 ' s skin report by LVN C dated 6/16/15 reflected: Resident # 1 had a pressure ulcer. (Physician orders [REDACTED]. Review of Resident # 1 ' s treatment records from May 26th 2015 - June 15th 2015 did not reflect documentation for treatment of [REDACTED]. Review of Resident # 1 ' s quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 5/26/15 reflected that Resident # 1 had no pressure ulcers. Review of Resident # 1 ' s care plan with a revision date of 6/4/15 reflected a goal that Resident # 1 would have no skin breakdown over the next 90 days. Resident # 1 ' s care plan did not reflect the pressure ulcer to her coccyx/sacrum. During an interview on 7/1/15 at 9:45 am DON stated that she was not sure why Resident # 1 ' s pressure sore was not reflected on the MDS 3.0 assessment that had an assessment reference date of 5/26/15. DON said the MDS nurse was out on vacation, but that she would try to contact her and find out. DON said she could not explain why Resident # 1 had skin reports on 5/26/15 and 6/3/15 that reflected a pressure sore, yet Resident # 1 ' s Treatment Administration Record (TAR) didn ' t reflect an active treatment. DON said she would have to research it all and find out what happened. During an interview on 7/1/15 at 1:30 pm DON stated that the MDS nurse did not code the pressure ulcer on the MDS because it was not reflected on the TARS so she was not aware that Resident # 1 had a pressure sore. During an interview on 7/1/15 at 1:30 pm DON said that LVN A did not follow policy and procedure when the ulcer was reported to her on 5/26/15 in that she failed to transcribe a treatment order per facility protocol to treat pressure ulcers. DON said that LVN A did not notify the family, physician, or supervisory staff of the area opening up again, but that she was treating it as it was reflected once in her nurse documentation on 6/8/15. DON stated that she could not say that Resident # 1 received consistent or ongoing monitoring or treatment of [REDACTED]. DON said it was at that time that 6/16/15 everyone was made aware of the area. DON said she was not able to provide documentation to show that Resident # 1 ' s pressure area had been treated or monitored by nursing consistently from 5/26/15 - 6-15/15. DON said the area had progressed from a stage 2 to a stage 3 as on 6/16/15 a treatment for [REDACTED]. DON stated that Resident # 1 ' s doctor was at the facility and reviewed and signed order that the nurse practitioner gave the nurse over the phone on 6/16/15. DON said that she found that LVN A had not been doing the skin assessments routinely and she brought it to her attention. DON said that LVN A left shortly after that without giving notice. During an interview on 7/1/15 at 1:30 pm DON said LVN B was aware of the area on 6/3/15 as she changed a stage 2 protocol dressing, but she doesn ' t see that LVN B followed through with protocol either. During an interview on 7/1/15 at 2:05 pm LVN B stated that she had been adequately trained and understood the facility ' s policy and procedures for wound care. LVN B stated that on 6/3/15 she assessed and changed the duoderm for the stage 2 area to Resident # 1 ' s coccyx/sacral area. LVN B said the area was pink. LVN B said that she removed a soiled dressing from the wound that day and replaced with a new one. LVN B said that she assumed that orders and Stage 2 pressure ulcer treatment protocol had previously been initiated. LVN B said that she took full responsibility for not checking the orders or signing that she provided a treatment for [REDACTED]. During an interview on 7/1/15 at 1:30 pm DON said that it was her responsibility to check behind the nurses to ensure that they complete work assignments including the skin assessments. DON said that during that time there was a lot going on and her priority was getting coverage for care and she was a few weeks behind on checking paper work and missed it. DON stated that she expected all nurses to follow facility policy and procedure and they are thoroughly trained to do such. DON stated that there was a Skin/Wound Documentation System in place and she couldn ' t explain why the nurses did not follow through. Review of the Skin Wound Documentation System not dated reflected: 1. Nurse will do total body review on all admissions and re-admissions and document on skin report form. 2. Nurse Aide ' s will do a bath and skin report with every bath/shower and turn in to charge nurse. 3. Nurse will review bath and skin reports and document follow up on report. a. TX already in progress b. Chronic/Long term problem c. New=Nurse does her own assessment skin report and notifies MD/RP 4. Weekly skin assessments will be done on all skin problems by nurse indicating whether current TX/Care is working. Call MD/RP if worse or not healing. Nurse will also do routine weekly body review with shower. 5. DON reviews all of the above and nursing management each reviews their assigned hall. Review of Resident # 1 ' s telephone order dated 6/16/15 reflected: 1. Do not use duoderm on patients skin- fragile skin 2. Clean sacral wound with SWC. Pat dry. Apply santyl. Cover with coverderm. Change every day and PRN till healed. { Santyl ointment is an enzyme used to debris devitalized tissue (slough) }. Review of Resident # 1 ' s Wound Care Specialist Evaluation dated 6/25/15 reflected: Stage 3 Pressure Wound of the Sacrum Etiology (Quality): Pressure MDS 3.0 Stage: 3 Wound Size (L x W x D): 1 x 0.5 x 0.1 cm Exudate: Moderate Serous Yellow Necrotic: 100% Wound Progress: Deteriorated Observation of wound care for Resident # 1 on 7/2/15 at 11:15 am revealed a pressure ulcer to the sacral area with yellow tissue in the center and pink edges. Resident # 1 tolerated the treatment without facial grimaces or complaints of pain. Nurse performing wound care inquired about pain before, during, and after treatment. During an interview on 7/2/15 at 11:20 am Resident # 1 was unable to recall when she developed the sore on her sacrum. Resident # 1 said that the area did not hurt. Review of the facility ' s policy and procedure for pressure ulcer assessment dated [DATE] reflected: 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a skin alert ' performing routine skin inspections daily or every other day as needed (with every shower, bath, and incontinent care). b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. Reporting 2. Report other information in accordance with facility policy and professional standards of practice. Review of the facility ' s policy and procedure for pressure ulcer treatment dated October 2010 reflected: Stage 2 Protocol: Stage 2 Pressure Ulcer Interventions/Care Strategies Clean, shallow, minimal drainage: 1. Protect 2. Manage Drainage 3. Promote moist wound healing 4. Treatment a. Cleanse with normal saline or other skin cleanser in accordance with physician orders [REDACTED]. b. Apply barrier cream, hydrogel, or hydrogel sheet (cut to fit) c. Cover with non-adhesive light gauze or transparent dressing. d. Alternate dressing ( use of thin [MEDICATION NAME]); and e. Change per physician order [REDACTED]. 5. Manage pain Follow-up If wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist. Stage 3 Protocol: Stage 3 Pressure Ulcer Interventions/Care Strategies 1. Protect 2. Fill dead space including tunnels and undermining 3. Manage drainage 4. Promote moist wound healing and 5. Manage pain No drainage 1. Treatment a. Irrigate wound with normal saline or other designated wound cleanser b. Irrigate wound with normal saline or other designated wound cleanser, use syringe to apply (4-15 psi) c. Apply hydrogel to wound cavity; and d. Change per order and manufacturer ' s directions Medium to heavy drainage: 1. Follow above procedure. Consider substituting alginate or foam. The facility wound care specialist evaluation reports dated 6/25/15 reflected 4 Residents with pressure ulcers. Facility census provided by the DON was 99.