Every finding on record at Avir at Commons

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (LVN A) and 1 of 2 residents (Resident #1) reviewed infection control. The facility failed to ensure LVN A wore gloves and a gown when providing wound care to Resident #1 on 8/18/26. This failure could place residents at risk for MDROs, cross-contamination, and the spread of infection.Findings Include:Record review of the face sheet dated 8/18/26 indicated Resident #1 was an [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (care that focuses on the healing the residual limb, managing swelling and pain, and preparing for mobility), heart failure (a medical condition where the heart muscle cannot pump blood and oxygen well enough to meet the body's needs), hypertension (elevated blood pressure), and diabetes. Record review of the physician orders dated 8/18/26 indicated Resident #1 had an order for EBP related to wound care starting 7/29/26. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 14 and was cognitively intact. The MDS indicated Resident #1 had diabetic foot ulcers and a surgical wound. Record review of the care plan revised on 8/7/26 indicated Resident #1 had a potential/actual impairment to skin integrity. During an observation and interview on 8/18/26 at 11:45 a.m. there was EBP signage on the outside of Resident #1's door. LVN A was observed touching Resident #1's right BKA incision site without gloves or gown on. LVN A placed a border dressing (an all-in-one wound cover featuring a central absorbent pad and a sticky outer margin that adheres to healthy skin) over the right BKA incision site. LVN A washed her hands and exited the room. LVN A said she did not have gloves on because she had just thrown her gloves away and went to get a towel to clean up something (she did not specify what) in the room. During an interview on 8/18/26 at 11:57 a.m. with ADON B and ADON C, ADON B said Resident #1 was on EBP related to his wounds. ADON C said Resident #1 had wounds to his left heel and ankle and a surgical incision site that had scabs to his right leg. ADON B said LVN A should not have touched the incision site without a gown or gloves on. ADON C said if LVN A had to leave the room she should have taken off her gown and gloves and performed hand hygiene and when returned to the resident's room she should have put on a clean gown and gloves before continuing with providing care to the incision site. During an interview on 8/18/26 at 2:22 p.m. LVN A said EBP was used to prevent MDROs. LVN A said EBP included wearing a gown and gloves when providing care. LVN A said residents with draining wounds, PEG tubes (a flexible feeding tube placed through the skin of the abdomen directly into the stomach), IV device (a device inserted into the vein commonly used for medical therapy that delivers fluids, medications, blood products, or nutrients), and dialysis shunts were on EBP. LVN A said she should have been wearing a gown and gloves when touching and placing the border dressing to Resident #1's right BKA surgical incision site. LVN A said an incision site should never be touched without gloves on. LVN A said the importance of wearing appropriate PPE for EBP and not touching an incision site without gloves on was to protect the staff and residents. During an interview on 8/19/26 at 11:55 a.m. the DON said EBP should be worn to protect the resident from unknown infections. The DON said EBP included gown and gloves. The DON said residents on EBP precautions included residents with wounds. The DON said staff should not touch a healing incision site bare hand. The DON said the importance of wearing proper PPE when providing care for a resident on EBP and wearing gloves when touching incision sites was to keep the resident free from harm from infectious diseases. Record review of the facility's Enhanced Barrier Precautions policy updated February 2025 indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP employs targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.h. wound care (any skin opening requiring a dressing) .

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #1) reviewed for incontinent care in that: LVN C failed to perform an ordered straight catheterization (tube inserted into the bladder through the urethra to drain urine and then immediately removed) for Resident #1 during the 6:00 p.m. to 6:00 a.m. shift on 8/8/26 and 8/9/26. LVN E failed to perform an ordered straight catheterization for Resident #1 during the 6:00 a.m. to 6:00 p.m. shift on 8/10/26. LVN F failed to perform an ordered straight catheterization for Resident #1 during the 6:00 a.m. to 6:00 p.m. shift on 8/9/26. This failure could place residents at risk for urinary retention, bladder distention, UTI, and hospitalization.Findings included: Record review of Resident #1's face sheet dated 8/12/26 indicated Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia (partial paralysis of all four limbs and the trunk), neuromuscular dysfunction of bladder (inability to fully empty bladder), neurogenic bowel (nerve damage to bowels), and Parkinson's disease (nervous system disorder causing tremor, muscular rigidity, and slow, imprecise movement). Record review of a quarterly MDS dated [DATE] indicated Resident #1 had a BIMS score of 3 which indicated severely impaired cognition. He required substantial to maximal assistance for personal hygiene, putting on/taking off footwear, shower/bathing, toileting hygiene; he required partial/moderate assistance with upper body dressing, oral hygiene, and eating. He was not rated for incontinence due to catheter use and was always incontinent of bowel. Record review of a comprehensive care plan revised 4/16/26 indicated Resident #1 was incontinent and required an In & Out straight cath. The same care plan indicated Resident #1 was incontinent of bowel related to spinal cord injury. Interventions were in place to check frequently for wetness and soiling and change as needed, and perform straight catheterization as ordered. Record review of an order summary dated 8/13/26 for Resident #1 indicated he had an order for In and out catheter Q Shift for urine retention dated 6/18/26. During an interview on 8/12/26 at 11:30 a.m., the ADON said she was working on hall 100 that day and was responsible for the care of Resident #1. The ADON said Resident #1 got up that morning and participated in game of cornhole and was currently in the dining room. The ADON said Resident #1 required a straight catheterization be performed every shift, or twice daily. The ADON said the order was originally to perform the straight catheterization four times daily, but it was changed to twice daily due to low residuals. The ADON said resident was able to express his needs and use a call light and usually asked to go to bed and lay down by 3:00 p.m. The ADON said she performed the straight catheterization that morning between 8:00 a.m. and 9:00 a.m. During an observation and interview on 8/12/26 at 11:40 a.m., Resident #1 was observed in the dining room sitting alone at a table. Resident appeared to be asleep but responded immediately to voice. Resident appeared to be clean and had no offensive odor present. There were no marks, bruises or skin tears observed on exposed skin. Resident #1 said he could not remember how often staff check on him or when the straight catheterization was last performed. Resident #1 said staff got him out of bed this morning with a mechanical lift and brought him to an activity in the dining room for a game. Resident #1 said he was waiting for lunch. During an observation and interview on 8/12/26 at 1:00 p.m., Resident #1 was observed in his room, sitting in a wheelchair. Resident's shorts appeared to be wet. Resident #1 said he wasn't sure when he was changed last. Resident #1 said he didn't like to get up in bed because staff didn't get him back down. Resident #1 said he wasn't sure if the staff still performed the straight catheterizations as ordered. Resident #1 said they used to do that, but they don't much anymore. Resident #1 said he could not recall the last time the procedure was performed. During an interview on 8/12/26 at 1:20 p.m., CNA A said she frequently checked on Resident #1 because he frequently used his call light. CNA said she usually changed him in the morning around 8:00 a.m., then again after lunch around 12:00 p.m., and once more around 3:00 p.m. CNA A said resident was resistant to care and refused to be changed often. CNA A said Resident #1 did not like to get back in bed to get changed. CNA A said she was not sure if nursing staff were performing resident's straight catheterization anymore. CNA A said she had not seen any nurse performing it and Resident #1 was usually heavily wet when she changed him. During an observation on 8/12/26 at 1:40 p.m. through 3:00 p.m., video clips from FM B's cell phone of camera in Resident #1's room indicated a straight catheterization was not performed overnight or during day shift on 8/8/26, 8/9/26, or during the day on 8/10/26. During an observation and interview on 8/13/26 at 9:30 a.m., Resident #1 was observed in his room sitting in a wheelchair, resident appeared clean and well-groomed. Resident had no offensive odor noted. Resident #1 said he thought staff performed the straight catheterization that morning, but he was unsure if it was performed yesterday or overnight. During an interview on 8/13/26 at 11:25 a.m., the ADON said she expected nursing staff to follow orders as they were written. The ADON said Resident #1 was ordered to have a straight catheterization once per shift. The ADON said risks to the resident if the procedure was not performed could be UTI, not emptying bladder, pain, or requirement of a permanent cath. During an interview on 8/13/26 at 11:35 a.m., LVN C said she worked 8/8/26 through 8/10/26 on the night shift and was responsible for care of Resident #1. LVN C said she did not perform the straight catheterization for Resident #1 on either 8/8/26 or 8/9/26 because the resident was frequently urinating and previous catheterizations had not returned much residual. LVN C said she did not contact the physician to change or clarify the order. LVN C said she talked to FM B, who explained the reason for the catheterization order, and she now understood the importance. LVN C said she did perform the straight catheterization on 8/10/26 night shift. LVN C said the risks to Resident #1 from not having the procedure performed could be urinary retention and UTI. During an interview on 8/13/26 at 11:45 a.m., the DON said she expected nursing staff to follow physician orders as they were written. The DON said risks to residents from physician orders not being followed as written could be increase or worsening of current illness/sickness or improper observation. The DON said she was not made aware of any concerns of care regarding Resident #1. During an interview on 8/13/26 at 11:55 a.m., the ADM said the physician orders were there for a reason and her expectation was that nursing staff follow the orders as they were written. The ADM said the risks to Resident #1 of not having straight catheterizations performed as ordered could be UTIs. The ADM said she had not been made aware of any concerns outside of resident being transferred without a sling via stand/pivot. During an interview on 8/13/26 at 12:00 p.m., the NP said she knew Resident #1 and saw him regularly as a patient. The NP said Resident #1 was ordered straight catheterizations once per shift. The NP said Resident #1 required these procedures due to his diagnosis of neurogenic bladder (inability to fully empty bladder). The NP said physician orders should be followed as they were written. The NP said the risks to Resident #1 of not having the procedure performed as ordered could be bladder distention, pain, and hospitalization. During an observation on 8/13/26 at 1:55 p.m., CNA A and CNA D provided incontinent care for Resident #1. Resident #1's skin was observed and he had no redness, excoriation, or wounds. CNAs completed provided care while maintaining infection control practices. During an interview on 8/13/26 at 2:45 p.m., LVN E said she worked on 8/10/26 on the day shift and took care of Resident #1. LVN E said she did not perform the straight catheterization on 8/10/26. LVN E said she was a new employee at the facility and was told by another nurse that Resident #1 didn't require the straight catheterization if he had an adequate urine output. LVN E said she could not remember the name of the nurse who provided her that instruction. LVN E said she now knew Resident #1 had urinary retention and risks to resident could be retaining fluids or UTIs. Interviews were attempted with LVN F, who worked the day shift on 8/8/26 and 8/9/26, on 8/13/26 at 10:30 a.m., 11:00 a.m.,12:35 p.m., and 3:03 p.m. A policy for straight catheterization was requested from the DON on 8/13/26 but not provided as the facility only had a policy for indwelling catheters. Review of a staffing assignment sheet for 8/10/26 indicated LVN E worked 6A-6P and was assigned halls 100 and 600. Review of a staffing assignment sheet for 8/9/26 indicated LVN F worked 6A-6P and was assigned halls 100 and 600; LVN C worked 6P-6A and was assigned halls 100 and 600. Review of a staffing assignment sheet for 8/8/26 indicated LVN F worked 6A-6P and was assigned halls 100 and 600; LVN C worked 6P-6A and was assigned halls 100 and 600.

Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records in that: LVN C failed to perform an ordered straight catheterization (tube inserted into the bladder through the urethra to drain urine and then immediately removed) for Resident #1 during the 6:00 p.m. to 6:00 a.m. shift on 8/8/26 and 8/9/26 but charted the procedure as completed with residual urine amounts documented. LVN E failed to perform an ordered straight catheterization for Resident #1 during the 6:00 a.m. to 6:00 p.m. shift on 8/10/26 but charted the procedure as completed with residual urine amounts documented. LVN F failed to perform an ordered straight catheterization for Resident #1 during the 6:00 a.m. to 6:00 p.m. shift on 8/8/26 and 8/9/26 but charted the procedure as completed with residual urine amounts documented. This failure could place residents at risk for urinary retention, bladder distention, UTI, and hospitalization.Findings included: Record review of Resident #1's face sheet dated 8/12/26 indicated Resident #1 was a [AGE] year-old male readmitted on [DATE] with diagnoses of quadriplegia (partial paralysis of all four limbs and the trunk), neuromuscular dysfunction of bladder (inability to fully empty bladder), neurogenic bowel (nerve damage to bowels), and Parkinson's disease (nervous system disorder causing tremor, muscular rigidity, and slow, imprecise movement). Record review of a quarterly MDS dated [DATE] indicated Resident #1 had a BIMS score of 3 which indicated severely impaired cognition and he required substantial to maximal assistance for personal hygiene, putting on/taking off footwear, shower/bathing, toileting hygiene; he required partial/moderate assistance with upper body dressing, oral hygiene, and eating. He was not rated for incontinence due to catheter use and was always incontinent of bowel. Record review of a comprehensive care plan revised 4/16/26 indicated Resident #1 was incontinent and required an In & Out straight cath. The same care plan indicated Resident #1 was incontinent of bowel related to spinal cord injury. Interventions were in place to check frequently for wetness and soiling and change as needed, and perform straight catheterization as ordered. Record review of an order summary for Resident #1 indicated he had an order for In and out catheter Q Shift for urine retention. During an interview on 8/12/26 at 11:30 a.m., the ADON said she was working on hall 100 that day and was responsible for care of Resident #1. The ADON said got up that morning and participated in game of cornhole and was currently in the dining room. The ADON said Resident #1 required a straight catheterization be performed every shift, or twice daily. The ADON said the order was originally to perform the straight catheterization four times daily, but it was changed to twice daily due to low residuals. The ADON said she performed the straight catheterization that morning between 8:00 a.m. and 9:00 a.m. The ADON said completion of the procedure and documentation of residuals should be accurately charted in the resident's electronic medical record. During an interview on 8/12/26 at 11:40 a.m., Resident #1 said he could not remember how often staff check on him or when the straight catheterization was last performed. Resident #1 said staff got him out of bed this morning with a mechanical lift and brought him to an activity in the dining room for a game. Resident #1 said he had not been back to his room and he was waiting for lunch. During an observation and interview on 8/12/26 at 1:00 p.m., Resident #1 was observed in his room, sitting in a wheelchair. Resident's shorts appeared to be wet. Resident #1 said he wasn't sure if he staff still performed the straight catheterizations as ordered. Resident #1 said they used to do that, but they don't much anymore. Resident #1 said he could not recall the last time the procedure was performed. During an interview on 8/12/26 at 1:20 p.m., CNA A said she frequently checked on Resident #1 because he frequently used his call light. CNA said she usually changed him in the morning around 8:00 a.m., then again after lunch around 12:00 p.m., and once more around 3:00 p.m. CNA A said she was not sure if nursing staff were performing resident's straight catheterization anymore. CNA A said she had not seen any nurse performing it and Resident #1 was usually heavily wet when she changed him. During an observation on 8/12/26 at 1:40 p.m. through 3:00 p.m., video clips from FM B's cell phone of camera in Resident #1's room indicated a straight catheterization was not performed during the day or overnight or 8/8/26, 8/9/26, or during the day on 8/10/26. Review of an NMAR dated 8/13/26 indicated the following:LVN C charted completing straight catheterization for Resident #1 on night shift 8/8/26 collecting 75ml of urine and on 8/9/26 collecting 75ml of urine.LVN E charted completing straight catheterization for Resident #1 on day shift 8/10/26 collecting 100ml of urineLVN F charted completing straight catheterization for Resident #1 on day shift on 8/9/26 collecting 50ml of urine During an observation and interview on 8/13/26 at 9:30 a.m., Resident #1 was observed in his room sitting in a wheelchair, resident appeared clean and well-groomed. Resident had no offensive odor noted. Resident #1 said he thought staff performed the straight catheterization that morning, but he was unsure if it was performed yesterday or overnight Resident said he was in no pain and felt no bladder distention/pressure. During an interview on 8/13/26 at 11:35 a.m., LVN C said she worked 8/8/26 through 8/10/26 on the 6:00p.m. to 6:00 a.m. shift and was responsible for care of Resident #1. LVN C said she did not perform the straight catheterization for Resident #1 on either 8/8/26 or 8/9/26 because the resident was frequently urinating and previous catheterizations had not returned much residual. LVN C said she did perform the straight catheterization on 8/10/26 night shift. LVN C said she was unsure if she charted the procedure as being completed on 8/8/26 and 8/9/26 and how much if any residual urine return was documented. During an interview on 8/13/26 at 11:45 a.m., the DON said she expected nursing staff to follow physician orders as they are written and to accurately chart on residents. The DON said risks to residents from inaccurate documentation could be increase or worsening of current illness/sickness or inaccurate information being presented to the physicians. The DON said the facility had already begun in-servicing and coaching staff to remediate identified concerns. During an interview on 8/13/26 at 11:55 a.m., the ADM said physician orders are the blueprint for resident care and should be followed as they are written and documentation should be accurate. The ADM said didn't want to speculate on the possible risks of inaccurate documentation, but the provider should be given accurate medical documentation. During an interview on 8/13/26 at 12:00 p.m., NP said she knew Resident #1 and saw him regularly as a patient. The NP said Resident #1 was ordered straight catheterizations once per shift. The NP said Resident #1 required those procedures due to his diagnosis of neurogenic bladder (inability to fully empty bladder). The NP said physician orders should be followed as they are written. The NP said she had no knowledge of inaccurate charting in Resident #1's medical record. The NP said accurate documentation was important to guide medical decisions. During an interview on 8/13/26 at 2:45 p.m., LVN E said she worked on 8/10/26 on the 6:00 a.m. to 6:00 p.m. shift and took care of Resident #1. LVN E said she did not perform the straight catheterization on 8/10/26. LVN E said she was a new employee at the facility and was told by another nurse that Resident #1 didn't require the straight catheterization if he had an adequate urine output. LVN E said she could not remember the name of the nurse who provided her that instruction. LVN E said she could not recall if she charted the procedure as completed or what residual amount was charted. Interviews were attempted with LVN F, who worked the 6:00 a.m. to 6:00 p.m. shift on 8/8/26 and 8/9/26, on 8/13/26 at 10:30 a.m., 11:00 a.m.,12:35 p.m., and 3:03 p.m. Review of a staffing assignment sheet for 8/10/26 indicated LVN E worked 6A-6P and was assigned halls 100 and 600. Review of a staffing assignment sheet for 8/9/26 indicated LVN F worked 6A-6P and was assigned halls 100 and 600; LVN C worked 6P-6A and was assigned halls 100 and 600. Review of a staffing assignment sheet for 8/8/26 indicated LVN F worked 6A-6P and was assigned halls 100 and 600; LVN C worked 6P-6A and was assigned halls 100 and 600. A policy for straight catheterization was requested from the DON but not provided as the facility only had a policy for indwelling catheters. Review of a facility policy titled Clinical Document Guideline revised on 3/25/14 indicated The patient's clinical record provides a record of the health status, including observations, measurements, history, and prognosis and serves as the primary document describing healthcare services provide to patient.Clinical document entries should be objective, factual information and communication that pertain to the care of the patient i.e. patient centered.

Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice including the right to choose activities and schedules (including sleeping and waking times) for 1 of 4 residents (Resident #1) reviewed for Residents Rights in that: Resident #1 was left in bed all 6:00 a.m. - 6:00 p.m. shift on 8/9/26 despite asking CNA A to get up out of bed. This failure could place all residents at risk for diminished quality of life, skin integrity breakdown, and hospitalization.Findings included: Record review of Resident #1's face sheet dated 8/12/26 indicated Resident #1 was a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia (partial paralysis of all four limbs and the trunk), neuromuscular dysfunction of bladder (inability to fully empty bladder), neurogenic bowel (nerve damage to bowels), and Parkinson's disease (nervous system disorder causing tremor, muscular rigidity, and slow, imprecise movement). Record review of a quarterly MDS dated [DATE] indicated Resident #1 had a BIMS score of 3 which indicated severely impaired cognition. He required substantial to maximal assistance for personal hygiene, putting on/taking off footwear, shower/bathing, toileting hygiene; he required partial/moderate assistance with upper body dressing, oral hygiene, and eating. He was not rated for incontinence due to catheter use and was always incontinent of bowel. Record review of a comprehensive care plan revised 5/21/26 indicated Resident #1 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Interventions were in place to provide ADL assistance including transfers using a mechanical lift and 2 staff members. During an interview on 8/12/26 at 11:30 a.m., the ADON said she was working on hall 100 that day and was responsible for the care of Resident #1. The ADON said Resident #1 got up that morning and participated in game of cornhole and was currently still in the dining room. The ADON said resident was able to express his needs and use a call light and usually asked to go to bed and lay down by 3:00 p.m. During an observation and interview on 8/12/26 at 11:40 a.m., Resident #1 was observed in dining room sitting alone at a table. Resident appeared to be asleep but responded immediately to voice. Resident #1 appeared to be clean and had no offensive odor present. There were no marks, bruises or skin tears observed on exposed skin. Resident #1 said he could not remember how often staff check on him or when he was last changed or checked for incontinence. Resident #1 said staff got him out of bed this morning with a mechanical lift and brought him to an activity in the dining room for a game. Resident #1 said he was waiting for lunch. During an observation and interview on 8/12/26 at 1:00 p.m., Resident #1 was observed in his room, sitting in a wheelchair. Resident's shorts appeared to be wet. Resident #1 said he wasn't sure when he was changed last or checked for incontinence. Resident #1 said he didn't like to get up in bed because staff didn't get him back down. Resident #1 said he stayed in the bed all night and didn't want to be in bed during the daytime. Resident said he had to be in bed to get changed. Resident #1 said he didn't have any skin integrity concerns. Resident #1 said he had been left in bed after being changed and didn't like going to bed early. During an interview on 8/12/26 at 1:20 p.m., CNA A said she frequently checked on Resident #1 because he frequently used his call light. CNA said she usually changed him in the morning around 8:00 a.m., then again after lunch around 12:00 p.m., and once more around 3:00 p.m. CNA A said resident was resistant to care and refused to be changed often. CNA A said resident did not like to get back in bed to get changed. CNA A said Resident #1 was usually heavily wet when she changed him. During an observation on 8/12/26 at 1:40 p.m. through 3:00 p.m., video clips from FM B's cell phone of camera in Resident #1's room indicated Resident #1 was not gotten out of bed during the day on 8/9/26. In a time-stamped video clip dated 8/9/26 at 1:24 p.m. Resident #1 can be heard asking something to the effect of Am I getting up today? and CNA A was seen shaking her head and was heard replying Not today before leaving the room. Resident #1 was observed to be in bed all day. It is unknown if Resident #1 asked more than once to get up from bed. Med Aide G was also identified as being present in the video (by the DON) in the room at the time of the incident. During an observation and interview on 8/13/26 at 9:30 a.m., Resident #1 was observed in his room sitting in a wheelchair, resident appeared clean and well-groomed. Resident had no offensive odor noted. Resident #1 said he was doing okay that morning. During an interview on 8/13/26 at 11:25 a.m., the ADON said Resident #1 enjoyed getting up out of bed to participate in activities. The ADON said Resident #1 liked to be up and out of bed even if he was just watching television in his room. The ADON said not providing Resident #1 ADL assistance to get up out of bed would be violating his resident rights. During an interview on 8/13/26 at 11:45 a.m., the DON said Resident #1 had been able to stand and pivot to transfer with therapy as well as walking with assistance but was still care planned for mechanical lift transfers with 2 staff members. The DON said if Resident #1 was not provided assistance to get up out of bed when he wanted it could be a violation of resident rights. The DON said Resident #1 liked to be up out of his bed and enjoyed activities and watching westerns. During an interview on 8/13/26 at 11:55 a.m., the ADM said Resident #1 required stand and pivot assistance to transfer with therapy but also utilized a mechanical lift for staff when needed if resident was ill or staff were otherwise unable to transfer. The ADM said not providing assistance to a resident who wants to get out of bed could be a violation of their resident rights. During an interview on 8/13/26 at 1:45 p.m., CNA A said she possibly changed or assisted Resident #1 with care with Med Aide G. CNA A said she couldn't remember. CNA said Resident #1 liked to get back up out of bed, but then will complain to the next shift that he wasn't put in bed earlier. CNA A said she probably should have gotten Resident #1 back up out of bed when he asked on 8/9/26. CNA A said Resident #1 will sometimes fight with staff about being laid down because he's scared he won't get back up. During an observation on 8/13/26 at 1:55 p.m., CNA A and CNA D were preparing to transfer Resident #1 to bed using a mechanical lift. Resident #1 repeatedly asked are you going to get me back down? requiring frequent reassurance from staff that he would be gotten back up out of bed. Resident #1 stated I'm in that damn bed all night, I don't want to stay in bed. Resident #1 was then transferred into bed by CNAs using a mechanical lift. Resident #1 was provided incontinent care and his brief was saturated with urine and soiled with stool. Resident #1's mechanical lift sling (medical device that sits under resident and attaches to a mechanical lift) was saturated in urine as well. Resident had no noted redness, excoriation, or wounds as observed during incontinent care. During an interview on 8/13/26 at 3:08 p.m., Med Aide G said Resident #1 had been left in bed on day shifts on weekends from time to time due to staffing shortages but did not specify a specific time or date. Med Aide G said she doesn't recall assisting CNA A in providing any care to Resident #1 or hearing her tell Resident #1 Not today regarding resident getting up from bed. Med Aide G said she didn't know CNA A by name. Interviews were attempted with LVN F, who worked the 6:00 a.m. to 6:00 p.m. shift on 8/9/26, on 8/13/26 at 10:30 a.m., 11:00 a.m.,12:35 p.m., and 3:03 p.m. Review of a staffing assignment sheet for 8/9/26 indicated:LVN F worked 6A-6P and was assigned halls 100 and 600; CNA A worked 6A--AP and was assigned hall 100 and the Dining Room Review of a staffing assignment sheet for 8/9/26 indicated all staff positions were covered and CNA A was assigned to Resident #1's hall which was hall 100. Review of a facility policy titled Resident Rights revised February 2021 indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.self-determination.

Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accident and hazards in that: CNA H transferred Resident #1 from his wheelchair to his bed using a mechanical lift by herself, without the care planned second staff member assisting on 8/8/26 at approximately 9:36 p.m. This failure could place residents who require mechanical lift transfers at risk for falls and hospitalization.Findings included: Record review of Resident #1's face sheet dated 8/12/26 indicated Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia (partial paralysis of all four limbs and the trunk), neuromuscular dysfunction of bladder (inability to fully empty bladder), neurogenic bowel (nerve damage to bowels), and Parkinson's disease (nervous system disorder causing tremor, muscular rigidity, and slow, imprecise movement). Record review of a quarterly MDS dated [DATE] indicated Resident #1 had a BIMS score of 3 which indicated severely impaired cognition and he required substantial to maximal assistance for personal hygiene, putting on/taking off footwear, shower/bathing, toileting hygiene; he required partial/moderate assistance with upper body dressing, oral hygiene, and eating. He was not rated for incontinence due to catheter use and was always incontinent of bowel. He required substantial/maximal assistance for transfers. Record review of a comprehensive care plan revised 5/21/24 indicated Resident #1 had an ADL self-care deficit and was at risk for not having their needs met in a timely manner. Interventions were in place including transfer assistance requiring a mechanical lift and 2 staff members. During an interview on 8/12/26 at 11:30 a.m., the ADON said she was working on hall 100 that day and was responsible for care of Resident #1. The ADON said got up that morning and participated in game of cornhole and was currently in the dining room. The ADON said Resident #1 required mechanical lift transfer and 2 staff members. The ADON said no staff member besides therapy assistants should be getting staff up to transfer by standing/pivoting. The ADON said resident was able to express his needs and use a call light and usually asked to go to bed and lay down by 3:00 p.m. During an observation and interview on 8/12/26 at 11:40 a.m., Resident #1 was observed in dining room sitting alone at a table. Resident appeared to be asleep but responded immediately to voice. Resident appeared to be clean and had no offensive odor present. There were no marks, bruises or skin tears observed on exposed skin. Resident #1 said he could not remember how often staff check on him. Resident #1 said staff got him out of bed this morning with a mechanical lift and brought him to an activity in the dining room for a game. Resident #1 said he was not sure how many staff members assisted him in transferring him in the mechanical lift. Resident #1 said he was waiting for lunch. During an observation and interview on 8/12/26 at 1:00 p.m., Resident #1 was observed in his room, sitting in a wheelchair. Resident #1 said he was not sure who transferred him in the mechanical lift. Resident #1 said he had fallen previously, in the past, from a mechanical lift and didn't like using them. Resident #1 said he was unsure if he had been transferred by any staff member alone using the mechanical lift. During an interview on 8/12/26 at 1:20 p.m., CNA A said she frequently checked on Resident #1 because he frequently used his call light. CNA A said she always transferred Resident #1 using a mechanical lift and two staff members. CNA A said risks to resident from improper mechanical lift transfer could be a resident fall. During an observation on 8/12/26 at 1:40 p.m. through 3:00 p.m., video clips from FM B's cell phone of camera in Resident #1's room indicated Resident #1 was transferred from his wheelchair to his bed by CNA H on 8/8/26 at approximately 9:36 p.m CNA H used the mechanical lift and performed the transfer by herself without a second staff member. CNA H performed the transfer without Resident #1 waving unsteadily or dropping resident down suddenly. During an interview on 8/13/26 at 3:40 p.m., CNA H said she could not recall ever transferring Resident #1 by herself. CNA H said she would not transfer Resident #1 by herself unless maybe we were short staffed. CNA H said she normally got help to transfer residents in a mechanical lift. CNA H said the risk to residents from transferring them in a mechanical lift without a second staff member could be resident death. CNA H said she knew better than to transfer a resident alone using a mechanical lift and had been trained to use require 2 staff members. CNA H was asked about the video footage and stated If I transferred him there was somebody else around. During an observation and interview on 8/13/26 at 9:30 a.m., Resident #1 was observed in his room sitting in a wheelchair, resident appeared clean and well-groomed. Resident had no offensive odor noted. Resident #1 said he thought staff had two staff members transfer him in the mechanical lift that morning, but he was unsure. During an interview on 8/13/26 at 11:45 a.m., the DON said Resident #1 was care planned for transfers using a mechanical lift and 2 staff members. The DON said Resident #1's care plan did not accurately reflect resident's transfer status and he didn't require a mechanical lift transfer unless ill. The DON said the mechanical lift was not removed from the care plan in case Resident #1 needed it when ill. The DON said their policy advised two staff members to perform a mechanical lift transfer, but did not require it. The DON said she did not believe CNA H put Resident #1 at risk by transferring him in a mechanical lift by herself. The DON said they teach their staff not to transfer residents in a mechanical lift without a second staff member due to resident safety risk. During an interview on 8/13/26 at 11:55 a.m., the ADM said there was no risk to Resident #1 being transferred stand/pivot as opposed to a mechanical lift. The ADM said Resident #1 had been up walking with therapy. The ADM said she Resident #1 was still care planned for mechanical lift transfer with 2 staff members. The ADM said she expected staff members to follow care plans. A facility policy titled Mechanical Lift reviewed on 4/24/14 indicated .Although one (1) person can operate most models of hydraulic lifts, it is advisable to have two (2) staff members present to stabilize and support the resident. And step 7 of the instructions indicated .Have second employee to assist by standing on opposite side of the bed, and roll resident toward second employee. Review of the Protekt 500 Power Patient Lift user manual did not contain specifications for minimum number of staff required to operate the lift.

Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 6 (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure Resident #2 was administered Enoxaparin Sodium (used to prevent and treat blood clots) Injection 40mg/.4ml on per physician order due to the medication being unavailable. The facility failed to ensure Resident #2 was administered Lisinopril-hydrochlorothiazide (used to treat high blood pressure) 20-25mg as prescribed due to the medication being unavailable These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings include: 1. Record review of the face sheet dated 7/10/2026 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone that happens in the area directly surrounding an artificial joint replacement), constipation, gastro-esophageal reflux disease without esophagitis (acid reflux), type 2 diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal blood sugar levels), morbid obesity (a severe form of obesity where excess body fat threatens a person's health and daily life) due to excess calories, essential hypertension (high blood pressure), polyosteoarthritis (osteoarthritis in many joints at the same time). Record review of the MDS dated [DATE] indicated Resident #2's 5-day Medicare MDS Assessment reflected she has a BIMS score of 15, indicating she was cognitively intact. Record review of Resident #2 care plan dated 5/29/2026 indicated she has hypertension and is at risk for fluctuations in blood pressure. Interventions include check blood pressure prior to the administration of antihypertensive medications, monitor for and record any noted medication side effects, obtain and monitor lab work and diagnostic studies as ordered. Record review of Resident #2's physician orders dated 7/10/2026 indicated Resident #2's had an order for Enoxaparin Sodium Injection Syringe 40mg/0.4ml given intramuscularly every 12 hours starting on 5/22/26 with no stop date. The physician orders indicated Resident #2 had an order for Lisinopril/Hydrochlorothiazide 20-25mg given 1 tablet by mouth in the morning for HTN starting 5/23/2026. Record review of June 2026 MAR indicated Resident #2 was not administered the following medications as per physician orders: Enoxaparin Sodium 40mg/0.4ml injection: - 6/26/2026 the AM dose;-6/3/2026, 6/14/2026, 6/17/2026, 6/18/2026, 6/23/2026, 6/25/2026, and 6/28/2026 the PM dose; and-6/9/2026, 6/11/2026, 6/13/2026, 6/15/2026, 6/16/2026, and 6/24/2026 the AM and PM dose. Lisinopril-hydrochlorothiazide Oral tablet 20-25mg: -6/22/2026, 6/23/26, 6/24/26, 6/25/26 and 6/26/2026 the AM dose. Based on a record review of the progress notes dated 6/1/2026 to 6/30/2026, indicated that the medications Enoxaparin Sodium Injection 40mg/.4ml and Lisinopril-hydrochlorothiazide were documented as unavailable on dates not given. Based on a record review on 7/10/2026 of blood pressures documented on the MAR from 6/22/2026 to 6/26/2026, Resident #2 had no elevated blood pressures. During an interview conducted on 7/10/2026 at 11:00 AM, Resident #2 stated that she was at the facility for rehabilitation following surgery on her leg. She stated that there had been days when she missed her enoxaparin sodium injection 40mg/0.4ml and lisinopril-hydrochlorothiazide 20-25mg, and stated that the staff told her the medication was not available. She stated that she did not feel her health had been affected, but she remained concerned. During an interview conducted on 7/10/26 at 11:07 AM, the DON stated that Resident #2 should have received her enoxaparin sodium injection 40mg/0.4ml and lisinopril-hydrochlorothiazide 20-25mg as ordered. The DON stated that there should have been documentation regarding notifying the physician or calling the pharmacy if those actions had been taken regarding Resident #2's medication. The DON stated that the facility had experienced issues with getting medications from the pharmacy following the change of ownership on 6/1/26. The DON stated that she expected the nursing staff to notify the physician of a resident missing medications or of medications not being available from the pharmacy[PH4.1]. During an interview conducted on 7/11/2026 at 11:22 AM, the NP stated that she was aware that the facility was having some issues with the changeover of the new company and switching pharmacies. She stated she is in the building 5 days a week and was never notified that Resident #2 had missed her Lisinopril-hydrochlorothiazide oral tab 20-25mg from 6/22/2026 to 6/26/2026. She would expect the staff to notify her if resident is missing any medications. She stated she feels there was no harm if her blood pressure was controlled and she would prefer; she miss the doses due to her not wanting her blood pressure to bottom out. She feels confident that facility would have notified her if resident's blood pressure were not being controlled. She stated as far as the Enoxaparin Sodium she would not [PH5.1]be comfortable managing that medication and would expect the facility to contact the physician regarding the Enoxaparin Sodium. During an interview conducted on 7/11/2026 at 11:52 AM, the Physician stated that he was aware the facility was having some overall issues with getting medication from the new pharmacy due to the changeover. He stated that he was familiar with Resident #2 and confirmed that he was not notified when she did not receive 21 doses of Enoxaparin Sodium Injection 40mg/0.4ml between 6/3/2026 and 6/28/2026. Physician stated that the medication was given prophylactically and not as an active treatment. Physician stated he was unsure why Resident #2 had been discharged from the hospital with no stop date. He also stated that normally the order would be one injection once daily instead of twice daily; therefore, even though she missed 21 doses, she still received over half of what a normal prescription would be and exhibited no clinical issues or concerns. The Physician stated that he believed Resident #2 received no harm due to the facility not following the order. During an interview conducted on 7/13/2026 at 11:15 AM, RN A stated that if medication was unavailable for administration, she would go to the Pyxis machine to retrieve it, and if it was not there, she would notify the DON. She noted that the risks or outcomes would depend on the specific medication that was missed, but stated that at that time, she was unaware of any issues resulting from the missed medications. During an interview conducted on 7/13/2026 at 11:30 AM, the DON stated that the risk for residents if they did not receive medications as ordered could prevent the medication from providing its intended therapeutic effect, leading to an adverse reaction[PH6.1]. During an interview conducted on 7/13/2026 at 11:57 AM, the Administrator stated that she expected staff to give medications as ordered and noted that not following physician orders for medications could cause adverse effects for the residents. She stated that she was aware that there had been issues with getting medications from the pharmacy timely. She stated that the facility had created training regarding the chain of custody of medications, along with notifying the pharmacy when medications needed refills. Record review of the facility's Medication Shortages/Unavailable Medications policy not dated indicated, When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. if a medication shortage is noted at the time of medication administration, the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed.

Based on interviews and record reviews, the facility failed to consult the resident's physician and notify when there was a need to alter treatment significantly for 1 of 6 residents (Resident #2) reviewed for notification of changes. The facility failed to contact the prescribing physician for Resident #2's Enoxaparin Sodium (used to prevent and treat blood clots) Injection Syringe 40mg/0.4ml to obtain a stop date or confirm or clarify administration duration. The facility failed to notify the MD Resident #2 missed a total of 21 doses of Enoxaparin Sodium Injection 40mg/0.4ml due to the medication being unavailable. The facility failed to notify the MD Resident #2 missed a total of 5 doses of Lisinopril-hydrochlorothiazide (used to treat high blood pressure) 20-25mg due to the medication being unavailable. These failures could place residents at risk for not receiving the therapeutic effect of prescribed medications or a decline in health.Findings include: 1. Record review of the face sheet dated 7/10/2026 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone that happens in the area directly surrounding an artificial joint replacement), constipation, gastro-esophageal reflux disease without esophagitis (acid reflux), type 2 diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal blood sugar levels), morbid obesity (a severe form of obesity where excess body fat threatens a person's health and daily life) due to excess calories, essential hypertension (high blood pressure), polyosteoarthritis (osteoarthritis in many joints at the same time). Record review of the MDS dated [DATE] indicated Resident #2's 5-day Medicare MDS Assessment reflected she had a BIMS score of 15, indicating she was cognitively intact. Record review of Resident #2's hospital discharge orders dated 05/22/2026, indicated Resident #2 had an order for Enoxaparin Sodium Injection Syringe 40mg/0.4ml starting on 5/22/26 with no stop date. Record review of Resident #2's care plan dated 5/29/2026 indicated she had hypertension and is at risk for fluctuations in blood pressure. Interventions include checking blood pressure prior to the administration of antihypertensive medications, monitor for and record any noted medication side effects, obtain and monitor lab work and diagnostic studies as ordered. Record review of Resident #2's physician orders dated 7/10/2026 indicated Resident #2 had an order for Enoxaparin Sodium Injection Syringe 40mg/0.4ml given intramuscularly every 12 hours starting on 5/22/26 with no stop date. The physician orders indicated Resident #2 had an order for Lisinopril/Hydrochlorothiazide 20-25mg give 1 tablet by mouth in the morning for HTN starting 5/23/2026. Record review of the Resident #2's June 2026 MAR indicated Resident #2 was not administered the following medications as per physician orders: Enoxaparin Sodium 40mg/0.4ml injection: - 6/26/2026 AM dose;-6/3/2026, 6/14/2026, 6/17/2026, 6/18/2026, 6/23/2026, 6/25/2026, and 6/28/2026 PM dose; and-6/9/2026, 6/11/2026, 6/13/2026, 6/15/2026, 6/16/2026, and 6/24/2026 AM and PM dose. Lisinopril-hydrochlorothiazide Oral tablet 20-25mg: -6/22/2026, 6/23/26, 6/24/26, 6/25/26 and 6/26/2026 AM dose. Record review of Resident #2's electronic medical records, accessed on 07/10/2026, did not indicate contact with the prescribing physician regarding the Enoxaparin Sodium Injection to obtain a stop date or confirm or clarify administration duration. Record review of the progress notes conducted dated 6/1/2026 to 6/30/2026 indicated that Resident #2's medications were documented as unavailable. The progress notes did not indicate the facility had notified the doctor or NP that the medications Enoxaparin Sodium Injection 40mg/0.4ml and Lisinopril-hydrochlorothiazide were unavailable or not given. During an interview conducted on 7/10/26 at 11:07 a.m., the DON stated that Resident #2 should have received her enoxaparin sodium injection 40mg/0.4ml and lisinopril-hydrochlorothiazide 20-25mg as ordered. The DON stated that there should have been documentation regarding notifying the physician or NP if medication was unavailable[PH1.1][SS1.2]. During an interview conducted on 7/11/2026 11:22 a.m., the NP stated that she was aware that the facility was having some issues with the changeover of the new company and switching pharmacies. She stated she is in the building 5 days a week and was never notified that Resident #2 had missed her Lisinopril-hydrochlorothiazide oral tab 20-25mg from 6/22/2026 to 6/26/2026. She would expect the staff to notify her if resident is missing any medications. She stated she feels there was no harm if her blood pressure was controlled and she would prefer; she miss the doses due to her not wanting her blood pressure to bottom out. She feels confident that facility would have notified her if the resident's blood pressure were not being controlled. She stated as far as the Enoxaparin Sodium she would not be comfortable managing that medication and would expect the facility to contact the physician regarding the Enoxaparin Sodium. During an interview conducted on 7/11/2026 at 11:52 AM, the Physician stated he was aware the facility was having some overall issues with getting medication from the new pharmacy due to the changeover. He stated that he was familiar with Resident #2 and confirmed[PH2.1] that he was not notified when she did not receive 21 doses of Enoxaparin Sodium Injection 40mg/0.4ml between 6/3/2026 and 6/28/2026. The Physician expressed that the medication was given prophylactically and not as an active treatment. The Physician stated he was unsure why Resident #2 had been discharged from the hospital with no stop date. He also stated that normally the order would be one injection once daily instead of twice daily; therefore, even though she missed 21 doses, she still received over half of what a normal prescription would be and exhibited no clinical issues or concerns. The Physician said that he believed Resident #2 received no harm due to the facility not following the order. During an interview conducted on 7/13/2026 at 11:15 AM, RN A stated that if medication was unavailable for administration, she would go to the Pyxis (an automated dispensing cabinet [PH3.1][SS3.2]used in hospitals to securely store, track, and dispense medications and medical supplies) machine to retrieve it, and if it was not there, she would notify the DON. She stated that she should have contacted the NP. RN A stated she did not notify the physician of Resident #2 not receiving her medications or her medications being unavailable. RN A stated the risks of a resident not receiving their prescribed medication would depend on what the medication was that was not administered. During an interview conducted on 7/13/2026 at 11:30 AM, the DON stated that the risk for residents if the doctor was not notified could include adverse reactions. The DON noted that if notification had been completed, the physician would have been able to evaluate the resident and decide if another medication could be substituted or discontinued of medication. The DON stated that the physician would not be aware of following up on the condition of the resident after not receiving the medication if he was not informed. The DON stated that staff should document all communication with the physician. During an interview conducted on 7/13/2026 at 11:57 AM, the Administrator stated that she expected staff to give medications as ordered and noted that not following physician orders for medications could cause adverse effects for the residents. She stated that she expected that at any time medications were not available, staff were to notify the physician or NP, along with nursing management. She stated that nursing management could then coordinate with the NP or physician to come up with an alternative solution. Record review of the facility's Change in a Resident's Condition or Status policy last revised 4/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview and record review the facility failed to ensure that residents received medication at time ordered by the physician for 2 of 3 residents (Resident #'s 1 and 2) reviewed for medication administration. The facility failed to ensure Resident #'s 1 and 2 received their medications timely according to the physician's orders on 5/13/2026. This failure could place residents at risk for adverse outcome, ineffective therapeutic response, and decline in health status. Findings included: During an interview on 05/14/2026 at 10:41 A.M., Resident #1 was in her bed with husband at bedside the resident was interviewable, alert, oriented, clean, and well groomed, bed in regular position, water at bedside, and the call light was in reach. Resident #1 stated she had an issue with yesterday's medication pass (5/13/2026) in that she received all her morning medications around two o'clock in the afternoon. A record review of Resident #1'sface sheet, dated 5/14/2026, revealed a [AGE] year-old female admitted on [DATE], diagnoses included diverticulitis(small bulging pouches) of large intestine, colostomy, anxiety disorder, insomnia, personal history of other diseases of circulatory system, acquired absence of right leg below the knee, neuropathic bladder, chronic atrial fibrillation, chronic pain syndrome muscle weakness, chronic obstructive pulmonary disease, acute respiratory failure, obesity due to excess calories, and methicillin resistant staphylococcus aureus infection(an infection resistance to methicillin or other common antibiotics) A record review of Resident #1's quarterly MDS assessment, Section C(focuses on assessing a resident's attention, orientation and ability to register and recall new information and signs of delirium), dated 3/31/2026, revealed a BIMS score of 15, which indicated she was cognitively intact. During a record review of Resident #1's Medication Administration Record, dated 5/15/2026, it was determined that all morning medications were administered, there was no negative outcome to the resident as a result of the late administration. During an observation and interview on 05/14/2026 at 11:00 A.M., Resident #2, was in her room sitting in a wheelchair beside her bed. She was alert, oriented, clean, well groomed, water at bedside, and call light was in reach. Resident #2 stated she had an issue with yesterday's medication pass (5/13/2026) in that she received all her morning medication about 1:30 p.m. in the afternoon. A record review of Resident #2's face sheet, dated 5/14/2026, revealed a [AGE] year-old female admitted on [DATE], diagnoses included Peripheral Vascular Disease( disease or disorder of the circulatory system outside of the brain or heart), acute embolism and Thrombosis of Left lower extremity, chronic diastolic heart disease, anemia, impacted cerumen right ear (occurs when earwax (cerumen) builds up and hardens in the ear canal, blocking it) overactive bladder, bursitis(inflammation of the bursae in your hip), abnormal gait, muscle weakness, adjustment disorder with anxiety, dyspnea(difficulty breathing), Osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), hypertension(high blood Pressure). A record review of Resident #2's quarterly MDS assessment, Section C (focuses on assessing a resident's attention, orientation and ability to register and recall new information and signs of delirium),, dated 3/31/2026, revealed a BIMS score of 15, which indicated she was cognitively intact. A record review of Resident #2's Medication Administration Record, dated 5/14/2026, it was determined that all morning medications were administered, there was no negative outcome to the residents as a result of the late administration. During an interview on 5/14/2026 at 11:44 A.M., LVN B, charge nurse for hall 3, stated that between 6:30 A.M. to 7:00 A.M. On 5/14/2026 she reported to the scheduler that the medication aide for Hall 3 had not showed up and there was no one to give meds. LVN B stated during the morning department head meeting, at around 9:00 A.M., she informed the DON, ADON, Administrator, and Social Worker that there was still no medication aide for morning medication pass. LVN B stated she was told by the DON it would be taken care of. LVN B stated she did pass some pain medications, and at around 1:30 P.M. - 2:00 P.M. the morning meds, which were anytime medications, were passed by the scheduler MA D, who was also a medication aide. During an interview on 5/14/2026 at 12:21 P.M., MA D stated she was also the scheduler and was aware they were shorthanded. MA D stated that all residents did receive their medications. During an interview and record review on 5/14/2026 at 1:30 P.M., the DON provided in-services where staff were educated on giving medications timely. She stated any nurse or medication aid could have done the medication pass, and that she had instructed the scheduler, who was also a MA, to pass the medications and she assumed it was done.; however, it was not done until after 1:30 p.m. The DON stated there was no policy for anytime medication (that the medication can be taken usually daily at any time). Per DON, the medical director was notified of the medication error(s) and there was no negative outcome. During an interview with MA D on 5/15/2026 at 9:30 A.M., she stated she was also the scheduler and was to be on a training call on the 5/13/2026. She stated the DON and Administrator knew she was on the call for the day. MA D stated they knew by nine o'clock that morning there was no medication aide on hall 3. She stated she assumed they had covered and resolved the issue. She stated she was not notified until one o'clock that afternoon that medications were not passed. She stated she then got on the cart and passed all medications. She repeatedly said she didn't want to say the wrong thing regarding who all was aware of the issues. During an interview with the Administrator on 5/15/2026 at 12:00 P.M., she said there was no negative outcome with any medications that were given late.Record review of the facility policy titled, Medication Administration, dated 2/10/2020,Indicated, Purpose: to safely and accurately prepare and administer medication according to physicians' orders and patient needs. 9.Administer medication - Administer medication in accordance with frequency prescribed by physician - within 60 minutes before or after prescribed dosing time - if patient is not in room to receive medication lag the MAR and at conclusion of medication pass, roll cart to patients' location and administer medications In-services were reviewed and were compliant.

Based on observation, interview, and record review, the facility failed to distribute ice under sanitary conditions for 1 of 3 ice chests on hall 200. The facility failed to ensure ice was distributed under sanitary conditions on hall 200. These failures could place residents at risk of being served in unsanitary conditions and for waterborne illnesses.Findings included: During an observation on 05/15/2026 at 10:46 A.M., CNA Awas observed passing ice on Hall 2 without a proper scoop. She was using a pink water pitcher and allowing the ice scoop to touch the rims of used residents' pitches before dipping it back into the ice chest then leaving the pink water pitcher in the ice chest. During an interview on 5/15/2026 at 10:46 A.M., CNA A said she knew she was not supposed to use a pitcher for a scoop and the pitcher should not be left in the ice chest. CNA A said she was not sure how the ice chest got cleaned and who was responsible for cleaning the chest. During an observation of the Halls 2,3,4 on 05/15/2026 at 10:55 A.M.,, the ice Chest on halls 2,3,4 all had improper drainage for the ice chest. Observation indicated the ice chests were dirty with black, slimy scum, build up on the bottom of chest. During an interview with the DON on 05/15/2026 at 10:58 A.M., she said they did not have any more ice scoops and CNA A was using a pink pitcher as an ice scoop but did not know CNA A was leaving it in the ice chest. She said they would go get ice scoopers and have a container to store the scoop properly. During an interview with the DM on 05/15/2026 at 11:00 A.M., she said dietary was responsible for cleaning the ice chest but it was the CNA's job to get the ice chest to the kitchen. During an Record review of the Dietary Cleaning Log on 5/15/2026, there was not a cleaning schedule for the Ice Chest. During an interview on 5/15/2026 at 11:05 AM, the Administrator said they did not have a policy for dietary on how and when the hall ice chest was to be cleaned and knew this could lead to some kind of waterborne illness. During an Record review of the facility's policy on 05/15/2026, titled, Safe Ice Handling, dated 11/2006 and revision date of 3/2012, indicated, Policy: Ice will be handled in a manner to protect the ice from contamination. Appropriate ice handling practices prevent contamination and the potential for waterborne illness.1. Only ice scoops, held by the handle or ice dispensers, will be used for dispensing ice2. Ice chest used for ice pass and or ice service will be kept clean and sanitized and will have holders do ice scoops storage a. clean ice chest at least weekly and as needed b. Discard ice3. Ice Scoops and holders will be cleaned, sanitized and allowed to dry air routinely.

Based on observation, interview, and record review, the facility failed to have an effective infection control program to prevent the development and transmission of disease and infection for 1 of 2 residents reviewed for incontinent care/peri care (Resident #30).CNA A contaminated clean areas and did not thoroughly clean Resident #30 when providing incontinent care.This failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections.Findings included:Record review of a face sheet dated 03/25/2026 indicated Resident #30 was an [AGE] year-old female who admitted on [DATE] with diagnoses including: diabetes, dementia, wedge compression fractures of the 4th and 5th thoracic vertebrae, cognitive communication deficit, high blood pressure and heart disease. Record review of the most recent quarterly MDS dated [DATE] for Resident #30 indicated the resident required partial assistance of 1 staff with transfers, dressing, toileting and personal hygiene. She was frequently incontinent of bladder and bowel.Record review of a care plan initiated on 03/29/2023 indicated Resident #30 had an ADL self care performance deficit and required extensive assistance of 1 person with toileting and personal hygiene. A care plan initiated on 11/25/2022 and last revised 08/04/2025 indicated Resident #30 was incontinent of bowel and bladder and required to be kept clean and odor free and would be checked frequently for wetness and soiling and changed as needed.During an observation and interview on 03/23/2026 at 10:09 AM CNA A was performing incontinent care on Resident #30. The resident was lying on her left side and her brief was undone exposing her buttocks. CNA A had the package of wipes laying on the bed, there was no setup on the overbed table and no sanitizer bottle in use. CNA A wiped the right hip and top part of the right buttock with a wipe. CNA A flipped the wipe towards the rest of the resident's buttocks but did not actually touch or clean her buttocks or open the anal area for cleansing. She discarded the wipe in the trash can. She rolled up the old brief and placed it in the trash can. Using her soiled gloves, she placed a fresh brief under the resident. Without changing or removing her gloves she turned the resident to her back. The resident was able to assist and she raised her left hip and the CNA pulled the brief through on her side and up through her legs and fastened the brief. She then removed her gloves. She did not wash her hands. Without washing her hands she proceeded to remove clothes from the closet, dressed the resident, helped the resident transfer to the wheelchair and brushed the resident's hair. She did not wash her hands before doing any of those activities and was not wearing gloves. She said she did not come prepared to do incontinent care in front of the state surveyor she said they did extra things when the surveyors watched them. She said if she knew she was going to be watched to perform incontinent care she would have brought more items. She said she did not have enough gloves with her and she only had one pair to perform incontinent care.During an interview on 03/26/2026 at 3:40 PM the DON said she had completed CNA proficiency training and return demonstration on incontinent care in January 2026. She said she utilized a Perineal Care check-off list to make sure the individual followed every step in the process correctly. She said she expected the staff member to bring no less than 5 pairs of gloves when providing care. She said the staff member should wash their hands before setting hp their supplies and beginning incontinent care. She said equipment should be placed on a clean overbed table at the bedside. She said after cleaning and drying the front area of the resident their gloves should be removed and they should wash their hands or use a liquid hand sanitizer. She said they should put on fresh gloves and turn the resident on their side and clean the back area of the resident cleansing from front to back and cleaning the rectal area and both buttocks and hips. She said they should then remove their gloves and wash their hands before placing the clean brief under the resident. She said once they had finished applying and fastening the brief they should remove their gloves and wash their hands. She said if they did other things for the resident they should wash their hands before leaving the room. She said they could never wash their hands enough times. She said she emphasized the process always went from clean to dirty.Record review of the Incontinent Care Policy, dated 04/10/2017, indicated .11. Cleanse peri-area and buttocks with cleansing agent wiping from the front of perineum toward rectum.dry peri-area and buttocks from front to back.14. Remove linen/underpad and discard. 15. Remove and discard gloves. 16. Wash hands. Apply clean linen/underpad, brief or other incontinent products.Record review of an undated Perineal Care checklist used to check CNAs for proficiency in providing perineal care indicated the following: .5. Wash hands and put on gloves.7. Place wipes package on clean bedside table.14. Clean rectal area.15. Dry resident.17. Change gloves and wash hands. 18. Place a clean incontinent pad or brief on resident. 22. Remove gloves and wash hands.Record review of the World Health Organization's Glove Use Information Leaflet revised August 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal

Based on observation, interview and record review, the facility failed to ensure they took steps to prevent further potential abuse or neglect while the investigation was in progress and they took appropriate corrective action after the alleged violation was verified for all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. 1. The facility failed to correct identified neglect identified in grievances filed on 02/02/26 related to Resident #1, Resident #3, and Resident #4 extra dummy call lights. 2. The facility failed to suspend CNA A and CNA B when they were identified in an allegation of neglect related to grievances filed on 02/02/26 for Resident #1, Resident #3, and Resident #4's extra dummy call lights. 3. The facility failed to prevent verbal abuse of Resident #2 on 02/04/26, when they did not suspend CNA A after an allegation of neglect that was reported on 02/02/26 and after confirmation from the DON to Family Member H on 02/04/26 at 9:24 AM that CNA A would be suspended. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 02/13/26 at 10:20AM, While the IJ was removed on 02/13/26 at 04:43PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of emotional harm and neglect.Findings included: 1. Record review of Resident #1's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cervical disc disorder with myelopathy (a serious, progressive condition where degenerated discs and bone spurs compress the spinal cord in the neck), Parkinson's disease (a progressive neurodegenerative disorder caused by the loss of dopamine-producing brain cells, leading to movement-related symptoms), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cervical spinal cord injury (involves damage to the vertebrae or nerves in the neck), neurogenic bowel (the loss of normal bowel function due to nerve damage), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Record review of Resident #1's quarterly MDS assessment, dated 12/12/25, reflected he had a BIMS score of 03, which indicated severe cognitive impairment. He was able to make himself understood, and he was able to understand others. He had a functional limitation in range of motion for all four extremities. He required supervision or touching assistance with eating and oral hygiene. He required substantial assistance with toileting, bathing, upper body dressing, personal hygiene, and roll left and right, and sit to lying bed mobility. He was dependent on staff for lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfers, and tub/shower transfers. He required moderate assistance with wheelchair ambulation. He was always incontinent of both bowel and bladder. Record review of Resident #1's care plan, included a focus of falls, last revised on 05/21/24. The focus reflected Resident had the potential for falls related to unspecified injury at unspecified level of cervical spinal cord. Interventions included, place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concerns that another CNA, [CNA B], has been switching out [Resident #1's] call light cord/button with a dummy one that does not work. The concern is that this is happening during evening/weekend shifts when [CNA B] is working.Facility follow up was assigned to the Administrator/DON. A meeting was not held. Specific actions taken to resolve the grievance was maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. Record review of Resident #3's face sheet, dated 02/12/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), wedge compression fracture of 4th thoracic vertebra (occurs when the front part of this upper-back bone collapses), and dysphagia (difficulty swallowing). Record review of Resident #3's quarterly MDS assessment, dated 12/26/25, reflected that she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood, and she was able to understand others. She required supervision or touching assistance with toileting hygiene, and sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfers, and tub/shower transfer. She required setup or clean-up assistance with oral hygiene, upper body dressing, and roll left and right. She required moderate assistance with bathing and putting on/taking off footwear. She was frequently incontinent of bowel and bladder. Record review of Resident #3's care plan reflected a focus of Falls, last revised on 03/02/23. The focus further reflected Resident had the potential for falls related to poor safety awareness, bowel and bladder incontinence, weakness, debility, and varying cognition. The focus identified 3 fall incidents. Interventions included patient educated on use of call light and assist from staff to assist with mobility tasks and place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker a concern that another CNA, [CNA B], had given [Resident #3] a dummy call light cord/button that does not work, the weekend of January 31st and February 1st.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. Record review of Resident #4's face sheet, dated 02/12/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included displaced fracture of right femur (a serious injury where the thighbone is broken and the pieces are misaligned), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and repeated falls. Record review of Resident #4's quarterly MDS assessment, dated 01/02/26, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. She was able to make herself understood, and she was able to understand others. She required substantial assistance with toileting, bathing, lower body dressing, and sit to lying, lying to sitting, chair/bed-to-chair transfers, toilet transfer, and tub/shower transfer. She required moderate assistance with upper body dressing, personal hygiene, roll left and right, and sit to stand. She was always incontinent of both bowel and bladder. Record review of Resident #4's care plan reflected a focus of Resident will call out loudly instead of using call light, last revised 01/28/26. Interventions included Redirect resident to utilize call light for assistance. The care plan further reflected a focus of Falls, last revised on 11/10/25. This focus included Resident had the potential for falls related to history of falls. Interventions included Place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concern that another CNA, [CNA B], has possibly been switching out [Resident #4's] call light cord/button with a dummy one that does not work. It is believed this is happening during evening/weekend shifts when [CNA B] is working.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/06/26. Record review of an untitled document, dated 02/05/26 and provided by the Administrator on 02/12/26 at 11:36AM reflected: Date 02.05.2026Re: Dummy Call LightsOn 02.02.2026 around 4:30 pm, Administrator received Grievances from Social Worker regarding employees using a Fake Call Light.I asked staff about Dummy Call Lights, and they stated they had heard about it, but they were not sure if it [was] true or who was doing it.On 02.03.2026, Administrator asked Maintenance Director to assess all the call lights in the building, which he did. He found all Lights in working order and functioning properly.I interviewed [Resident #4] and she says it happens sometimes in the evening that her call light isn't answered timely. She wasn't too clear on the exact dates. She did not see two call lights in her room, but says it takes a long time for anyone to answer the lights.I interviewed [Resident #1], and he said it takes a long time to get his call light answered. He did not give the Administrator a name, but his roommate, [Resident #2] stated that it was [CNA A] who was unplugging the call Lights. I asked [Resident #2] if he had seen two call lights and he answered No but [The HR Director] told him a few weeks ago that she saw two Call Lights in [Resident #1's] room.Administrator later returned to [Resident #1's] room and found his Call Light tangled in the wheels of his wheelchair and the Call Light was pulled out of the wall. Administrator asked for help from ADON and she assisted the Resident and placed his Call Light back into his wall.I interviewed both [CNA B] and [CNA A] together on 02.04.2026. Both denied unplugging call lights, but [CNA B] stated that she heard it was [CNA A].CNA B does not work on [Resident #1's hall], but [CNA A] does. Record review of an undated statement signed by the HR Director reflected: I don't remember the exact day, but it was the end of December. I pushed [Resident #1] into his room after breakfast and found a call light on the floor, not plugged in. I looked over at the call light plug on the wall and saw another call light plugged in. I handed him the call light that was plugged in and took the other one to the ADON office as I assumed it was broken. Record review of an email, dated 02/04/26 at 09:28PM, sent by LVN F to the Administrator, reflected: On February 2, 2026, at around 0700 my [Resident #3's hall] aide approached me with a call light issue that had happened the night before. A resident by the name of [Resident #3] stated the night aide [CNA B] had put her call light out of reach and put another light in her room that wasn't plugged in as a dummy light. The day shift aide mentioned two other residents she had done the same thing [to]. This incident was reported to the social worker who then wrote grievances on the aide. Record review of an Associate Disciplinary Memorandum, dated 02/12/26, reflected that CNA B was suspended pending an investigation on 02/12/26 related to .Staff member was involved in an incident where it was alleged that she was changing out [resident] call lights with ones that didn't work. 2. Record review of Resident #2's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included respiratory failure (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body), sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep, causing low blood oxygen and poor sleep quality), and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #2's quarterly MDS assessment, dated 01/09/26, reflected he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. Record review of a Provider Investigation Report, dated 02/11/26, reflected in the investigation summary section: On 02.04.2026, [Resident #2] reported he asked [CNA A] to get [Resident #1], and she said she would in a few minutes. The Resident stated he said No, get him up now! According to [Resident #2] she still refused to follow his instructions. He began using profanity towards [CNA A]. The CNA replied, You need to mind your business. He yelled, [F-word] you! The CNA responded to [Resident #2], You need to shut the [F-word] up and mind your business![CNA A] denied making that statement.The Resident stated he was offended when he heard [CNA A] curse.[LVN G] stated she overheard [Resident #2] yelling and using profanity, but did not hear [CNA A] yell or curse at Resident. Record review of Resident #5's face sheet, dated 02/12/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a term for lung and airway diseases that restrict your breathing), aphasia (an impairment in a person's ability to comprehend or formulate language), and dysphagia (difficulty swallowing). Record review of Resident #5's quarterly MDS assessment, dated 11/11/25, reflected she had a BIMS score of 14, which indicated intact cognition. She was usually able to make herself understood, and she was able to understand others. Record review of an Associate Disciplinary Memorandum, dated 02/04/26, reflected that CNA A was suspended pending an investigation on 02/04/26, related to .CNA was named as the employee that spoke [with] resident using foul language towards them . and .Staff member allegedly told a resident to shut up. Record review of timesheets for CNA A and CNA B, dated 02/02/26 through 02/12/26, reflected:CNA A worked on 02/04/26 from 07:26 AM through 05:20PM for a total of 9.25 clocked hours.CNA B worked 02/01/26-02/02/26 from 05:55PM through 06:01AM for a total of 11.5 clocked hours.CNA B worked on 02/05/26-02/06/26 from 05:45PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/07/26-02/08/26 from 05:47PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/08/26-02/09/26 from 03:31PM through 06:01AM for a total of 13.5 clocked hours.CNA B worked on 02/09/26-02/10/26 from 05:40PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/10/26-02/11/26 from 05:53PM through 06:03AM for a total of 11.5 clocked hours. Record review of Nurse/CNA schedules for February 2nd through the 11th reflected:*On 02/04/26, CNA A was assigned to Resident #1, Resident #2, and Resident #4's hall.*On 02/05/26, CNA B was assigned to Resident #3's hall.*On 02/09/26, CNA B was assigned to Resident #3's hall.*On February 10th, 2026, CNA B was assigned to Resident #3's hall. During an interview on 02/11/26 at 12:09PM, Family Member H said she was a family member of Resident #1. She said she had major complaints about the administration in the facility. She said when she was reporting the call light issue to the Administrator, she would not help her unless she told the Administrator what residents had talked to her. She said she heard that CNA A and CNA B take the resident's call light away and then provide a call light that is not plugged into the wall. She said sometimes, he did not have water when some aides took care of him. She said she had came up to the facility and there have been many times Resident #1's sheets were saturated. She said Resident #1 had an old spinal cord injury and is not aware when he is in pain. She said Resident #1 fell a few years ago and had to have a lifesaving surgery on his C1-T2 vertebrae. He did not have any bowel/bladder control. She said his pain receptors did not work due to this surgery. She said on February 3rd she came up to the facility to report the call light problem to the DON. She said she received a voicemail from the DON on 04/04/25 at 09:24 am and the DON told her that CNA A and CNA B had been suspended. She said she came to visit Resident #1 on 04/04/25 at 4:00PM and CNA A was in the facility working and taking care of Resident #1. She said the DON had a different story then. She said she then spoke with the Administrator and she would not help her. She said she saw CNA A in the facility and confronted her. She said at 04:38PM, the DON came to her and apologized to her for the situation. She said the DON did not know who CNA A was. She said she took videos of these interactions and would provide them to this surveyor. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/03/26 at 02:10PM, this surveyor observed the following:*Family Member H can be heard talking to the DON and asking about her day.*Family Member H identifies herself to the DON as a family member of Resident #1.*Family Member H notifies the DON about someone removing Resident #1's call light and providing one that is not plugged in to him.*Family Member H said she heard that a man from Maintenance had came into Resident #1's room and checked his call light and had further indicated to her that he also was going to check Resident #4's room.*Family Member H identified CNA B and CNA A as the two aides she heard that may have removed Resident #1's call light and provided him with an unplugged call light.*Family Member H said she heard this from several different people.*The DON said she heard about the call lights this morning in a meeting this morning, but I was not told of the specific rooms. During an observation of a voicemail recording provided to this surveyor by Family Member H, dated 02/04/26 09:24AM, this surveyor observed the following:*The DON identified herself by name and said this call was for Family Member H. She further identified the facility name she was calling from.*The DON identified she was calling about the call light situation.*The DON said CNA B was off the schedule.*The DON said she was suspending CNA A off the schedule until further notice, as of today [02/04/26]. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:07PM, this surveyor observed the following:*Family Member H can be heard initiating a conversation with the DON who is in view on the video.*Family Member H asked the DON is [CNA A] still here?*The DON said, one of them was here earlier.*Family Member H said, well you told me [CNA A] was suspended earlier.*Family Member H said, was she here earlier?*DON said, she may have been here a little bit.*Family Member H and the DON argue about the situation and then the DON walked away from Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 4:12PM, this surveyor observed the following:*Family Member H asked the Administrator how she was doing and the Administrator replied fine.*The Administrator can be heard identifying Family Member H as Resident #1's family member and asking her tell me what's going on.*Family Member H can be heard So you don't know about the call light situation?*The Administrator said, I am asking you, I want to hear from your mouth. I am hearing different stories.* Family Member H said, Well obviously this has been a thing going on.*The Administrator said, Have you seen it?*Family Member H said No, but I have been told by several people.*The Administrator said But have you seen it, because.*Family Member H interrupted the Administrator and said, So you're trying to say it didn't happen?*The Administrator said, I'll listen to you.*Family Member H said I know for a fact that the call light has been, I heard from multiple people who have witnessed it. Okay? She has unplugged the call light. [CNA B] started it, and [CNA A] has continued it. I know she got moved off that hall and she has been doing it to more than [Resident #1]. I know these things. *The Administrator said but my question is.*Family member H interrupted the Administrator and said No, I have not seen it, and I am not going to tell you who told me either, so don't ask me please.*The Administrator said, If you can't tell me where you got the information from, how am I going to help solve this?*The Administrator said, I need to know where this information is coming from.*The Administrator said, when you unplug the cord, it sends an alarm.*Family Member H said, They don't unplug it, they put it in the floor and give them a fake one.*The Administrator said, We don't have a fake one.*Family Member H said, Yeah you do, in the other rooms.*The Administrator said So show me.*Family Member H said Show you? You think I know where to find stuff in this place?. Family Member H then stood up and left the Administrator's office. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:15PM, this surveyor observed the following:*The Administrator entered the room and asked Family Member H, so show me what you are talking about.*Family Member H said I'm talking about this call light.It is on the floor, and they are giving him one in his hand.*Family Member H explained to the Administrator about the voicemail she received from the DON explaining CNA A and CNA B were suspended. She told the Administrator that CNA A was present in the facility this day and at this time. She said CNA A was assigned to Resident #1. So, what I want to know is why somebody who took a call light from someone is still here right now and still with [Resident #1]. *The Administrator said, I'll have to find that out for you, because I didn't know that. The Administrator then identified herself as the Administrator after being asked by Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:19PM, this surveyor observed the following:*The Administrator can be seen speaking. She said she discussed the call lights with her supervisor, the regional. we wrote a grievance about it. We are trying to figure it out. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:23PM, this surveyor observed the following:Family Member H can be heard approaching and speaking with a female staff member. The staff member denied giving anyone a fake call light. She identified herself as CNA A. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:38PM, this surveyor observed the following:The DON can be seen on the video speaking. She said, I gave my resignation to the director because of that. We did not know specific rooms. I did not realize that girl was [CNA A]. I dropped the ball. We dropped the ball. I had every intention of going to the Administrator, pulling her in there, and getting this resolved this morning when I left you that message. And then other drama unfolded The DON then acknowledged that Family Member H reported the call light issue to her on 02/03/26 and they were made aware of the issue the morning of 02/03/26. The DON said she reported this to the Administrator on 02/03/26. I gave them my resignation; I did not want them to pin me with patient abandonment. During an observation on 02/12/26 at 12:53PM, this surveyor observed an extra call light in a drawer at the central nurse's station. During an interview on 02/11/26 at 02:56PM, Resident #2 said that he was Resident #1's roommate. He said CNA A moved Resident #1's call light out of his reach. He said he goes over to Resident #1 when this happens and gives him the light back. He said that had been ongoing for at least a month or so. He said he had reported this to the ADON, the Administrator, and the HR Director. He said the Administrator spoke with him about the call light on 02/05/26. He said the Administrator told him they were going to investigate it. He said the Administrator asked him who told him about the call light. He said he reported to her that CNA A was plugging a fake call light into the wall on his roommate's side. He said on 02/05/26, he was told CNA A was suspended. During an interview on 02/12/26 at 08:47AM, the HR Director said her office was on Resident #1's hall. She said back in December, she went into Resident #1's room and noticed his light was on the floor. She said there were two call lights on his side of the room. She said the one that was plugged in, was draped over between his bed and bedside table. She said the other call light on his side of the room was not plugged in and was coiled up on the floor. She said she did not notify the Administrator about this. She said she assumed that it was not working, and they forgot to take the old one out when they changed it. She said she took it to the ADON. She said she did not know at the time of the allegations of a fake call light being used. She said this was towards the end of December. During an interview on 02/12/26 at 9:25AM, the Administrator said she did not suspend CNA B related to the call light incident. She said she spoke with Resident #2, and he said CNA A did it to Resident #1. During an interview on 02/12/26 at 9:56AM, Resident #2 said Resident #1 got upset when he was not able to use his call light. He said Resident #1 hollers and screams when he does not have his call light. He said he tries to help Resident #1 when he can and he gives him the call light back. He said Resident #1 uses his call light a lot. During an interview on 02/12/26 at 10:17AM, CNA D said she usually took care of Resident #1. She said she had worked at this facility for about 7 months. She said a while back, she found an extra call light on the floor in Resident #1's room. She said his regular call light was plugged into the wall and draped over his bedside drawers. She said the other call light was not plugged in and it was in his hand. She said this was about 2-3 months ago. She said when she found this, she went to the DON at the time. She said she grabbed the extra call light and tried to turn it into the Maintenance Director, but he was already gone for the day. She said she gave the light to the HR Director. She said she only saw this happen one time. She said she has not seen this happen to any other residents, only Resident #1. She said she did not know who it may have been. She said the schedule changes a lot. She said Resident #1 hits his call light a lot. She said he hollers out when he does not have it or when the staff do not answer. She said she felt like the person that did this, did it because Resident #1 calls a bunch and they did not want to let him call. She said she felt like the resident may feel secluded or neglected when this happens. She said the resident is forgetful and may not remember this happening. During an interview on 02/12/26 at 11:00AM, the Administrator said CNA A was suspended on 02/04/26 at 5:20PM. She said she was aware of the call light issue at that point. She said she was aware of a complaint of dummy call lights in the facility. She said she had the Maintenance Director go check all the call lights. She said CNA A was named as a potentially involved staff. She said Resident #2 told her a dummy call light was being used. She said she did not suspend CNA B because she was not on the schedule that day. She said she learned about the call light issue on the 2nd or 3rd of February. She said then she heard it could have been [CNA B] or [CNA A]. She said she was told CNA A's name on the 2nd or 3rd of February. She said she talked to CNA B on the 4th of February. She said CNA A worked on the 4th of February. She said the DON told the family of Resident #1 that they were going to suspend CNA A on the 4th. They did not suspend her until 5:20PM on the 4th of February, for the incident regarding alleged verbal abuse of Resident #2. She said she also was told CNA B may be involved on the 2nd or 3rd of February. During an interview on 02/12/26 at 11:20AM, the DON said she was aware of the call light allegation. She said she was made aware of this during a clinical meeting on the 3rd of February. She said she was told someone was doing this with the light. She said they had the Maintenance Director go and check all the call lights. She said she was told the names of CNA A and CNA B on the evening of the 3rd of February. She said the Family Member of Resident #1 notified her of this issue and the names of the two CNAs and which rooms she heard of this. She said she did not suspend CNA A or CNA B. She said they should have been suspended at this point. She said this could be considered neglect or seclusion, especially because Resident #1's means of communication was taken away. She said Resident #1 depended on staff for his needs and ADLs. She said she told the Administrator on the 3rd of February of the allegations with the call light and the two identified staff. She said the Administrator should have suspended CNA A and CNA B when she learned of the allegation. She said she did not know if any of this was reported to HHSC. She said an allegation of neglect or seclusion should have been reported to the state. She said CNA A worked on Resident #1's hall on the 4th of February. She said there was a risk that CNA A could have replaced or moved Resident #1's call light while she was working on the 4th of February. She said she did not feel like the Administrator did a thorough investigation. She said she should have done the investigation as soon as she knew about it on the 3rd, not the 4th. She said she was not sure if CNA B was suspended. She said she was not sure when CNA A was suspended. She said she has not seen this issue personally with her eyes. She said no other resident complained about this, other than Resident #1 and his family. She said in the time she had been in the facility, she was not aware of any issues between Resident #1 and CNA B or CNA A. She said these failures put the residents at risk for further neglect, seclusion, and mistreatment. During an interview on 02/12/26 at 11:35AM, the Administrator said she received a grievance of an issue of fake call lights on the 2nd of February. She said she heard CNA B's name on the 2nd. She heard CNA A's name on the 3rd. She said the complaint was that a fake call light or extra call light was being used. She said her understanding was that the resident would have a call light and it would not work. She said her understanding was that the light was pulled from the wall. She said she thought it was impossible because if it was unplugged it would alarm. She said the next day on the 3rd she was told, no they use two call lights. She said she was told that an extra call light was being used and given to the resident. She said this could be considered an allegation of neglect or seclusion. She said the two identified aides should have been suspended immediately. She said they were not suspended on the 3rd of February. She said CNA B was not on the schedule around the time this was going on. She said CNA B came back around 2-3 days after this. She said CNA A was allowed to work on the 4th of February. She said CNA A was suspended later in the evening on the 4th related to a verbal abuse allegation. She said allowi

Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. 1. The facility failed to ensure Resident #1, Resident #3, and Resident #4 were provided with a call light to call for assistance when their call light was thrown on the floor and provided an extra one dummy that was not plugged into the call light system. 2. The facility failed to ensure Resident #2 was free from verbal abuse when CNA A told him Shut the [F-word] up and mind your business. These failures could place residents at risk of emotional harm. Findings included: 1. Record review of Resident #1's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cervical disc disorder with myelopathy (a serious, progressive condition where degenerated discs and bone spurs compress the spinal cord in the neck), Parkinson's disease (a progressive neurodegenerative disorder caused by the loss of dopamine-producing brain cells, leading to movement-related symptoms), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cervical spinal cord injury (involves damage to the vertebrae or nerves in the neck), neurogenic bowel (the loss of normal bowel function due to nerve damage), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Record review of Resident #1's quarterly MDS assessment, dated 12/12/25, reflected he had a BIMS score of 03, which indicated severe cognitive impairment. He was able to make himself understood, and he was able to understand others. He had a functional limitation in range of motion for all four extremities. He required supervision or touching assistance with eating and oral hygiene. He required substantial assistance with toileting, bathing, upper body dressing, personal hygiene, and roll left and right, and sit to lying bed mobility. He was dependent on staff for lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfers, and tub/shower transfers. He required moderate assistance with wheelchair ambulation. He was always incontinent of both bowel and bladder. Record review of Resident #1's care plan, included a focus of falls, last revised on 05/21/24. The focus reflected Resident had the potential for falls related to unspecified injury at unspecified level of cervical spinal cord. Interventions included, place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concerns that another CNA, [CNA B], has been switching out [Resident #1's] call light cord/button with a dummy one that does not work. The concern is that this is happening during evening/weekend shifts when [CNA B] is working.Facility follow up was assigned to the Administrator/DON. A meeting was not held. Specific actions taken to resolve the grievance was maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. Record review of Resident #3's face sheet, dated 02/12/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), wedge compression fracture of 4th thoracic vertebra (occurs when the front part of this upper-back bone collapses), and dysphagia (difficulty swallowing). Record review of Resident #3's quarterly MDS assessment, dated 12/26/25, reflected that she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood, and she was able to understand others. She required supervision or touching assistance with toileting hygiene, and sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfers, and tub/shower transfer. She required setup or clean-up assistance with oral hygiene, upper body dressing, and roll left and right. She required moderate assistance with bathing and putting on/taking off footwear. She was frequently incontinent of bowel and bladder. Record review of Resident #3's care plan reflected a focus of Falls, last revised on 03/02/23. The focus further reflected Resident had the potential for falls related to poor safety awareness, bowel and bladder incontinence, weakness, debility, and varying cognition. The focus identified 3 fall incidents. Interventions included patient educated on use of call light and assist from staff to assist with mobility tasks and place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker a concern that another CNA, [CNA B], had given [Resident #3] a dummy call light cord/button that does not work, the weekend of January 31st and February 1st.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. Record review of Resident #4's face sheet, dated 02/12/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included displaced fracture of right femur (a serious injury where the thighbone is broken and the pieces are misaligned), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and repeated falls. Record review of Resident #4's quarterly MDS assessment, dated 01/02/26, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. She was able to make herself understood, and she was able to understand others. She required substantial assistance with toileting, bathing, lower body dressing, and sit to lying, lying to sitting, chair/bed-to-chair transfers, toilet transfer, and tub/shower transfer. She required moderate assistance with upper body dressing, personal hygiene, roll left and right, and sit to stand. She was always incontinent of both bowel and bladder. Record review of Resident #4's care plan reflected a focus of Resident will call out loudly instead of using call light, last revised 01/28/26. Interventions included Redirect resident to utilize call light for assistance. The care plan further reflected a focus of Falls, last revised on 11/10/25. This focus included Resident had the potential for falls related to history of falls. Interventions included Place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concern that another CNA, [CNA B], has possibly been switching out [Resident #4's] call light cord/button with a dummy one that does not work. It is believed this is happening during evening/weekend shifts when [CNA B] is working.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/06/26. Record review of an untitled document, dated 02/05/26 and provided by the Administrator on 02/12/26 at 11:36AM reflected: Date 02.05.2026Re: Dummy Call LightsOn 02.02.2026 around 4:30 pm, Administrator received Grievances from Social Worker regarding employees using a Fake Call Light.I asked staff about Dummy Call Lights, and they stated they had heard about it, but they were not sure if it [was] true or who was doing it.On 02.03.2026, Administrator asked Maintenance Director to assess all the call lights in the building, which he did. He found all Lights in working order and functioning properly.I interviewed [Resident #4] and she says it happens sometimes in the evening that her call light isn't answered timely. She wasn't too clear on the exact dates. She did not see two call lights in her room, but says it takes a long time for anyone to answer the lights.I interviewed [Resident #1], and he said it takes a long time to get his call light answered. He did not give the Administrator a name, but his roommate, [Resident #2] stated that it was [CNA A] who was unplugging the call Lights. I asked [Resident #2] if he had seen two call lights and he answered No but [The HR Director] told him a few weeks ago that she saw two Call Lights in [Resident #1's] room.Administrator later returned to [Resident #1's] room and found his Call Light tangled in the wheels of his wheelchair and the Call Light was pulled out of the wall. Administrator asked for help from ADON and she assisted the Resident and placed his Call Light back into his wall.I interviewed both [CNA B] and [CNA A] together on 02.04.2026. Both denied unplugging call lights, but [CNA B] stated that she heard it was [CNA A].CNA B does not work on [Resident #1's hall], but [CNA A] does. Record review of an undated statement signed by the HR Director reflected: I don't remember the exact day, but it was the end of December. I pushed [Resident #1] into his room after breakfast and found a call light on the floor, not plugged in. I looked over at the call light plug on the wall and saw another call light plugged in. I handed him the call light that was plugged in and took the other one to the ADON office as I assumed it was broken. Record review of an email, dated 02/04/26 at 09:28PM, sent by LVN F to the Administrator, reflected: On February 2, 2026, at around 0700 my [Resident #3's hall] aide approached me with a call light issue that had happened the night before. A resident by the name of [Resident #3] stated the night aide [CNA B] had put her call light out of reach and put another light in her room that wasn't plugged in as a dummy light. The day shift aide mentioned two other residents she had done the same thing [to]. This incident was reported to the social worker who then wrote grievances on the aide. Record review of an Associate Disciplinary Memorandum, dated 02/12/26, reflected that CNA B was suspended pending an investigation on 02/12/26 related to .Staff member was involved in an incident where it was alleged that she was changing out [resident] call lights with ones that didn't work. 2. Record review of Resident #2's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included respiratory failure (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body), sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep, causing low blood oxygen and poor sleep quality), and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #2's quarterly MDS assessment, dated 01/09/26, reflected he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. Record review of a Provider Investigation Report, dated 02/11/26, reflected in the investigation summary section: On 02.04.2026, [Resident #2] reported he asked [CNA A] to get [Resident #1], and she said she would in a few minutes. The Resident stated he said No, get him up now! According to [Resident #2] she still refused to follow his instructions. He began using profanity towards [CNA A]. The CNA replied, You need to mind your business. He yelled, [F-word] you! The CNA responded to [Resident #2], You need to shut the [F-word] up and mind your business![CNA A] denied making that statement.The Resident stated he was offended when he heard [CNA A] curse.[LVN G] stated she overheard [Resident #2] yelling and using profanity, but did not hear [CNA A] yell or curse at Resident. Record review of Resident #5's face sheet, dated 02/12/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a term for lung and airway diseases that restrict your breathing), aphasia (an impairment in a person's ability to comprehend or formulate language), and dysphagia (difficulty swallowing). Record review of Resident #5's quarterly MDS assessment, dated 11/11/25, reflected she had a BIMS score of 14, which indicated intact cognition. She was usually able to make herself understood, and she was able to understand others. Record review of an Associate Disciplinary Memorandum, dated 02/04/26, reflected that CNA A was suspended pending an investigation on 02/04/26, related to .CNA was named as the employee that spoke [with] resident using foul language towards them . and .Staff member allegedly told a resident to shut up. Record review of timesheets for CNA A and CNA B, dated 02/02/26 through 02/12/26, reflected:CNA A worked on 02/04/26 from 07:26 AM through 05:20PM for a total of 9.25 clocked hours.CNA B worked 02/01/26-02/02/26 from 05:55PM through 06:01AM for a total of 11.5 clocked hours.CNA B worked on 02/05/26-02/06/26 from 05:45PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/07/26-02/08/26 from 05:47PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/08/26-02/09/26 from 03:31PM through 06:01AM for a total of 13.5 clocked hours.CNA B worked on 02/09/26-02/10/26 from 05:40PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/10/26-02/11/26 from 05:53PM through 06:03AM for a total of 11.5 clocked hours. Record review of Nurse/CNA schedules for February 2nd through the 11th reflected:*On 02/04/26, CNA A was assigned to Resident #1, Resident #2, and Resident #4's hall.*On 02/05/26, CNA B was assigned to Resident #3's hall.*On 02/09/26, CNA B was assigned to Resident #3's hall.*On February 10th, 2026, CNA B was assigned to Resident #3's hall. During an interview on 02/11/26 at 12:09PM, Family Member H said she was a family member of Resident #1. She said she had major complaints about the administration in the facility. She said when she was reporting the call light issue to the Administrator, she would not help her unless she told the Administrator what residents had talked to her. She said she heard that CNA A and CNA B take the resident's call light away and then provide a call light that is not plugged into the wall. She said sometimes, he did not have water when some aides took care of him. She said she had came up to the facility and there have been many times Resident #1's sheets were saturated. She said Resident #1 had an old spinal cord injury and is not aware when he is in pain. She said Resident #1 fell a few years ago and had to have a lifesaving surgery on his C1-T2 vertebrae. He did not have any bowel/bladder control. She said his pain receptors did not work due to this surgery. She said on February 3rd she came up to the facility to report the call light problem to the DON. She said she received a voicemail from the DON on 04/04/25 at 09:24 am and the DON told her that CNA A and CNA B had been suspended. She said she came to visit Resident #1 on 04/04/25 at 4:00PM and CNA A was in the facility working and taking care of Resident #1. She said the DON had a different story then. She said she then spoke with the Administrator and she would not help her. She said she saw CNA A in the facility and confronted her. She said at 04:38PM, the DON came to her and apologized to her for the situation. She said the DON did not know who CNA A was. She said she took videos of these interactions and would provide them to this surveyor. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/03/26 at 02:10PM, this surveyor observed the following:*Family Member H can be heard talking to the DON and asking about her day.*Family Member H identifies herself to the DON as a family member of Resident #1.*Family Member H notifies the DON about someone removing Resident #1's call light and providing one that is not plugged in to him.*Family Member H said she heard that a man from Maintenance had came into Resident #1's room and checked his call light and had further indicated to her that he also was going to check Resident #4's room.*Family Member H identified CNA B and CNA A as the two aides she heard that may have removed Resident #1's call light and provided him with an unplugged call light.*Family Member H said she heard this from several different people.*The DON said she heard about the call lights this morning in a meeting this morning, but I was not told of the specific rooms. During an observation of a voicemail recording provided to this surveyor by Family Member H, dated 02/04/26 09:24AM, this surveyor observed the following:*The DON identified herself by name and said this call was for Family Member H. She further identified the facility name she was calling from.*The DON identified she was calling about the call light situation.*The DON said CNA B was off the schedule.*The DON said she was suspending CNA A off the schedule until further notice, as of today [02/04/26]. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:07PM, this surveyor observed the following:*Family Member H can be heard initiating a conversation with the DON who is in view on the video.*Family Member H asked the DON is [CNA A] still here?*The DON said, one of them was here earlier.*Family Member H said, well you told me [CNA A] was suspended earlier.*Family Member H said, was she here earlier?*DON said, she may have been here a little bit.*Family Member H and the DON argue about the situation and then the DON walked away from Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 4:12PM, this surveyor observed the following:*Family Member H asked the Administrator how she was doing and the Administrator replied fine.*The Administrator can be heard identifying Family Member H as Resident #1's family member and asking her tell me what's going on.*Family Member H can be heard So you don't know about the call light situation?*The Administrator said, I am asking you, I want to hear from your mouth. I am hearing different stories.* Family Member H said, Well obviously this has been a thing going on.*The Administrator said, Have you seen it?*Family Member H said No, but I have been told by several people.*The Administrator said But have you seen it, because.*Family Member H interrupted the Administrator and said, So you're trying to say it didn't happen?*The Administrator said, I'll listen to you.*Family Member H said I know for a fact that the call light has been, I heard from multiple people who have witnessed it. Okay? She has unplugged the call light. [CNA B] started it, and [CNA A] has continued it. I know she got moved off that hall and she has been doing it to more than [Resident #1]. I know these things. *The Administrator said but my question is.*Family member H interrupted the Administrator and said No, I have not seen it, and I am not going to tell you who told me either, so don't ask me please.*The Administrator said, If you can't tell me where you got the information from, how am I going to help solve this?*The Administrator said, I need to know where this information is coming from.*The Administrator said, when you unplug the cord, it sends an alarm.*Family Member H said, They don't unplug it, they put it in the floor and give them a fake one.*The Administrator said, We don't have a fake one.*Family Member H said, Yeah you do, in the other rooms.*The Administrator said So show me.*Family Member H said Show you? You think I know where to find stuff in this place?. Family Member H then stood up and left the Administrator's office. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:15PM, this surveyor observed the following:*The Administrator entered the room and asked Family Member H, so show me what you are talking about.*Family Member H said I'm talking about this call light.It is on the floor, and they are giving him one in his hand.*Family Member H explained to the Administrator about the voicemail she received from the DON explaining CNA A and CNA B were suspended. She told the Administrator that CNA A was present in the facility this day and at this time. She said CNA A was assigned to Resident #1. So, what I want to know is why somebody who took a call light from someone is still here right now and still with [Resident #1]. *The Administrator said, I'll have to find that out for you, because I didn't know that. The Administrator then identified herself as the Administrator after being asked by Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:19PM, this surveyor observed the following:*The Administrator can be seen speaking. She said she discussed the call lights with her supervisor, the regional. we wrote a grievance about it. We are trying to figure it out. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:23PM, this surveyor observed the following:Family Member H can be heard approaching and speaking with a female staff member. The staff member denied giving anyone a fake call light. She identified herself as CNA A. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:38PM, this surveyor observed the following:The DON can be seen on the video speaking. She said, I gave my resignation to the director because of that. We did not know specific rooms. I did not realize that girl was [CNA A]. I dropped the ball. We dropped the ball. I had every intention of going to the Administrator, pulling her in there, and getting this resolved this morning when I left you that message. And then other drama unfolded The DON then acknowledged that Family Member H reported the call light issue to her on 02/03/26 and they were made aware of the issue the morning of 02/03/26. The DON said she reported this to the Administrator on 02/03/26. I gave them my resignation; I did not want them to pin me with patient abandonment. During an observation on 02/12/26 at 12:53PM, this surveyor observed an extra call light in a drawer at the central nurse's station. During an interview on 02/11/26 at 02:56PM, Resident #2 said that he was Resident #1's roommate. He said CNA A moved Resident #1's call light out of his reach. He said he goes over to Resident #1 when this happens and gives him the light back. He said that had been ongoing for at least a month or so. He said he had reported this to the ADON, the Administrator, and the HR Director. He said the Administrator spoke with him about the call light on 02/05/26. He said the Administrator told him they were going to investigate it. He said the Administrator asked him who told him about the call light. He said he reported to her that CNA A was plugging a fake call light into the wall on his roommate's side. He said on 02/05/26, he was told CNA A was suspended. During an interview on 02/12/26 at 08:47AM, the HR Director said her office was on Resident #1's hall. She said back in December, she went into Resident #1's room and noticed his light was on the floor. She said there were two call lights on his side of the room. She said the one that was plugged in, was draped over between his bed and bedside table. She said the other call light on his side of the room was not plugged in and was coiled up on the floor. She said she did not notify the Administrator about this. She said she assumed that it was not working, and they forgot to take the old one out when they changed it. She said she took it to the ADON. She said she did not know at the time of the allegations of a fake call light being used. She said this was towards the end of December. During an interview on 02/12/26 at 9:25AM, the Administrator said she did not suspend CNA B related to the call light incident. She said she spoke with Resident #2, and he said CNA A did it to Resident #1. During an interview on 02/12/26 at 9:56AM, Resident #2 said Resident #1 got upset when he was not able to use his call light. He said Resident #1 hollers and screams when he does not have his call light. He said he tries to help Resident #1 when he can and he gives him the call light back. He said Resident #1 uses his call light a lot. During an interview on 02/12/26 at 10:17AM, CNA D said she usually took care of Resident #1. She said she had worked at this facility for about 7 months. She said a while back, she found an extra call light on the floor in Resident #1's room. She said his regular call light was plugged into the wall and draped over his bedside drawers. She said the other call light was not plugged in and it was in his hand. She said this was about 2-3 months ago. She said when she found this, she went to the DON at the time. She said she grabbed the extra call light and tried to turn it into the Maintenance Director, but he was already gone for the day. She said she gave the light to the HR Director. She said she only saw this happen one time. She said she has not seen this happen to any other residents, only Resident #1. She said she did not know who it may have been. She said the schedule changes a lot. She said Resident #1 hits his call light a lot. She said he hollers out when he does not have it or when the staff do not answer. She said she felt like the person that did this, did it because Resident #1 calls a bunch and they did not want to let him call. She said she felt like the resident may feel secluded or neglected when this happens. She said the resident is forgetful and may not remember this happening. During an interview on 02/12/26 at 11:00AM, the Administrator said CNA A was suspended on 02/04/26 at 5:20PM. She said she was aware of the call light issue at that point. She said she was aware of a complaint of dummy call lights in the facility. She said she had the Maintenance Director go check all the call lights. She said CNA A was named as a potentially involved staff. She said Resident #2 told her a dummy call light was being used. She said she did not suspend CNA B because she was not on the schedule that day. She said she learned about the call light issue on the 2nd or 3rd of February. She said then she heard it could have been [CNA B] or [CNA A]. She said she was told CNA A's name on the 2nd or 3rd of February. She said she talked to CNA B on the 4th of February. She said CNA A worked on the 4th of February. She said the DON told the family of Resident #1 that they were going to suspend CNA A on the 4th. They did not suspend her until 5:20PM on the 4th of February, for the incident regarding alleged verbal abuse of Resident #2. She said she also was told CNA B may be involved on the 2nd or 3rd of February. During an interview on 02/12/26 at 11:20AM, the DON said she was aware of the call light allegation. She said she was made aware of this during a clinical meeting on the 3rd of February. She said she was told someone was doing this with the light. She said they had the Maintenance Director go and check all the call lights. She said she was told the names of CNA A and CNA B on the evening of the 3rd of February. She said the Family Member of Resident #1 notified her of this issue and the names of the two CNAs and which rooms she heard of this. She said she did not suspend CNA A or CNA B. She said they should have been suspended at this point. She said this could be considered neglect or seclusion, especially because Resident #1's means of communication was taken away. She said Resident #1 depended on staff for his needs and ADLs. She said she told the Administrator on the 3rd of February of the allegations with the call light and the two identified staff. She said the Administrator should have suspended CNA A and CNA B when she learned of the allegation. She said she did not know if any of this was reported to HHSC. She said an allegation of neglect or seclusion should have been reported to the state. She said CNA A worked on Resident #1's hall on the 4th of February. She said there was a risk that CNA A could have replaced or moved Resident #1's call light while she was working on the 4th of February. She said she did not feel like the Administrator did a thorough investigation. She said she should have done the investigation as soon as she knew about it on the 3rd, not the 4th. She said she was not sure if CNA B was suspended. She said she was not sure when CNA A was suspended. She said she has not seen this issue personally with her eyes. She said no other resident complained about this, other than Resident #1 and his family. She said in the time she had been in the facility, she was not aware of any issues between Resident #1 and CNA B or CNA A. She said these failures put the residents at risk for further neglect, seclusion, and mistreatment. During an interview on 02/12/26 at 11:35AM, the Administrator said she received a grievance of an issue of fake call lights on the 2nd of February. She said she heard CNA B's name on the 2nd. She heard CNA A's name on the 3rd. She said the complaint was that a fake call light or extra call light was being used. She said her understanding was that the resident would have a call light and it would not work. She said her understanding was that the light was pulled from the wall. She said she thought it was impossible because if it was unplugged it would alarm. She said the next day on the 3rd she was told, no they use two call lights. She said she was told that an extra call light was being used and given to the resident. She said this could be considered an allegation of neglect or seclusion. She said the two identified aides should have been suspended immediately. She said they were not suspended on the 3rd of February. She said CNA B was not on the schedule around the time this was going on. She said CNA B came back around 2-3 days after this. She said CNA A was allowed to work on the 4th of February. She said CNA A was suspended later in the evening on the 4th related to a verbal abuse allegation. She said allowing CNA A to work on the 4th put Resident #1 at risk for further neglect or seclusion. She said this was not reported to HHSC. She said it should have been reported to HHSC. She said another resident reported this issue to her in a grievance. She said the grievance was for another resident and named CNA B. She said she felt like she could have done a more thorough investigation. She said these failures put the residents at risk for further neglect, seclusion, and mistreatment. During an interview on 02/12/26 at 12:02PM, the Social Worker said CNA E informed her that CNA B was using dummy lights on 02/02/26. She said she was told the aide was moving the good light out of the resident's reach and using an extra one to give to the residents. She said she reported this to her about Resident #1, Resident #3, and Resident #4. She said she did not investigate this, but the Administrator was responsible for investigating this. She said the allegat

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 3 (Resident #1, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. The facility failed to report an allegation of neglect to HHSC within 24 hours. An allegation of neglect was reported to the Administrator regarding Resident #1, Resident #3, and Resident #4 on 02/02/26. The allegation was that the identified residents were provided extra dummy call lights. This failure could place residents at risk of emotional and physical harm.Findings included: 1. Record review of Resident #1's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cervical disc disorder with myelopathy (a serious, progressive condition where degenerated discs and bone spurs compress the spinal cord in the neck), Parkinson's disease (a progressive neurodegenerative disorder caused by the loss of dopamine-producing brain cells, leading to movement-related symptoms), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cervical spinal cord injury (involves damage to the vertebrae or nerves in the neck), neurogenic bowel (the loss of normal bowel function due to nerve damage), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Record review of Resident #1's quarterly MDS assessment, dated 12/12/25, reflected he had a BIMS score of 03, which indicated severe cognitive impairment. He was able to make himself understood, and he was able to understand others. He had a functional limitation in range of motion for all four extremities. He required supervision or touching assistance with eating and oral hygiene. He required substantial assistance with toileting, bathing, upper body dressing, personal hygiene, roll left and right, and sit to lying. He was dependent on staff for lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfers, and tub/shower transfers. He required moderate assistance with wheelchair ambulation. He was always incontinent of both bowel and bladder. Record review of Resident #1's care plan, included a focus of falls, last revised on 05/21/24. The focus reflected Resident has the potential for falls related to unspecified injury at unspecified level of cervical spinal cord. Interventions included place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concerns that another CNA, [CNA B], has been switching out [Resident #1's] call light cord/button with a dummy one that does not work. The concern is that this is happening during evening/weekend shifts when [CNA B] is working.Facility follow up was assigned to the Administrator/DON. A meeting was not held. Specific actions taken to resolve the grievance was maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. 2. Record review of Resident #3's face sheet, dated 02/12/26, reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), wedge compression fracture of 4th thoracic vertebra (occurs when the front part of this upper-back bone collapses), and dysphagia (difficulty swallowing). Record review of Resident #3's quarterly MDS assessment, dated 12/26/25, reflected that she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood, and she was able to understand others. She required supervision or touching assistance with toileting hygiene, sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. She required setup or clean-up assistance with oral hygiene, upper body dressing, and roll left and right. She required moderate assistance with bathing and putting on/taking off footwear. She was frequently incontinent of bowel and bladder. Record review of Resident #3's care plan reflected a focus of Falls, last revised on 03/02/23. The focus further reflected Resident has the potential for falls related to poor safety awareness, bowel and bladder incontinence, weakness, debility, and varying cognition. The focus identified 3 fall incidents. Interventions included patient educated on use of call light and assist from staff to assist with mobility tasks and place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker a concern that another CNA, [CNA B], had given [Resident #3] a dummy call light cord/button that does not work, the weekend of January 31st and February 1st.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/05/26. 3. Record review of Resident #4's face sheet, dated 02/12/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included displaced fracture of right femur (a serious injury where the thighbone is broken and the pieces are misaligned), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and repeated falls. Record review of Resident #4's quarterly MDS assessment, dated 01/02/26, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. She was able to make herself understood, and she was able to understand others. She required substantial assistance with toileting, bathing, lower body dressing, sit to lying, lying to sitting, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. She required moderate assistance with upper body dressing, personal hygiene, roll left and right, and sit to stand. She was always incontinent of both bowel and bladder. Record review of Resident #4's care plan reflected a focus of Resident will call out loudly instead of using call light, last revised 01/28/26. Interventions included Redirect resident to utilize call light for assistance. The care plan further reflected a focus of Falls, last revised on 11/10/25. This focus included Resident has the potential for falls related to history of falls. Interventions included Place the resident's call light within reach and encourage the resident to use it for assistance as needed. 4. Record review of Resident #2's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included respiratory failure (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body), sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep, causing low blood oxygen and poor sleep quality), and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #2's quarterly MDS assessment, dated 01/09/26, reflected he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. Record review of a Grievance/Complaint Report, dated 02/02/26, received by the Social Worker, and initiated by CNA E stated: CNA reported to Social Worker concern that another CNA, [CNA B], has possibly been switching out [Resident #4's] call light cord/button with a dummy one that does not work. It is believed this is happening during evening/weekend shifts when [CNA B] is working.Facility follow-up was assigned to the Administrator / DON. A meeting was not held. Specific action taken to resolve the grievance was Maintenance assessed call lights. Results of action taken was Lights working - no dummy lights found. The grievance was marked as resolved and an in-service was conducted on call lights. The grievance was signed by the Administrator and dated 02/06/26. Record review of an untitled document, dated 02/05/26 and provided by the Administrator on 02/12/26 at 11:36AM reflected: Date 02.05.2026Re: Dummy Call LightsOn 02.02.2026 around 4:30 pm, Administrator received Grievances from Social Worker regarding employees using a Fake Call Light.I asked staff about Dummy Call Lights, and they stated they had heard about it, but they were not sure if it [was] true or who was doing it.On 02.03.2026, Administrator asked Maintenance Director to assess all the call lights in the building, which he did. He found all Lights in working order and functioning properly.I interviewed [Resident #4] and she says it happens sometimes in the evening that her call light isn't answered timely. She wasn't too clear on the exact dates. She did not see two call lights in her room, but says it takes a long time for anyone to answer the lights.I interviewed [Resident #1], and he said it takes a long time to get his call light answered. He did not give the Administrator a name, but his roommate, [Resident #2] stated that it was [CNA A] who was unplugging the call Lights. I asked [Resident #2] if he had seen two call lights and he answered No but [The HR Director] told him a few weeks ago that she saw two Call Lights in [Resident #1's] room.Administrator later returned to [Resident #1's] room and found his Call Light tangled in the wheels of his wheelchair and the Call Light was pulled out of the wall. Administrator asked for help from ADON and she assisted the Resident and placed his Call Light back into his wall.I interviewed both [CNA B] and [CNA A] together on 02.04.2026. Both denied unplugging call lights, but [CNA B] stated that she heard it was [CNA A].CNA B does not work on [Resident #1's hall], but [CNA A] does. Record review of an undated statement signed by the HR Director reflected: I don't remember the exact day, but it was the end of December. I pushed [Resident #1] into his room after breakfast and found a call light on the floor, not plugged in. I looked over at the call light plug on the wall and saw another call light plugged in. I handed him the call light that was plugged in and took the other one to the ADON office as I assumed it was broken. Record review of an email, dated 02/04/26 at 09:28PM, sent by LVN F to the Administrator, reflected: On February 2, 2026, at around 0700 my [Resident #3's hall] aide approached me with a call light issue that had happened the night before. A resident by the name of [Resident #3] stated the night aide [CNA B] had put her call light out of reach and put another light in her room that wasn't plugged in as a dummy light. The day shift aide mentioned two other residents she had done the same thing [too]. This incident was reported to the social worker who then wrote grievances on the aide. Record review of an Associate Disciplinary Memorandum, dated 02/04/26, reflected that CNA A was suspended pending an investigation on 02/04/26, related to .CNA was named as the employee that spoke [with] resident using foul language towards them . and .Staff member allegedly told a resident to shut up. Record review of an Associate Disciplinary Memorandum, dated 02/12/26, reflected that CNA B was suspended pending an investigation on 02/12/26 related to .Staff member was involved in an incident where it was alleged that she was changing out [resident] call lights with ones that didn't work. Record review of timesheets for CNA A and CNA B, dated 02/02/26 through 02/12/26, reflected:CNA A worked on 02/04/26 from 07:26 AM through 05:20PM for a total of 9.25 clocked hours.CNA B worked 02/01/26-02/02/26 from 05:55PM through 06:01AM for a total of 11.5 clocked hours.CNA B worked on 02/05/26-02/06/26 from 05:45PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/07/26-02/08/26 from 05:47PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/08/26-02/09/26 from 03:31PM through 06:01AM for a total of 13.5 clocked hours.CNA B worked on 02/09/26-02/10/26 from 05:40PM through 06:02AM for a total of 11.75 clocked hours.CNA B worked on 02/10/26-02/11/26 from 05:53PM through 06:03AM for a total of 11.5 clocked hours. Record review of Nurse/CNA schedules for February 2nd through the 11th reflected:*On February 4th, 2026, CNA A was assigned to Resident #1, Resident #2, and Resident #4's hall.*On February 5th, 2026, CNA B was assigned to Resident #3's hall.*On February 9th, 2026, CNA B was assigned to Resident #3's hall.*On February 10th, 2026, CNA B was assigned to Resident #3's hall. During an interview on 02/11/26 at 12:09PM, Family Member H said she was a family member of Resident #1. She said she has major complaints about the administration in this facility. She said when she was reporting the call light issue to the Administrator, she would not help her unless she told the Administrator what residents had talked to her. She said she heard that CNA A and CNA B take the resident's call light away and then provide a call light that is not plugged into the wall. She said sometimes he does not have water when some aides take care of him. She said she had came up to the facility and there have been many times Resident #1's sheets were saturated. She said Resident #1 has an old spinal cord injury and is not aware when he is in pain. She said Resident #1 fell a few years ago and had to have a lifesaving surgery on his C1-T2 vertebrae. He does not have any bowel/bladder control. She said his pain receptors do not work due to this surgery. She said on February 3rd she came up to the facility to report the call light problem to the DON. She said she received a voicemail from the DON on 04/04/25 at 09:24 am and the DON told her that CNA A and CNA B had been suspended. She said she came to visit Resident #1 on 04/04/25 at 4:00PM and CNA A was in the facility working and taking care of Resident #1. She said the DON had a different story then. She said she then spoke with the Administrator and she would not help her. She said she saw CNA A in the facility and confronted her. She said at 04:38PM the DON came to her and apologized to her for the situation. She said the DON did not know who CNA A was. She said she took videos of these interactions and would provide them to this surveyor. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/03/26 at 02:10PM, this surveyor observed the following:*Family Member H can be heard talking to the DON and asking about her day.*Family Member H identifies herself to the DON as a family member of Resident #1.*Family Member H notifies the DON about someone removing Resident #1's call light and providing one that is not plugged in to him.*Family Member H said she heard that a man from Maintenance had came into Resident #1's room and checked his call light and had further indicated to her that he also was going to check Resident #4's room.*Family Member H identified CNA B and CNA A as the two aides she had heard may have removed Resident #1's call light and provided him with an unplugged call light.*Family Member H said she had heard this from several different people.*The DON said she heard about the call lights this morning in a meeting this morning, but I was not told of the specific rooms. During an observation of a voicemail recording provided to this surveyor by Family Member H, dated 02/04/26 09:24AM, this surveyor observed the following:*The DON identified herself by name and said this call was for Family Member H. She further identified the facility name she was calling from.*The DON identified she was calling about the call light situation.*The DON said CNA B was off the schedule.*The DON said she was suspending CNA A off the schedule until further notice, as of today [02/04/26]. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:07PM, this surveyor observed the following:*Family Member H can be heard initiating a conversation with the DON who is in view on the video.*Family Member H asked the DON is [CNA A] still here?*The DON said, one of them was here earlier.*Family Member H said, well you told me [CNA A] was suspended earlier.*Family Member H said, was she here earlier?*DON said, she may have been here a little bit.*Family Member H and the DON argue about the situation and then the DON walks away from Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 4:12PM, this surveyor observed the following:*Family Member H asked the Administrator how she was doing and the Administrator replied fine.*The Administrator can be heard identifying Family Member H as Resident #1's family member and asking her tell me what's going on.*Family Member H can be heard So you don't know about the call light situation?*The Administrator said, I am asking you, I want to hear from your mouth. I am hearing different stories.* Family Member H said, Well obviously this has been a thing going on.*The Administrator said, Have you seen it?*Family Member H said No, but I have been told by several people.*The Administrator said But have you seen it, because.*Family Member H interrupted the Administrator and said, So you're trying to say it didn't happen?*The Administrator said, I'll listen to you.*Family Member H said I know for a fact that the call light has been, I heard from multiple people who have witnessed it. Okay? She has unplugged the call light. [CNA B] started it, and [CNA A] has continued it. I know she got moved off that hall and she has been doing it to more than [Resident #1]. I know these things. *The Administrator said but my question is.*Family member H interrupted the Administrator and said No, I have not seen it, and I am not going to tell you who told me either, so don't ask me please.*The Administrator said, If you can't tell me where you got the information from, how am I going to help solve this?*The Administrator said, I need to know where this information is coming from.*The Administrator said, when you unplug the cord, it sends an alarm.*Family Member H said, They don't unplug it, they put it in the floor and give them a fake one.*The Administrator said, We don't have a fake one.*Family Member H said, Yeah you do, in the other rooms.*The Administrator said So show me.*Family Member H said Show you? You think I know where to find stuff in this place?. Family Member H then stood up and left the Administrator's office. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:15PM, this surveyor observed the following:*The Administrator entered the room and asked Family Member H, so show me what you are talking about.*Family Member H said I'm talking about this call light. It is in the floor, and they are giving him one in his hand.*Family Member H explained to the Administrator about the voicemail she received from the DON explaining CNA A and CNA B were suspended. She told the Administrator that CNA A was present in the facility this day and at this time. She said CNA A was assigned to Resident #1. So, what I want to know is why somebody who took a call light from someone is still here right now and still with [Resident #1]. *The Administrator said, I'll have to find that out for you, because I didn't know that. The Administrator then identified herself as the Administrator after being asked by Family Member H. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:19PM, this surveyor observed the following:*The Administrator can be seen speaking. She said she discussed the call lights with her supervisor, the regional. we wrote a grievance about it. We are trying to figure it out. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:23PM, this surveyor observed the following:Family Member H can be heard approaching and speaking with a female staff member. The staff member denied giving anyone a fake call light. She identified herself as CNA A. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/04/26 at 04:38PM, this surveyor observed the following:The DON can be seen on the video speaking. She said, I gave my resignation to the director because of that. We did not know specific rooms. I did not realize that girl was [CNA A]. I dropped the ball. We dropped the ball. I had every intention of going to the Administrator, pulling her in there, and getting this resolved this morning when I left you that message. And then other drama unfolded The DON then acknowledged that Family Member H reported the call light issue to her on 02/03/26 and they were made aware of the issue the morning of 02/03/26. The DON said she reported this to the Administrator on 02/03/26. I gave them my resignation; I did not want them to pin me with patient abandonment. During an observation on 02/12/26 at 12:53PM, this surveyor observed an extra call light in a drawer at the central nurse's station. During an interview on 02/11/26 at 02:56PM, Resident #2 said that he was Resident #1's roommate. He said CNA A moves Resident #1's call light out of his reach. He said he goes over to Resident #1 when this happens and gives him the light back. He said this had been ongoing for at least a month or so. He said he has reported this to the ADON, the Administrator, and the HR Director. He said the Administrator spoke with him about the call light on 02/05/26. He said the Administrator told him they were going to investigate this. He said the Administrator asked him who told him about the call light. He said he reported to her that CNA A was plugging a fake call light into the wall on his roommate's side. He said on 02/05/26 he was told CNA A was suspended. During an interview on 02/12/26 at 08:47AM the HR Director said her office is on Resident #1's hall. She said back in December she went into Resident #1's room and noticed his light was on the floor. She said there were two call lights on his side of the room. She said the one that was plugged in was draped over between his bed and bedside table. She said the other call light on his side of the room was not plugged in and was coiled up on the floor. She said she did not notify the Administrator about this. She said she assumed that it was not working, and they forgot to take the old one out when they changed it. She said she took it to the ADON. She said she did not know at the time of the allegations of a fake call light being used. She said this was towards the end of December. During an interview on 02/12/26 at 9:25AM, the Administrator said she did not suspend CNA B related to the call light incident. She said she spoke with Resident #2, and he said CNA A did it to Resident #1. During an interview on 02/12/26 at 9:56AM, Resident #2 said Resident #1 gets upset when he is not able to use his call light. He said Resident #2 hollers and screams when he does not have his call light. He said he tries to help Resident #1 when he can and he gives him the call light back. He said Resident #1 uses his call light a lot. During an interview on 02/12/26 at 10:17AM, CNA D said she usually takes care of Resident #1. She said she had worked at this facility for about 7 months. She said a while back she found an extra call light on the floor in Resident #1's room. She said his regular call light was plugged into the wall and draped over his bedside drawers. She said the other call light was not plugged in and it was in his hand. She said this was about 2-3 months ago. She said when she found this she went to the DON at the time. She said she grabbed the extra call light and tried to turn it into the Maintenance Director, but he was already gone for the day. She said she gave the light to the HR director. She said she only saw this happen one time. She said she has not seen this happen to any other residents, only Resident #1. She said she did not know who it may have been. She said the schedule changes a lot. She said Resident #1 hits his call light a lot. She said he hollers out when he does not have it or when the staff do not answer. She said she felt like the person that did this did it because Resident #1 calls a bunch and they did not want to let him call. She said she felt like the resident may feel secluded or neglected when this happens. She said the resident is forgetful and may not remember this happening. During an interview on 02/12/26 at 11:00AM, the Administrator said CNA A was suspended on 02/04/26 at 5:20PM. She said she was aware of the call light issue at that point. She said she was aware of a complaint of dummy call lights in the facility. She said she had the Maintenance Director go check all the call lights. She said CNA A was named as a potentially involved staff. She said Resident #2 told her a dummy call light was being used. She said she did not suspend CNA B because she was not on the schedule that day. She said she learned about the call light issue on the 2nd or 3rd of February. She said then she heard it could have been [CNA B] or [CNA A]. She said she was told CNA A's name on the 2nd or 3rd of February. She said she talked to CNA B on the 4th of February. She said CNA A worked on the 4th of February. She said the DON told the family of Resident #1 that they were going to suspend CNA A on the 4th. They did not suspend her until 5:20PM on the 4th of February, for the incident regarding alleged verbal abuse of Resident #2. She said she also was told CNA B may be involved on the 2nd or 3rd of February. During an interview on 02/12/26 at 11:20AM, the DON said she was aware of the call light allegation. She said she was made aware of this during a clinical meeting on the 3rd of February. She said she was told someone was doing this with the light. She said they had the Maintenance Director go and check all the call lights. She said she was told the names of CNA A and CNA B on the evening of the 3rd of February. She said the Family Member of Resident #1 notified her of this issue and the names of the two CNAs and which rooms she heard of this. She said she did not suspend CNA A or CNA B. She said they should have been suspended at this point. She said this could be considered neglect or seclusion, especially because Resident #1's means of communication was taken away. She said Resident #1 depended on staff for his needs and ADLs. She said she told the Administrator on the 3rd of February of the allegations with the call light and the two identified staff. She said the Administrator should have suspended CNA A and CNA B when she learned of the allegation. She said she did not know if any of this was reported to HHSC. She said an allegation of neglect or seclusion should have been reported to the state. She said CNA A worked on Resident #1's hall on the 4th of February. She said there was a risk that CNA A could have replaced or moved Resident #1's call light while she was working on the 4th of February. She said she did not feel like the Administrator did a thorough investigation. She said she should have done the investigation as soon as she knew about it on the 3rd, not the 4th. She said she was not sure if CNA B was suspended. She said she was not sure when CNA A was suspended. She said she has not seen this issue personally with her eyes. She said no other resident has complained about this other than Resident #1 and his family. She said in the time she had been in the facility she was not aware of any issues between Resident #1 and CNA B or CNA A. She said these failures put the residents at risk for further neglect, seclusion, and mistreatment. During an interview on 02/12/26 at 11:35AM, the Administrator said she received a grievance of an issue of fake call lights on the 2nd of February. She said she heard CNA B's name on the 2nd. She heard CNA A's name on the 3rd. She said the complaint was that a fake call light or extra call light was being used. She said her understanding was that the resident would have a call light and it would not work. She said her understanding was that the light was pulled from the wall. She said she thought it was impossible because if it was unplugged it would alarm. She said the next day on the 3rd she was told, no they use two call lights. She said she was told that an extra call light was being used and given to the resident. She said this could be considered an allegation of neglect or seclusion. She said the two identified aides should have been suspended immediately. She said they were not suspended on the 3rd of February. She said CNA B was not on the schedule around the time this was going on. She said CNA B came back around 2-3 days after this. She said CNA A was allowed to work on the 4th of February. She said CNA A was suspended later in the evening on the 4th related to a verbal abuse allegation. She said allowing CNA A to work on the 4th put Resident #1 at risk for further neglect or seclusion. She said this was not reported to HHSC. She said it should have been reported to HHSC. She said another resident reported this issue to her in a grievance. She said the grievance was for another resident and named CNA B. She said she felt like she could have done a more thorough investigation. She said these failures put the residents at risk for further neglect, seclusion, and mistreatment. During an interview on 02/12/26 at 12:02PM the Social Worker said CNA E informed her that CNA B was using dummy lights on 02/02/26. She said she was told the aide was moving the good light out of the resident's reach and using an extra one to give to the residents. She said she reported this to her about Resident #1, Resident #3, and Resident #4. She said she did not investigate this, but the Administrator was responsible for investigating this. She said the allegation related to the call light could be considered neglect or seclusion. She said she has not heard this allegation about any other residents. During an interview on 02/12/26 at 12:23PM, CNA E said she had heard of the call light situation. She said she had not observed it herself. She said CNA A told her about it. She said CNA A told her about the call light being moved away from the resident and then the resident being given a dummy call light. She said CNA [NAME] told her that she had seen this done before. She said this situation could be considered seclusion. During an interview on 02/12/26 at 12:28PM, CNA B said she had not noticed anyone use a fake call light in the facility. She said she had not heard of anyone doing this to a resident other than these allegations. She said she was not suspended until this day on 02/12/26. She said she was inv

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for quality of care. The facility failed to ensure CNA DD properly transferred Resident #1 on 02/10/26. This deficient practice could place residents at risk of injury.Findings included: 1. Record review of Resident #1's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cervical disc disorder with myelopathy (a serious, progressive condition where degenerated discs and bone spurs compress the spinal cord in the neck), Parkinson's disease (a progressive neurodegenerative disorder caused by the loss of dopamine-producing brain cells, leading to movement-related symptoms), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cervical spinal cord injury (involves damage to the vertebrae or nerves in the neck), neurogenic bowel (the loss of normal bowel function due to nerve damage), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Record review of Resident #1's quarterly MDS assessment, dated 12/12/25, reflected he had a BIMS score of 03, which indicated severe cognitive impairment. He was able to make himself understood, and he was able to understand others. He had a functional limitation in range of motion for all four extremities. He required supervision or touching assistance with eating and oral hygiene. He required substantial assistance with toileting, bathing, upper body dressing, personal hygiene, roll left and right, and sit to lying. He was dependent on staff for lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfers, and tub/shower transfers. He required moderate assistance with wheelchair ambulation. Record review of Resident #1's care plan, included a focus of ADLs, last revised 05/21/24. The focus reflected, Resident had an ADL self care performance deficit and was at risk for not having their needs met in a timely manner, performance deficit is related to unspecified injury at unspecified level of cervical spinal cord. Interventions included transfers Total/mechanical lift x2 (two person assist). Record review of Resident #1's Visual/Bedside Kardex Report, dated 02/12/26, reflected Resident #1 required total assist with a mechanical lift for transfers with two people. Record review of Resident #1's Post Fall Evaluation, dated 02/10/26, reflected: .In IDT meeting, after in person interview and reading CNA statement along with resident's current POC, it is determined that resident is a total/[mechanical lift] x2. CNA did not check Kardex prior to providing care to patient. In person education was completed at facility by DON and employee advised he may be placed on suspension pending final results of investigation. Record review of Resident #1's incident form titled Witnessed Fall, dated 02/10/26, reflected: .CNA came to the nurses station and said he needed help getting resident off the floor. Upon arrival to room, resident found to be sitting in floor next to bed. CNA stated he was transferring him from the wheel chair to his bed and his grip was slipping so he started to lower him to the floor. CNA guided resident down to floor before calling for assistance. 2. Record review of Resident #2's face sheet, dated 02/11/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included respiratory failure (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body), sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep, causing low blood oxygen and poor sleep quality), and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood). Record review of Resident #2's quarterly MDS assessment, dated 01/09/26, reflected he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. During an observation of a video recording provided to this surveyor by Family Member H, dated 02/10/26 at 06:44PM, this surveyor observed the following:*Family Member H can be heard speaking with someone at the nurse's station. Family Member H asked the nurse .So, was it just [CNA DD]?.was he supposed to have two people getting him in and out of bed?*the nurse can be heard telling Family Member H: yes, I let him know, he should have had two people.I guess he misjudged his capabilities. I let the DON know, and someone else will be taking care of [Resident #1] tonight.*Family Member H said .was he supposed to be using the [mechanical lift]? was there a [mechanical lift] available?*the nurse said Yes, there was a [mechanical lift] available. Record review of CNA DD's statement, dated 02/10/26, reflected: I was trying to manually transfer the resident because he did not have a [mechanical lift] pad under him. In the process I lost my grip and had to sit the resident on the floor. I notified the charge nurse and she came down and helped get the resident in bed. On the statement there were two sets of handwriting, and the above quote was written in the same handwriting as CNA DD's signature. The additions to the statement are in a different handwriting, and included under both arms Nurse [and] CNA use a sheet for transfer back to bed and He did try stand on lift but [due to] contractures of both hands he could not hold his own weight up. During an interview on 02/11/26 at 12:09PM, Family Member H said she was a family member of Resident #1. She said on 02/10/26 at 06:13PM, she received a phone call from RN O. She said RN O sounded like she was out of breath. She said the nurse had to call her and tell her that CNA DD was trying to put Resident #1 to bed and dropped him. She said Resident #1 was unable to feel pain so she was worried he may have broken something. She said she drove over to the facility to check on Resident #1. She said Resident #1 told her he hit his head. During an interview on 02/11/26 at 02:41PM, Resident #1 said he had a fall on 02/10/26. He said CNA DD was going to use a mechanical lift but did not. He said CNA DD was the only staff in the room. He said CNA DD told him something was wrong with the mechanical lift. He said CNA DD did not explain to him what was wrong with the mechanical lift. He said CNA DD tried to lift him with his hands and he was unable to transfer him and then dropped him. He said he did not remember if CNA DD stayed or left the room. He said someone came and helped get him off the floor. He said someone looked him over and made sure he did not have any injuries. He said he did not think he had any injuries or pain from the fall. During an interview on 02/11/26 at 02:56PM, Resident #2 said he was Resident #1's roommate. He said he was in the room around the time that Resident #1 fell on [DATE]. He said he did not see what happened, but he heard a loud noise and then he heard CNA DD call for help. He said the nurse came to check on Resident #1. He said when he heard Resident #1 hit the floor he heard a scream. He said at the time of the transfer CNA DD was the only staff in the room. He said the mechanical lifts were working again at that time. He said the staff usually used a mechanical lift to transfer Resident #1. During an interview on 02/11/26 at 03:33PM, RN O said she recalled Resident #1's fall on 02/10/26. He said CNA DD came to the nurse's station and requested help because Resident #1 was on the floor. She said CNA DD told her I Dropped him. She said she asked from the [mechanical lift]? and he said no. She said she went to the room and the resident was lying on the floor next to the bed. She said his head was at the foot of the bed and his feet were toward the head of the bed. She said she assessed him, checked for pain, asked him if he hit his head or heard anything pop. Resident #1 denied this. She said she helped Resident #1 up to his bottom with his back to the bed. She said her, another CNA, and CNA DD lifted Resident #1 to the bed. She said she thoroughly looked him over. She said Resident #1 was normally a mechanical lift transfer. She said CNA DD did not say why he did not use the mechanical lift. She said she assessed Resident #1's neuro status. She said she called Resident #1's family member as she was texting the DON and the doctor. She said she thought CNA DD knew better and should have used the mechanical lift to transfer Resident #1. During an interview on 02/11/26 at 03:48PM, the DON said she added to CNA DD's statement. She said she did not have him initial the changes. She said the additions were what CNA DD said to her while writing the statement. During an interview on 02/12/26 at 09:13AM, the DON said she was notified about Resident #1's fall the evening of the 10th of February. She said the nurse told her that the aide was trying to put Resident #1 in the bed and was unable to carry him. She said the nurse did say that CNA DD did not use the mechanical lift. She said he was supposed to use the mechanical lift. She said that the aide told her that the resident did not have a sling under him and he did not check the Kardex. She said it was possible to put a sling on someone in the wheelchair. She said she did not suspend him until the following morning, and he was allowed to work all night. She said she was not sure if he should have been suspended at the time of the incident. She said she was not aware of the policy. During an interview on 02/12/26 at 09:25AM, the Administrator said she was not aware of Resident #1's fall with CNA DD until the morning of February 11th. She said she did not know that the aide improperly transferred him until the morning of the 11th. She said she suspended CNA DD on the morning of the 11th. She said the DON did not inform her of the extent of the fall on the evening of February 10th. She said if she had known all the details at the time of the fall she would have suspended him at that time. Record review of the facility's policy, Mechanical Lift, last revised on 09/08/23, reflected: Purpose:To move immobile or obese patients for whom manual transfer poses potential for a resident injury.NOTE: Although one (1) person can operate most models of hydraulic lifts, it is advisable to have two (2) staff members present to stabilize and support the resident.

Based on observations, interviews, and record reviews, the facility failed to review and revise resident care plans based on changing goals, preferences, and in response to current interventions for 1 of 6 residents reviewed for care plans (Resident #1). The facility failed to ensure Resident #1's care plan was revised and updated to address safety, mental health, and nursing needs related to a history of exploitation and changes in discharge planning. This failure could place residents at risk for not having their safety, mental health, and goal setting needs addressed and communicated to the appropriate staff. Findings included:A record review of Resident #1's face sheet dated 11/17/2025 indicated Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia, cognitive deficit, diabetes, and COPD (a condition which causes difficulty in breathing), and weakness. Resident #1's face sheet indicated Resident #1 was not to leave the facility with anyone except his family member #1 who had medical and financial power of attorney. A record review of a quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 11 indicating his cognition was moderately impaired. He was ambulatory for short distances, continent of bowel and bladder, and able to voice needs. A review of Resident #1's care plan dated 11/17/2025 indicated there was no identification or mention of any concerns for Resident #1's history of exploitation nor potential for elopement. There were no interventions to reduce the risk of future exploitation nor instructions regarding visitor restrictions. There were no interventions to address concerns of elopement. Resident #1's mental status and feelings regarding not being able to call anyone or leave the facility were not addressed in the care plan. The care plan included a discharge plan with an initiation date of 11/27/2024 and revised on 12/05/2024 with a goal for Resident #1 to return to the community/home. The care plan had not been revised or updated to reflect Resident #1's long term plan for permanent residency at the facility. A review of the progress notes dated 01/05/2025 indicated a family member called the facility to let them know Resident #1 was wanting to leave the facility and the unnamed caller was afraid Resident #1 would either elope or call someone to come get him. A review of progress notes dated 01/06/2025 indicated Female A came to the facility and said she was going to take Resident #1 to his home and to the bank. Further review of the notes indicated family member #1 was notified of Female A's attempt to leave with Resident #1 with family member #1 giving instructions to not allow it to happen. The progress notes reflected Female A, and boyfriend left the facility. A review of Resident #1's MDS history indicated MDS assessments were completed as follows: 2 comprehensive MDS assessments were completed on 11/28/2024 and 09/01/2025 and 4 quarterly MDS assessments were completed on 02/28/2025, 04/07/2025, 07/08/2025, and 11/05/2025. No updates or revisions to the discharge planning section of the care plan were noted following these MDS assessments. Resident #1's care plan was not updated or revised to reflect his history of exploitation nor interventions to reduce further occurrence after the MDS assessments. During an observation and interview on 11/17/2025 at 09:45 AM, Resident #1 said one of his two family members lived close by and visited him about once week and brought him snacks. He said he could not call anybody because his family member took his phone away from him and he wasn't allowed to leave the facility. He said he had some money, but his family member would not tell him how much he had left. He said he had a woman that came in and helped him when he lived in his house, but he didn't know where she was. He said, I just have to sit here. Resident #1 did not look at this surveyor while talking. He kept his face downcast toward his hands and lap and spread his hands apart in front of him when he ended that part of the conversation by saying there was nothing he could do about his circumstances. Resident #1 said the BOM knew about it. During a phone interview on 11/17/2025 at 09:40 AM, Resident #1's family member who lived close by said Resident #1 was admitted to the facility after being hospitalized for a fall. He said that prior to Resident #1 admitting to the facility, Resident #1 had allowed Female A to move in with him after his mother passed away. The family member said Female A exploited Resident #1 by taking him to the bank multiple times where Resident #1 wrote checks and withdrew money. He said the bank called him one time and told him Resident #1 and Female A were at the bank, and Resident #1 had withdrawn $9,999.00 after they asked the bank how much money he could write a check for without it being reported. The family member said multiple items were missing from Resident #1's farm including trailers, lawn [NAME], and other equipment. The family member said Female A had used his Resident #1's information to obtain credit cards and had tried to purchase a car about 6 months ago using Resident #1's information. He said he tried to make Resident #1 understand that he was being exploited by Female A and her friends. He said Resident #1's health and mental ability was declining which brought about Resident #1 being admitted to the nursing home. The family member said he made it clear when Resident #1 admitted to the facility that Resident #1 would not be returning to his home. He said he did not know why the care plan had a discharge plan for Resident #1 to discharge back to the community because he said he made it clear on admission that Resident #1 admission was for permanent placement. He said Female A and her boyfriend were not allowed to visit Resident #1 at the facility because Female A had come to the facility once and tried to take Resident #1 out to go to the bank. Resident #1 said the facility did not allow Resident#1 to leave with the Female A because he had made it clear that Resident #1 was not to leave the facility with anyone except family member #1 and family member #2. The family member #1 said he had given Resident #1 a cell phone, but Resident #1 either found a way to contact Female A, or Female A had contacted Resident #1 which ended up with the Female A coming to the facility and attempting to take Resident #1 out to the bank. He said he had to take the cell phone for Resident #1's safety, but he said he told Resident #1 to let the staff know when he wanted to use the facility phone to call him. The family member #1 said there had been a big turnover at the facility since Resident #1 admitted and he did not know if the current administration and nursing staff knew about Resident #1's history of being exploited and the actions to prevent it from occurring again. The family member #1 said he knew of no exploitation attempts in the last 6 months and said he reported all his concerns to the police. During an interview on 11/17/2025 at 10:30 AM with the BOM, she said she had been at the facility a few months and had heard there was a woman and man that would take Resident #1 out and to the bank to get money when Resident #1 lived in his own home, but the family member #1 stopped that from happening when Resident #1 admitted to the facility. She said the woman and man were not allowed to visit Resident #1 at the facility nor take him out of the facility. She said she did not know their names or where that information was documented. During an interview on 11/17/2025 at 10:40 AM, LVN B said she had worked at the facility for about 4 months and was not aware of any resident having any visitor restrictions. She said she did not know of any resident who had any restrictions regarding who they could leave the facility with. She said she did not know where she could look to see if a resident had specific instructions regarding visitors or going out on pass. During an interview on 11/17/2025 at 10:45 AM, LVN C said she had worked at the facility for about 1 month and knew of no residents having any visitor restrictions. She said she did not know where that would be documented. During an interview on 11/17/2025 at 10:50 AM, the SW said she was new to the facility and was not familiar with Resident #1's history. She said specific instructions regarding visitors and residents leaving the facility with someone would be communicated on the face sheet. The SW said she did not know what Resident #1's discharge plans were. During an interview with the Administrator on 11/17/2025 at 11:02 AM, the Administrator said she was not aware of Resident #1's history of being exploited. She said the nursing staff should know where information regarding special instructions about visitors and other safety matters were in the chart. During an interview with the DON on 11/18/2025, she said the MDS staff were responsible for care plans being updated and/or revised with input from the IDT. During an interview with MDS Coordinator D on 11/18/2025 at 11:18 AM, she said the MDS Coordinators schedule care plan meetings to coordinate with MDS scheduled assessments. She said Resident #1's care plan had not been updated or revised to reflect his history of exploitation and the restrictions on visitors because she and MDS Coordinator E were not aware of Resident #1's exploitation history nor visitor restrictions. She said the care plan had not been revised to reflect Resident #1's plan to remain in the facility long term because it had not been confirmed. A review of the facility's policy dated 02/10/202/revised 09/04/2024 and titled Comprehensive Care Plans included the following: Policy:It is the policy of this facility to develop and implement a comprehensive perResident #1-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Policy Explanation and Compliance Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's strength and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Medication Aides used available resources to administer 3 missed doses of eye drops to Resident #2 as ordered by the physician. This failure could place residents at risk of not receiving medications as ordered. Findings included: A record review of Resident #2's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dry eye syndrome, anxiety, dementia, and quadriplegia C5-C7 (paralysis of all four limbs). A record review of the quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 14 which indicated her cognition was intact. Further review of the MDS indicated she was dependent on staff for most activities of daily living and was able to voice needs and concerns. A record review of the physician orders dated 11/18/2025 indicated Resident #2 had an order to receive 0.5% Carboxymethylcellulose Ophthalmic Solution 1 applicator in both eyes at bedtime for dry eyes. Record review of Resident #2's MAR dated 11/18/2025 indicated Resident #2 was to receive 0.5% Carboxymethylcellulose Ophthalmic Solution (eye drops) at 09:00 PM every night. The doses scheduled for 09:00 PM on 11/12/2025, 11/13/2025, and 11/17/2025 were documented as not being administered. Record review of Risk Management reports indicated there were no Medication Error Reports for the 3 missed doses of Carboxymethylcellulose Ophthalmic Solution. Record review of the progress notes did not reflect any reason for the eye drops not being administered on 11/12/25, 11/13/25, and 11/17/25. During observation and interview on 11/18/2025 at 09:40 AM, Resident #2 said she had not received her eye drops for the last 6 days. She said the medication aides kept telling her they didn't have any eye drops available to give her. Resident #2 said her eyes would get irritated and burn a little if she went too long without the eye drops. She said her eyes were ok then but did not want them to become irritated. During an interview on 11/18/2025 at 09:50 AM, MA F said the eye drops were an over-the-counter medication and come in a box with multiple individual ampules. She pointed to an area in a drawer of the medication cart and said that was where they would be but there were none there. MA F continued to look throughout the cart and located 4 single plastic ampules of the Carboxymethylcellulose Ophthalmic Solution in a basket in the small, top drawer. MA F said if she did not have an over-the-counter medication, she would look in the medication room first and if none were there, she would talk to the other medication aides to see if they had any in their carts. If they had none, she would tell the nurse or ADON. She said the ADON would run to one of the stores and get over the over-the-counter medications. During an interview on 11/18/2025 at 11:55 AM, MA G said he worked the evening of 11/17/2025. He said he did not administer the ordered eye drops to Resident #2 because he did not have any in his cart. He said Resident #2 told him she had not received her eye drops in 3 or 4 days. He said he notified the nurse after he checked the medication room and did not find any there. MA G said he only worked as needed and did not know the name of the nurse he spoke to about the missing eye drops. MA G said he had been a medication aide about 6 months. He said he forgot to document the reason for not administering the eye drops. On 11/18/2025 at 12:30 PM, an attempt to interview the medication aide who worked on the evenings of 11/12/20225 and 11/13/2025 by phone was unsuccessful. A message was received that the telephone number was no longer a working number. During an interview on 11/18/2025 at 12:05 PM, LVN H said she worked the evening of 11/17/2025. She said she was not made aware that Resident #2 did not have any eye drops for administration. During an interview on 11/18/2025 at 12:20 PM, the DON said the medication aides were supposed to tell the charge nurse, ADON, or her when they did not have prescribed medication available for administration. She said the Carboxymethylcellulose eye solution had been ordered last week, and the facility was awaiting delivery. She said there was an ample supply of the eye drops on the other medication carts and there was enough for all residents who had orders for the eye drops for several days. The DON said the 11/12/2025, 11/13/2025, and 11/17/2025 doses of Carboxymethylcellulose eye drops solution were documented as not being given. She said the reason for not administering a medication was supposed to be documented but she said she did not see where that was documented for the 3 missed doses of Resident #2's eye drops. She said someone would go out and purchase more if needed before the order was delivered. A review of the facility's policy dated 01/09/2024 and revised 04/06/2023 and titled Medication-Treatment Administration and Documentation included the following: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatmentsProcess: 4. Administer the medication according to the physician order.7. Medications or treatments that were not administered should be documented as not administered on the EMAR/TAR with the reason for the not administration. 8. Complete a Medication Error Report for medication administration discrepancies .

Based on observation, interview, and record review, the facility failed to immediately consult with the physician when a need to alter treatment significantly due to adverse consequences for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds.On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #1 went to the hospital on 8/11/25 with a diagnosis of groin infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. An Immediate Jeopardy (IJ) situation was identified on 8/14/25 at 1:00 p.m. While the IJ was removed on 8/15/25 at 3:22 p.m., the facility remained out of compliance at a potential for not actual harm with a potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for pain and suffering. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a readmission date of 8/5/25. He had diagnoses of peripheral vascular disease (PVD) (a condition where the arteries and veins in the arms, legs, and feet become narrowed or blocked reducing blood flow.) and a history of stroke. Record review of Resident #1's admission MDS assessment dated [DATE] indicated his cognition was intact with a BIMS score of 13. The MDS indicated he used a walker and a wheelchair, but required supervision or touching assistance with most ADLs. Record review of Resident #1's care plan dated 6/2/25 indicated he was incontinent of bowel and bladder. Some of the interventions were to assist to toilet as needed, provide weekly skin checks to monitor for redness, circulatory problems, breakdown or skin concerns, and report any new skin conditions to the physician. Record review of Resident #1's computerized physician orders dated 8/11/25 indicated no orders for treatment to his groin incisions were listed. Record review of Resident #1's After Visit Summary dated 8/4/25 provided instructions to call the provider if redness, tenderness or signs of infection (pain, swelling, redness, odor or green/yellow discharge around incision site, and for severe uncontrolled pain. Record review of Resident #1's Admit/Readmit Evaluation dated 8/5/25 at 1:32 a.m. indicated he had surgical incision wounds on the left groin, right groin, and left front knee. There were no other descriptions. Record review of Resident #1's Admit/Readmit note dated 8/5/25 at 1:32 a.m. indicated he was admitted from the hospital with a diagnosis of deep vein thrombosis, and PVD. He needed limited assistance with transfers, self-performance. He was continent of urine and bowels and needed limited assistance with toileting, self-performance. He had pitting edema to both lower extremities. He complained of pain and was given pain medications. (no mention of surgical wounds) Record review of Resident #1's nursing notes dated 8/5/25 indicated he had a telehealth visit. The resident was readmitted last night with bilateral groin stent placement for PVD. He reported difficult urinating and severe incisional pain. He was requesting to be sent back to the ER and was transferred at 6:12 a.m. to the hospital. At 8:00 a.m. the resident returned from the hospital and was given pain medications. Record review of Resident #1's nursing notes dated 8/7/25 at 1:14 p.m. indicated Resident has open wounds; vascular and surgical. The resident received wound care with no changes in skin condition noted, and there were no signs and symptoms of infection. Record review of Resident #1's Skilled Observation note dated 8/10/25 at 9:37 p.m. indicated no infection was present the wound had redness and inflammation. The skin was warm and dry. The surgical incision was open with wound care and notable changes in skin condition. The observation described the incision with staples on the left side of the groin to have a foul-smelling drainage. The area was red and inflamed, it was cleansed with wound cleanser and was tender to touch. The groin on the right side had no visible signs and symptoms of infection. The note indicated would report to the oncoming charge nurse. Written by LVN E (there was no indication the physician was notified. Record review of Resident #1's nursing notes dated 8/11/25 at 5:50 p.m. the resident was sent to the hospital due to altered mental status. No other information was documented. Record review of Resident #1's hospital records dated 8/11/25 revealed the resident was admitted due to generalized weakness. He had bilateral groin incisions with staples that were irritated, with redness to the left and right groin and a foul smell. It appeared yeasty in nature. He stated his groin infections hurt and itched. His diagnosis was surgical incision infection. He was prescribed Cephalexin 500 mg two times a day for 7 days and Nystatin cream apply to groin area two times a day for 7 days. He returned to the facility on 8/11/25 at 11:14 p.m. and new orders were noted. Record review of Resident #1's nursing note dated 8/11/25 at 11:14 p.m. indicated he was readmitted to the facility with diagnoses of generalized weakness, yeast infection, and incisional infection. He had new orders for cephalexin 500 mg three times a day for 7 days and Nystatin Cream 100,000 units to bilateral groin two times a day for 7 days. Record review of Resident #1's computerized physician orders indicated an order with a start date of 8/12/25 at 8:00 a.m. for Nystatin External cream 100,000 units to bilateral groin area two times daily. An order with a start date of 8/12/25 at 8:00 a.m. for Cephalexin Oral Capsule 500 mg by mouth three times daily for 7 days.After Investigator intervention a treatment administration record was generated on 8/13/25, and indicated his treatment was to start on 8/13/25 at 6 p.m. During a telephone interview on 8/11/25 at 12:06 p.m., an Anonymous staff said Resident #1 had staples to his right and left groin area. The staff said on 8/10/25, a nurse had gone to look at the surgical incisions and they looked infected. The staff said that an unidentified nurse had not called the physician. She stated she had cleansed the area with wound cleanser and wound care was supposed to be done today, 8/11/15 by the treatment nurse. During an observation and interview on 8/11/25 at 3:20 p.m., Resident #1 was noted with EMS in his room. LVN A said Resident #1 was going to the hospital due to a change in his level of consciousness. She said he had staples in his right and left groin area and the left groin area was inflamed. She said it had yellow slimy drainage. She stated she told EMS his blood pressure was 88/56. Resident #1 was noted to be able to ambulate from the bed to the stretcher and was taken by EMS. LVN A said Resident #1's surgical incision appeared infected. During an interview on 8/11/25 at 5:59 p.m., LVN C/Treatment nurse said Resident #1 had surgical incisions on both sides of his groin. She said she was informed the right side of Resident #1's groin was red and inflamed. She was going to reach out to see if they wanted to remove the staples, but had not done so yet. She said they had orders to monitor the areas and put on a dry dressing. (There was no order noted) During an interview on 8/13/25 at 10:46 a.m., the DON said Resident#1 did not have any orders to treat his surgical incisions. The DON said LVN D was on duty when Resident #1 was readmitted to the facility on [DATE], and she should have passed his information on to the oncoming nurse. The DON said LVN D sent Resident #1 back out the same night and did not get an order for his surgical incisions. She said her staff were trained to go by the hospital After Visit Summary for orders. However, if a resident came in as a new admit or a readmit and did not have an order, they were to call the doctor to get an order. The DON said since Resident #1 did not have an order to treat the surgical incisions, someone should have followed up with the physician. After review of the Resident #1's observation note dated 8/10/25, the DON said LVN E should have contacted the physician when she noted Resident #1's wound looked infected. During an interview on 8/13/25 at 1:54 p.m., the RN Weekend Supervisor said she filled in for the treatment nurse on the weekends, and when the treatment nurse was out. She said Resident#1 did not have an order to treat his surgical incisions on the groin area. She said if a resident did not have an order or treatment in place, she was not aware they had any areas. The RN Weekend Supervisor stated when Resident #1 came from the hospital with surgical wounds and did not have anything down to treatment the areas . She said the nursing staff should have called the doctor to see what he wanted done. She said good nursing judgment indicated they should have called the hospital for orders or called the doctor to at least see what the physician wanted done with the wounds. During an interview on 8/13/25 at 2:30 p.m., LVN E said she worked on Friday 8/10/25 and had seen Resident #1's wounds, but did not provide any treatment. She said she was under the impression the treatment nurse was providing treatments to his groin area. She said she asked LVN C/Treatment nurse earlier in the week, and she said Resident #1's wound was getting cleaned and left to open air. LVN E said on the afternoon of Sunday 8/10/25, Resident #1's family brought to her attention that they thought Resident #1's groin area was infected. She said they sent pictures, and she had gone to look at the wound. LVN E said she cleaned the wounds on Resident #1's groin and noted in an observation note the left side was inflamed and red. She said the area could have been infected; it had an odor, and yellow drainage, it was red and inflamed . She said she had not contacted the physician; she passed the information on to the oncoming shift. During an interview on 8/14/25 at 9:45 a.m., the MD said he was not told Resident #1's surgical wound was infected prior to his discharge. He said he expected staff to call him and let him know of changes that occurred with residents. He said when a resident came back from the hospital they needed orders in place. He said if the facility does not have any orders, they should reach out to him for orders. He said the facility usually did a skin assessment and would call him for an order. He said especially if a resident was a readmitted and did not have a previous order for wound care. He said he expected to be notified of Resident conditions. Resident #2 Record review of Resident #2's face sheet dated 8/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission date of 8/12/25. She had diagnoses of stroke, end stage renal disease, chronic respiratory failure, heart disease, diabetes, and bipolar disorder. Record review of Resident# 2's admission MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 14. Resident #2 required partial to substantial assist with ADLs. She required supervision with bed mobility, partial to moderate assist with sit to laying, and did not attempt to stand or transfer due to medical condition. The MDS indicated she was at risk for a pressure ulcer. Review of Resident #2's care plan dated 5/19/15 indicated she was at risk for pressures ulcers. One of the interventions was to monitor for redness, circulation problems, pressure sores, open areas, and changes in skin integrity. Review of Resident #2's computerized physician orders dated 8/13/25 at 4:00 p.m. did not reveal an order for treatment to her sacrum wound. Review of Resident #2's nursing notes dated 7/31/25 at 6:00 a.m. revealed the resident was sent to the hospital due to her calling EMS and stating she was having difficulty breathing. Record review of Resident #2's hospital records dated 7/31/25 indicated the resident was admitted to the hospital on [DATE] after a ground level fall. She was discharged to the facility on 7/30/25 and readmitted to the hospital on [DATE] with complaints of shortness of breath and pain associated with groin buttock wounds. Review of Resident #2's hospital After Visit Summary dated 8/12/25 indicated the primary diagnoses for hospitalization was pressure injury of sacral region stage 4, end stage renal disease, uncontrolled diabetes, and fluid overload. There was no order for the care of the pressure injury of the sacrum. Record review of Resident #2's Admit Readmit Evaluation 8/12/25 at 10:00 p.m. indicated skin integrity with wounds present on admission, with bruising, discoloration, and an open wound. The comments indicated a pressure injury of the sacral region, stage 4, and bruising to the hands and front of the elbow. Record review of the facility's 24-hour report for 8/12/25 indicated Resident #2 returned from the hospital at 9:35 p.m., and she had a stage 4 pressure wound on her sacrum. During an interview on 8/13/25 at 6:01 p.m., the Administrator said they did not have any treatment orders for Resident #2's treatments, and she did not have a TAR generated at the current time due to no orders being in place. During an interview 8/14/25 at 11:00 a.m., the RN Weekend Supervisor said whoever admitted Resident #2 should have gotten orders from the hospital. She said if not, they should've gotten orders from the doctor regarding resident service. She said she completed the wound care on Resident #2 yesterday evening.During an interview on 8/13/25 at 4:50 p.m., the DON said Resident #2 had been in the hospital for 45 days. She said every time Resident #2 came to the facility, she was only there for a day or a few hours and then back to the hospital. The DON said normally when a resident was admitted or readmitted , the admitting nurse contacted the hospital for additional orders or contacts the physician for orders. She stated if it was during the night, the treatment nurse would be notified and the next day to do a skin assessment, notify the physician . She said at that time if a resident had wounds or if they needed any kind of treatment, they would get orders. She said she did not know why there were no orders for Resident #2. Record review of the facility's Notification of Changes policy last revised 2/10/21 indicated their policy to provide guidance on when to communicate acute changes in status to the MD, NP and responsible party. The will would immediately inform the resident: consult with the resident's physician, and responsible party for any significant change in physical, mental, or psychosocial status of the resident. The facility documents resident assessments, interventions, physician and family notification on the SBAR, Nursing Progress Note, or Telephone order form as appropriate. This was determined to be an Immediate Jeopardy (IJ) on 8/14/25 at 1:00 p.m. The Administrator, DON, and RNC were informed of the IJ situation on 8/14/25 at 1:00 p.m. a copy of the IJ template was emailed to them at 1:00 p.m. A POR was requested and accepted on 8/15/25 at 10:45 a.m. [The facility failed to implement policies and procedures regarding physician notification to prevent the hospitalization of Resident #1 due to a surgical wound infection.Immediate Action Taken:On 08/14/2025 at 2:30 PM, the attending physician for Resident #1 and #2 was notified of the status of the surgical incision, wounds and the lack of prior communication regarding wound condition. Resident #1and #2 were immediately assessed by the facility's wound care nurse and physician. Orders were received and implemented, including wound care protocols and infectious disease consult. 2. Identification of Residents Affected or Likely to be Affected:A head-to-toe skin and wound assessment was completed on all residents by the Director of Nursing (DON) and Wound Nurse on 08/14/2025. A facility-wide audit was initiated on 08/14/2025 by the DON/Designee to ensure all residents have current wound descriptions, physician orders, and proper documentation of physician notification using skin observation sheets and any discrepancies will be documented in the nurse's notes. Any discrepancies were immediately corrected, and responsible nurses were given additional education by DON/Designee. Telehealth and/or physician will be notified after hours and on weekends. Notification to physician will be documented in the nurse's notes by the licensed nurses. DON/designee educated all licensed nurses on policy/procedure on Change of condition notification. Licensed nurses will use the 24-hour report, the care plan, and Treatment administration record to communicate from shift to shift for all resident's change of conditions and care needs. 3. Actions to Prevent Occurrence/Recurrence:Staff Education On 08/14/2025, all licensed nurses received personized education on: Physician notification requirements will be upon admission/readmission and any change of condition License nurses will contact physicians to clarify admission or readmission orders when there are discrepancies with hospital records, change of conditions of wounds and signs of infection and ensure orders transferred to computer, MAR and TAR,Documentation of wound assessments. Use of SBAR (Situation-Background-Assessment-Recommendation) communication tool upon change of condition prior to physician notification. DON/Designee educated staff on notification of physician and staff were required to demonstrate understanding via return demonstration or post-education quiz. Education will be completed on 8/14/25. Staff unavailable to attend in service on 08/14/2025 will receive personalized in service prior to assuming their duties. Wound Communication Process A daily Wound Rounds Checklist was implemented to ensure: Each wound has documented assessment, treatment orders, and notification status. Any change is reported immediately to DON/Designee and documented in progress notes DON/Designee will complete a weekly interdisciplinary wound rounds initiated as of 08/14/2025 with physician participation (in person or telehealth). Monitoring and Oversight PlanDaily audits of physician notification for any changes in condition by DON or designee for 14 days (08/14-08/28/2025), then weekly x4 weeks. DON/Designee will review all new admissions and readmissions within 24 hours to ensure physician orders and wound care protocols are in place by DON/ Weekend Supervisor/ Designee. Review will be documented on the admission Audit tool.DON or designee will: Review progress notes, nurse notes, and MARs for compliance. Validate timely physician notifications. Audit results will be reported weekly to the Quality Assurance & Performance Improvement (QAPI) committee for 3 months. Continued noncompliance will trigger retraining or disciplinary action. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/14/25] On 8/15/25 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of facility skin assessments, facility audit of records to include wound descriptions, physician orders, and documentation in the nursing notes. The skin assessments were reviewed for all residents in the facility and noted two residents were found with redness to the buttocks, one resident with an open area to the buttocks, and one resident with redness to an ostomy site. There were orders noted to be placed, a description of the areas, and the physician was notified. Review of documentation showed Resident #1 and Resident #2 had descriptions of their wounds and treatment orders in place. Review of the facility Wound Daily Audit dated 8/14/25 through 8/24/25 indicated 3 newly admitted residents with skin assessments completed, the physician notified, a wound order in place, the wound care physician notified, and family notified. Record review of in-service dated 8/14/25 indicated nurses were educated on Change in Condition, completing the SBAR when a resident has a change in condition. When a nurse was notified or identified a change in condition they were to immediately, assess the resident gather vital signs, ask specific questions, if possible, notify MD, responsible part, DON and then document in the computer and add to the 24-hour report. Record review of in-service dated 8/14/25 indicated 19 nurses were educated on pressure ulcers/wounds upon admission or readmission. They were instructed to complete a head-to-toe assessment, measure wounds or open areas, complete the skin assessment, document in the computer system on admission or readmission, call the physician or use the [NAME]- health after hours to receive wound care orders, notify family about the wounds and the wound care company, wounds will be care planned, and to call the DON regarding any wounds found on admission or readmission. A copy of the skin management policy was attached. Record review indicated the facility had conducted skilled nursing facility nursing competency testing on nursing staff dated 8/14/25. Some of the questions indicated the physician should be notified as soon as a change was identified, when a resident is admitted with a pressure sore, the responsibility was to notify the MD, after receiving Wound care orders, put them in the computer and initiate care protocol. When observations showed increased redness or drainage from a wound, notify the MD and request updated wound care orders. There were also true and false questions. During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments. She said one resident was up and 1 resident refused, and they are going to try and get them later. She said they did the in services and had a return demonstration test for the nurses. They were not able to have all nurses do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital. They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds. On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. An Immediate Jeopardy (IJ) situation was identified on 8/14/25 at 1:00 p.m. While the IJ was removed on 8/15/25 at 3:22 p.m., the facility remained out of compliance at a potential for not actual harm with a potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for pain and suffering.Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a readmission date of 8/5/25. He had diagnoses of peripheral vascular disease (PVD) (a condition where the arteries and veins in the arms, legs, and feet become narrowed or blocked reducing blood flow.) and a history of stroke. Record review of Resident #1's admission MDS assessment dated [DATE] indicated his cognition was intact with a BIMS score of 13. The MDS indicated he used a walker and a wheelchair, but required supervision or touching assistance with most ADLs. Record review of Resident #1's care plan dated 6/2/25 indicated he was incontinent of bowel and bladder. Some of the interventions were to assist to toilet as needed, provide weekly skin checks to monitor for redness, circulatory problems, breakdown or skin concerns, and report any new skin conditions to the physician. Record review of Resident #1's computerized physician orders dated 8/11/25 indicated no orders for treatment to his groin incisions were listed. Record review of Resident #1's After Visit Summary dated 8/4/25 provided instructions to call the provider if redness, tenderness or signs of infection (pain, swelling, redness, odor or green/yellow discharge around incision site, and for severe uncontrolled pain. Record review of Resident #1's Admit/Readmit Evaluation dated 8/5/25 at 1:32 a.m. indicated he had surgical incision wounds on the left groin, right groin, and left front knee. There were no other descriptions. Record review of Resident #1's Admit/Readmit note dated 8/5/25 at 1:32 a.m. indicated he was admitted from the hospital with a diagnosis of deep vein thrombosis, and PVD. He needed limited assistance with transfers, self-performance. He was continent of urine and bowels and needed limited assistance with toileting, self-performance. He had pitting edema to both lower extremities. He complained of pain and was given pain medications. (no mention of surgical wounds) Record review of Resident #1's nursing notes dated 8/5/25 indicated he had a telehealth visit. The resident was readmitted last night with bilateral groin stent placement for PVD. He reported difficult urinating and severe incisional pain. He was requesting to be sent back to the ER and was transferred at 6:12 a.m. to the hospital. At 8:00 a.m. the resident returned from the hospital and was given pain medications. Record review of Resident #1's nursing notes dated 8/7/25 at 1:14 p.m. indicated Resident has open wounds; vascular and surgical. The resident received wound care with no changes in skin condition noted, and there were no signs and symptoms of infection. Record review of Resident #1's Skilled Observation note dated 8/10/25 at 9:37 p.m. indicated no infection was present the wound had redness and inflammation. The skin was warm and dry. The surgical incision was open with wound care and notable changes in skin condition. The observation described the incision with staples on the left side of the groin to have a foul-smelling drainage. The area was red and inflamed, it was cleansed with wound cleanser and was tender to touch. The groin on the right side had no visible signs and symptoms of infection. The note indicated would report to the oncoming charge nurse. Written by LVN E (there was no indication the physician was notified. Record review of Resident #1's nursing notes dated 8/11/25 at 5:50 p.m. the resident was sent to the hospital due to altered mental status. No other information was documented. Record review of Resident #1's hospital records dated 8/11/25 revealed the resident was admitted due to generalized weakness. He had bilateral groin incisions with staples that were irritated, with redness to the left and right groin and a foul smell. It appeared yeasty in nature. He stated his groin infections hurt and itched. His diagnosis was surgical incision infection. He was prescribed Cephalexin 500 mg two times a day for 7 days and Nystatin cream apply to groin area two times a day for 7 days. He returned to the facility on 8/11/25 at 11:14 p.m. and new orders were noted. Record review of Resident #1's nursing note dated 8/11/25 at 11:14 p.m. indicated he was readmitted to the facility with diagnoses of generalized weakness, yeast infection, and incisional infection. He had new orders for cephalexin 500 mg three times a day for 7 days and Nystatin Cream 100,000 units to bilateral groin two times a day for 7 days. Record review of Resident #1's computerized physician orders indicated an order with a start date of 8/12/25 at 8:00 a.m. for Nystatin External cream 100,000 units to bilateral groin area two times daily. An order with a start date of 8/12/25 at 8:00 a.m. for Cephalexin Oral Capsule 500 mg by mouth three times daily for 7 days.After Investigator intervention a treatment administration record was generated on 8/13/25, and indicated his treatment was to start on 8/13/25 at 6 p.m. During a telephone interview on 8/11/25 at 12:06 p.m., an Anonymous staff said Resident #1 had staples to his right and left groin area. The staff said on 8/10/25, a nurse had gone to look at the surgical incisions and they looked infected. The staff said that an unidentified nurse had not called the physician. She stated she had cleansed the area with wound cleanser and wound care was supposed to be done today, 8/11/15 by the treatment nurse. During an observation and interview on 8/11/25 at 3:20 p.m., Resident #1 was noted with EMS in his room. LVN A said Resident #1 was going to the hospital due to a change in his level of consciousness. She said he had staples in his right and left groin area and the left groin area was inflamed. She said it had yellow slimy drainage. She stated she told EMS his blood pressure was 88/56. Resident #1 was noted to be able to ambulate from the bed to the stretcher and was taken by EMS. LVN A said Resident #1's surgical incision appeared infected. During an interview on 8/11/25 at 5:59 p.m., LVN C/Treatment nurse said Resident #1 had surgical incisions on both sides of his groin. She said she was informed the right side of Resident #1's groin was red and inflamed. She was going to reach out to see if they wanted to remove the staples, but had not done so yet. She said they had orders to monitor the areas and put on a dry dressing. (There was no order noted) During an interview on 8/13/25 at 10:46 a.m., the DON said Resident#1 did not have any orders to treat his surgical incisions. The DON said LVN D was on duty when Resident #1 was readmitted to the facility on [DATE], and she should have passed his information on to the oncoming nurse. The DON said LVN D sent Resident #1 back out the same night and did not get an order for his surgical incisions. She said her staff were trained to go by the hospital After Visit Summary for orders. However, if a resident came in as a new admit or a readmit and did not have an order, they were to call the doctor to get an order. The DON said since Resident #1 did not have an order to treat the surgical incisions, someone should have followed up with the physician. After review of the Resident #1's observation note dated 8/10/25, the DON said LVN E should have contacted the physician when she noted Resident #1's wound looked infected. During an interview on 8/13/25 at 1:54 p.m., the RN Weekend Supervisor said she filled in for the treatment nurse on the weekends, and when the treatment nurse was out. She said Resident#1 did not have an order to treat his surgical incisions on the groin area. She said if a resident did not have an order or treatment in place, she was not aware they had any areas. The RN Weekend Supervisor stated when Resident #1 came from the hospital with surgical wounds and did not have anything down to treatment the areas . She said the nursing staff should have called the doctor to see what he wanted done. She said good nursing judgment indicated they should have called the hospital for orders or called the doctor to at least see what the physician wanted done with the wounds. During an interview on 8/13/25 at 2:30 p.m., LVN E said she worked on Friday 8/10/25 and had seen Resident #1's wounds, but did not provide any treatment. She said she was under the impression the treatment nurse was providing treatments to his groin area. She said she asked LVN C/Treatment nurse earlier in the week, and she said Resident #1's wound was getting cleaned and left to open air. LVN E said on the afternoon of Sunday 8/10/25, Resident #1's family brought to her attention that they thought Resident #1's groin area was infected. She said they sent pictures, and she had gone to look at the wound. LVN E said she cleaned the wounds on Resident #1's groin and noted in an observation note the left side was inflamed and red. She said the area could have been infected; it had an odor, and yellow drainage, it was red and inflamed . She said she had not contacted the physician; she passed the information on to the oncoming shift. During an interview on 8/14/25 at 9:45 a.m., the MD said he was not told Resident #1's surgical wound was infected prior to his discharge. He said he expected staff to call him and let him know of changes that occurred with residents. He said when a resident came back from the hospital they needed orders in place. He said if the facility does not have any orders, they should reach out to him for orders. He said the facility usually did a skin assessment and would call him for an order. He said especially if a resident was a readmitted and did not have a previous order for wound care. He said he expected to be notified of Resident conditions. Resident #2 Record review of Resident #2's face sheet dated 8/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission date of 8/12/25. She had diagnoses of stroke, end stage renal disease, chronic respiratory failure, heart disease, diabetes, and bipolar disorder. Record review of Resident# 2's admission MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 14. Resident #2 required partial to substantial assist with ADLs. She required supervision with bed mobility, partial to moderate assist with sit to laying, and did not attempt to stand or transfer due to medical condition. The MDS indicated she was at risk for a pressure ulcer. Review of Resident #2's care plan dated 5/19/15 indicated she was at risk for pressures ulcers. One of the interventions was to monitor for redness, circulation problems, pressure sores, open areas, and changes in skin integrity. Review of Resident #2's computerized physician orders dated 8/13/25 at 4:00 p.m. did not reveal an order for treatment to her sacrum wound. Review of Resident #2's nursing notes dated 7/31/25 at 6:00 a.m. revealed the resident was sent to the hospital due to her calling EMS and stating she was having difficulty breathing. Record review of Resident #2's hospital records dated 7/31/25 indicated the resident was admitted to the hospital on [DATE] after a ground level fall. She was discharged to the facility on 7/30/25 and readmitted to the hospital on [DATE] with complaints of shortness of breath and pain associated with groin buttock wounds. Review of Resident #2's hospital After Visit Summary dated 8/12/25 indicated the primary diagnoses for hospitalization was pressure injury of sacral region stage 4, end stage renal disease, uncontrolled diabetes, and fluid overload. There was no order for the care of the pressure injury of the sacrum. Record review of Resident #2's Admit Readmit Evaluation 8/12/25 at 10:00 p.m. indicated skin integrity with wounds present on admission, with bruising, discoloration, and an open wound. The comments indicated a pressure injury of the sacral region, stage 4, and bruising to the hands and front of the elbow. Record review of the facility's 24-hour report for 8/12/25 indicated Resident #2 returned from the hospital at 9:35 p.m., and she had a stage 4 pressure wound on her sacrum. During an interview on 8/13/25 at 6:01 p.m., the Administrator said they did not have any treatment orders for Resident #2's treatments, and she did not have a TAR generated at the current time due to no orders being in place. During an interview 8/14/25 at 11:00 a.m., the RN Weekend Supervisor said whoever admitted Resident #2 should have gotten orders from the hospital. She said if not, they should've gotten orders from the doctor regarding resident service. She said she completed the wound care on Resident #2 yesterday evening.During an interview on 8/13/25 at 4:50 p.m., the DON said Resident #2 had been in the hospital for 45 days. She said every time Resident #2 came to the facility, she was only there for a day or a few hours and then back to the hospital. The DON said normally when a resident was admitted or readmitted , the admitting nurse contacted the hospital for additional orders or contacts the physician for orders. She stated if it was during the night, the treatment nurse would be notified and the next day to do a skin assessment, notify the physician . She said at that time if a resident had wounds or if they needed any kind of treatment, they would get orders. She said she did not know why there were no orders for Resident #2. Record review of the facility's Notification of Changes policy last revised 2/10/21 indicated their policy to provide guidance on when to communicate acute changes in status to the MD, NP and responsible party. The will would immediately inform the resident: consult with the resident's physician, and responsible party for any significant change in physical, mental, or psychosocial status of the resident. The facility documents resident assessments, interventions, physician and family notification on the SBAR, Nursing Progress Note, or Telephone order form as appropriate. This was determined to be an Immediate Jeopardy (IJ) on 8/14/25 at 1:00 p.m. The Administrator, DON, and RNC were informed of the IJ situation on 8/14/25 at 1:00 p.m. a copy of the IJ template was emailed to them at 1:00 p.m. A POR was requested and accepted on 8/15/25 at 10:45 a.m. [The facility failed to implement policies and procedures to prevent the hospitalization of Resident #1 due to a surgical wound infection.Immediate Action Taken:On 08/14/2025 at 2:30 PM, the attending physician for Resident #1 and #2 was notified of the status of the surgical incision, wounds and the lack of prior communication regarding wound condition. Resident #1and #2 were immediately assessed by the facility's wound care nurse and physician. Orders were received and implemented, including wound care protocols and infectious disease consult. 2. Identification of Residents Affected or Likely to be Affected:A head-to-toe skin and wound assessment was completed on all residents by the Director of Nursing (DON) and Wound Nurse on 08/14/2025. A facility-wide audit was initiated on 08/14/2025 by DON/Designee to ensure all residents have current wound descriptions, physician orders, and proper documentation of physician notification and will be completed by 8/15/25. Any discrepancies were immediately corrected, and responsible nurses were given additional education by DON/Designee.DON/Designee reviewed the last 5 admissions and completed an audit for any missing ordersDON/Designee provided education to licensed nurses on admission and readmission orders3. Actions to Prevent Occurrence/Recurrence:Staff Education On 08/14/2025, the DON/Designee educated all licensed nurses on: Documentation of wound assessments will be located in the progress notes and include descriptions of the wounds, skin tears, bruises, surgical incisions, sizes, measurements, drainage, and colors.Use of SBAR (Situation-Background-Assessment-Recommendation) communication tool will be completed upon identification of change in condition by the charge nurse immediately upon identification of change in conditionStaff were required to demonstrate understanding via return demonstration or post-education quiz. Staff unavailable to attend in service on 08/14/2025 will receive personalized in service prior to assuming their duties. Wound Communication Process A daily Wound Rounds Checklist was implemented to ensure: The DON/Designee audited each resident to ensure wound has documented assessment, treatment orders, orders transferred to computer, MAR and TAR, and notification status. The DON/Designee educated all licensed nurses on wound assessment, documentation, treatment orders, documentation on 24 hour report for shift to shift communication and notification to physicians . Any change is reported immediately to the physician and documented in progress notes.Weekly interdisciplinary wound rounds initiated as of 08/14/2025 with physician participation (in person or telehealth). Monitoring and Oversight PlanDaily audits of physician notification for any changes in condition by DON or designee for 14 days (08/14-08/28/2025), then weekly x4 weeks. All new admissions and readmissions will be reviewed within 24 hours to ensure physician orders and wound care protocols are in place by DON/ Weekend Supervisor/ Designee. Review will be documented on the admission Audit tool.DON or designee will: Review progress notes, nurse notes, and MARs for compliance. Validate timely physician notifications. Audit results will be reported weekly to the Quality Assurance & Performance Improvement (QAPI) committee for 3 months. Continued noncompliance will trigger retraining or disciplinary action. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/14/25] On 8/15/25 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of facility skin assessments, facility audit of records to include wound descriptions, physician orders, and documentation in the nursing notes. The skin assessments were reviewed for all residents in the facility and noted two residents were found with redness to the buttocks, one resident with an open area to the buttocks, and one resident with redness to an ostomy site. There were orders noted to be placed, a description of the areas, and the physician was notified. Review of documentation showed Resident #1 and Resident #2 had descriptions of their wounds and treatment orders in place. Review of the facility Wound Daily Audit dated 8/14/25 through 8/24/25 indicated 3 newly admitted residents with skin assessments completed, the physician notified, a wound order in place, the wound care physician notified, and family notified. Record review of in-service dated 8/14/25 indicated nurses were educated on Change in Condition, completing the SBAR when a resident has a change in condition. When a nurse was notified or identified a change in condition they were to immediately, assess the resident gather vital signs, ask specific questions, if possible, notify MD, responsible part, DON and then document in the computer and add to the 24-hour report. Record review of in-service dated 8/14/25 indicated 19 nurses were educated on pressure ulcers/wounds upon admission or readmission. They were instructed to complete a head-to-toe assessment, measure wounds or open areas, complete the skin assessment, document in the computer system on admission or readmission, call the physician or use the [NAME]- health after hours to receive wound care orders, notify family about the wounds and the wound care company, wounds will be care planned, and to call the DON regarding any wounds found on admission or readmission. A copy of the skin management policy was attached. Record review indicated the facility had conducted skilled nursing facility nursing competency testing on nursing staff dated 8/14/25. Some of the questions indicated the physician should be notified as soon as a change was identified, when a resident is admitted with a pressure sore, the responsibility was to notify the MD, after receiving Wound care orders, put them in the computer and initiate care protocol. When observations showed increased redness or drainage from a wound, notify the MD and request updated wound care orders. There were also true and false questions. During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments. She said one resident was up and 1 resident refused, and they are going to try and get them later. She said they did the in services and had a return demonstration test for the nurses. They were not able to have all nurses do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital. They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record, review the facility failed to provide care in a manner that ensured the residents dignity for 3 of 4 residents reviewed for dignity (Resident # 3, #4, and #5.) 1. The facility failed to provide Resident #3 with briefs that fit. 2. Resident #5 said she was anxious, and was afraid she would embarrass herself due to not having briefs that would fit.3. Resident #4 said she had briefs but that caused her discomfort because they were the wrong size.4. Residents and staff voiced concerns about not having briefs over the weekend on 8/9/25 and 8/10/25. These facility failure to provide residents with briefs that fit could place residents at risk at risk of anxiety, embarrassment and discomfort.Findings included: During an interview on 8/11/25 at 3:10 p.m. the Administrator said they had a shortage on briefs and wipes over this past weekend. He said they had ordered some last Tuesday, 8/5/25, and the order was supposed to arrive today 8/11/25. The Administrator said their census was 104 and they had about 10 or more residents that used bariatric briefs. He said they had bought some at the local store and had a limited amount available at the current time. During a telephone interview on 8/11/25 at 12:06 p.m., an unidentified staff revealed Resident #3's POA called the police because he had to lay in urine all day. The staff member said the facility did not have any bariatric briefs to fit Resident #3 or large residents during the weekend. The staff member said staff went to a neighboring facility to borrow a few briefs, but residents had to go without care, and the facility was also out of wipes. During an interview on 8/11/25 at 4:20 p.m., the HR Director said she had been appointed to order supplies after the former Administrator had left a few weeks ago. She said the problem was that staff waited until they were out of things before, they let her know. She said she did not work the floor, so she did not know what was needed until someone told her. She said they had put in an order on 8/5/25 and it was supposed to be delivered today but it did not look like it will be. However, they were out of some supplies or at least she had been informed they were out of briefs and wipes. During an observation and interview on 8/11/15 at 4:45 p.m. with CNA B revealed she was just placed over generating the orders for supplies. She said they did not have large, extra-large briefs, or bariatric briefs. She said they had issues over the weekend due to staff not having briefs that fit the residents. She said the Administrator had bought some wipes and a couple of bags of bariatric briefs that morning. CNA B said they had an overstock of medium briefs, so the smaller residents were fine. However, most of their residents wore, large and extra-large briefs. She said they had 10 or more that wore the bariatric briefs. Observation of the main supply room with CNA B revealed one package of 12 bariatric briefs, plenty of small briefs, and multiple packs of medium. However, there were no large or extra-large briefs. There was one package of bariatric briefs on the shelf. CNA B said the Administrator had purchased this morning. Observation throughout the facility revealed they had about 3 packs of large briefs. Some of the aides had hidden them away in the linen closets. They had less than 10 bariatric briefs on the hallway. Record review of Resident #3's quarterly MDS dated [DATE] indicated he was cognitively stable with a BIMS of 14. During an interview on 8/13/25 at 10:40 a.m., the DON said they were running low on briefs and wipes, but the staff had enough supplies to make do. She said they could put briefs together if needed. The DON stated the family of Resident #3 called the police and said he was laying in urine all day. The police came and she was told they found no issues. She also said they had the police incident written down; a copy was requested. There was no police report provided. During an interview on 8/13/25 at 1:40 p.m., Resident #3 said he was very upset this weekend at the way he was treated. He said the facility did not have briefs to fit him and he had to lay in urine most of the day. He said they did not have briefs from 7:30 p.m. Saturday night until about 2:30 p.m. Sunday 8/10/25. He said he was mad because he was told he could not get out of bed. He said he had called his family member and told them about the situation. He said the police came and the RN Weekend Supervisor came in and lied to the police in front of his face about having briefs. He said they brought a pack of brief in at that time with two briefs in it. He said he felt it was a stupid situation to have to lay in urine all that time because the facility did not have what they needed. He said he was told they had smaller briefs, but none that would fit him. He said it make him feel very low, like what he needed did not matter. He said they had some good aids, and they tried but had nothing to work with. During an interview on 8/13/25 at 1:54 p.m., the RN Weekend Supervisor said she was made aware the facility was out of bariatric briefs on Sunday morning, 8/10/25. She said she called the sister facility, and they loaned them one package of bariatric briefs about 10 in the pack. She said on Sunday afternoon, the police came after Resident #3's family member called them to report, Resident #3 was laying in urine all night and day. The RN Weekend Supervisor said she had seen Resident #3 out of the bed on Friday and Saturday. She said she had told her staff to put some medium briefs together to get residents up. She said the staff would not be unable to fasten the briefs on the sides, but they had to make do with what they had. She said earlier that day she asked Resident #3 if he wanted to get up and he said no. She said when the police came, they checked Resident # 3 and their supply of briefs at that time and they had no concerns and left. During an interview on 8/13/25 at 2:30 p.m., LVN E said she worked on Sunday 8/10/25. She said she heard they did not have briefs. She had several residents complained. She said Resident #3 was up Saturday and Sunday, but he heard him complain about not having briefs. She said the aides were having a hard time trying to find the supplies they needed to provide care to the residents. During an interview on 8/14/25 at 11:08 a.m. the family member of Resident #3 said he called on Sunday 8/10/25 and said Resident #3 was laying in urine because the facility did not have any briefs. The family member said they called the RN Weekend Supervisor and was told the facility did not have any briefs to fit Resident #3. The family member said she was told by the RN Weekend Supervisor the resident had to stay in the bed, and lay in urine and poo until they had to change the sheets. The family member said she was told the order did not come in, and they did not know where the truck was. The family member said the RN Weekend Supervisor was short and abrupt in her conversation and appeared to not want to be bothered. The family member said that was why they called the police. The family member said they felt it was a crime for the facility to treat the residents worse than animals; having them lay in their own waste and did nothing about it. The family member said the police did not let them know what they found. Record review of Resident #5's quarterly MDS dated [DATE] indicated she was cognitively stable with a BIMS of 14. During an interview on 8/13/25 at 1:05 p.m., Resident #5 said there were no briefs over the weekend, and it started on Friday, 8/8/25. She said on Friday, the aide found one brief that fit her. She said they had hidden the brief so that she could have it for her doctor's appointment on Monday. She said it caused her anxiety to think she would have to go to her doctor's appointment and embarrass herself due to not having any briefs that fit her. She said they had no wipes and no washcloths, so they didn't have anything to wipe her with either. Resident #5 said she felt, due to the shortage of wipes, the laundry could not keep up with the demand. She said an aide had taken two smaller briefs and put them together, but they did not fit. Resident #5 said, on Sunday night, they were able to find a washcloth and she was cleaned up for her appointment on 8/11/25. She said the whole episode caused her a lot of anxiety and discomfort. She said she was afraid to go to activities because she was afraid that she would embarrass herself. Resident #5 said she was more concerned about going to her physician's appointment. She said that it was a very upsetting weekend. She said on Saturday and Sunday they used the smaller briefs as best they could. She said one aide brought some wipes from home and left them in her room so she could have some. She said the briefs they had available would cut off her circulation if they were able to close them at all.Record review of Resident #6's BIMs score dated 7/23/25 indicated she was cognitively stable with a BIMS of 14. During an interview on 8/13/25 at 1:10 p.m., Resident #6 said she witnessed the lack of briefs over the weekend and witnessed her roommate's anxiety and frustration at the situation. During an interview on 8/13/25 at 5:54 p.m., CNA F said she worked this weekend, and they did not have any large briefs. She said she had one resident on the hall that required bariatric briefs, and that was Resident #5. She said she worked on 8/9/25 and 8/10/25, and they could only find one bariatric brief on her hall. She stated she used two medium briefs, layered them, and had to pull the resident's pants up to hold them in place. She said Resident #5 wanted to get up every day about 11:00 a.m., and she explained that there were no briefs. CNA F said Resident #5 said she could not lay in bed all day. CNA F said Resident #5 said it was uncomfortable, but better than lying in bed all day Record review of Resident #4's quarterly MDS dated [DATE] indicated he was cognitively stable with a BIMS of 15. During an interview on 8/13/25 at 3:35 p.m. Resident #4 said she had on a brief at the current time, but it was not the right size, and it was cutting into her skin. She said over the weekend they had found a couple of briefs that kind of fit her, but she did not have any problems getting up. Resident #4 said hopefully they would have some more briefs today because the ones they had were too tight for her. She said she was fine just a little uncomfortable. She said she did not know what size it was, but it was a size to small.During an interview and observation on 8/13/25 at 1:20 p.m. of CNA B and two other staff were placing briefs in a room as an overflow. They said that they had got 3 1/2 pallets of supplies and they had plenty of large, extra-large, and bariatric briefs that had arrived today. During an interview on 8/13/25 at 3:40 p.m., LVN G said she worked at over the weekend on 8/9/25 and 8/10/25 and they did not have large briefs. She said some of those residents could not get up because they did not have briefs to fit them. Review of a purchase order dated 8/7/25 indicated the facility had order 22 boxes of briefs in different sizes and 21 boxes of wipes. The order indicated it was approved for purchase on 8/8/25.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. 1. The Dishwasher was not wearing a hairnet while working in the kitchen. 2. The Dishwasher was running dishes through the dish machine while the temperature gauge indicated the water was 106 F. This failure could place residents who ate meals prepared in the kitchen at risk for food borne illness. Findings included: During an observation on 3/29/25 at 2:15 p.m., the Dishwasher was washing dishes in the kitchen while not wearing a hairnet. During an interview on 3/29/25 at 2:20 p.m., the Dishwasher said he only wore a hairnet in the main area of the kitchen, not while in the back washing dishes. He said the facility had an issue with running out of hot water when the laundry staff were running the laundry machines. He said they had to stay in communication with the laundry staff and make sure they would not run the laundry machines while the kitchen was washing dishes or during meal service. He said there had been no problems today and staff kept a log of anytime water temperature was too low to wash dishes . During an interview on 3/29/25 at 2:22 p.m., the Dishwasher washed a load of dishes in the dish machine while the temperature gauge indicated a water temperature of 106 F; a sign posted next to the dish machine indicated a temperature of 120 F was required for dishes to be sanitized. During an interview on 3/29/25 at 2:23 p.m., the Dishwasher said the temperature had been above 120 F all day. He said the dishes that he just washed in 106 F water looked clean and did not need to be rewashed. During an interview on 3/29/25 at 2:25 p.m., Dietary Aid A said the facility had an issue with running out of hot water, but it had been fixed by the Maintenance Supervisor. She said she could not recall the last day there was an incident of running out of hot water, and there had been no incidents today . During an interview on 3/29/25 at 3:00 p.m., the ADM said the facility had an incident of running out of hot water in January of 2025 and the Maintenance Supervisor repaired the water heater. She said the washing machines could not be run while the dish machine was being ran or they would use all the hot water. She said she in-serviced kitchen staff regarding infection control, dishwashing, and required temperatures for sanitizing dishes. She said she already in-serviced kitchen staff again today and instructed them to re-wash all dishes and to use the 3-compartment-sink, which used lower temperature and chemical sanitization, if the water temperature was below 120 F . During an interview on 3/29/25 at 3:45 p.m., the Housekeeping Supervisor said the issue of running out of hot water was first identified in January of 2025. He said the Maintenance Supervisor ordered the parts and made the repairs and there had been no incidents of running out of hot water since. He said the problem only affected the kitchen and laundry room, which had separate hot water tanks from the rest of the facility. He said the washing machines used too much hot water and there was none left in reserve for washing dishes. He said he in-serviced laundry staff not to run washing machines during meal service or when the kitchen was washing dishes. He said the ADM in-serviced kitchen staff to monitor the water temperatures and report any incidents concerning the hot water to supervisors . During observations on 3/29/25 at 4:25 p.m., the Dishwasher was wearing a hairnet and washing a load of dishes in the dish machine; the temperature gauge on the dish machine indicated the water temperature was 121 F. During a telephone interview on 3/29/25 at 4:30 p.m., the Maintenance Supervisor said he was unaware of any problems with the hot water at the facility. He said the facility began running out of hot water in the kitchen in January 2025. He said there were error codes displayed on the water heater that indicated the blower motor and a gas valve were faulty. He said he ordered the parts and repaired the unit and there had not been any more incidents reported to him. He said laundry staff were supposed to shut off laundry machines and not run them when dishes were being washed because the laundry machines used around 100 gallons of water and would use all of the hot water reserves. He said the issue only affected the kitchen and laundry room because the rest of the building had separate water heaters. He said he checked the water temperatures in resident rooms daily and kept a temperature check log and had not identified any concerns . Review of receipt from local a local plumbing company dated 1/9/24 revealed a ball valve was replaced in the boiler room kitchen. Review of DAILY WATER TEMP LOG for April 2024 through March 2025 revealed all daily water temperature checks in resident rooms and care areas fell within the 100 F to 110 F temperature. Review of in-service dated January 2025 titled Dish Machine and Ware Washing. Review of in-service dated 1/27/25 titled Laundry Wash Cycles and Time. Review of in-service dated 3/29/25 titled Infection Control and Regulations. Review of policy titled Ware Washing last revised on 5/2018 indicated the following: .Improper temperatures and/or sanitizer strength will be reported to the person in charge immediately and manual ware washing and/or paper products will be implemented until the problem is corrected .

Based on interview, observation and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 reviewed for pain. The facility failed to contact the physician in a timely manner regarding Resident #1's pain medication. The facility failed to provide Resident #1 with pain medication for 20 hours after admitting with pain at a 9 out of 10 (0 being no pain at all and 10 being the worst pain you have ever experienced). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/13/23 at 11:40 a.m. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health, behaviors, and quality of life. Findings Included: Record review of the consolidated physician orders dated 7/12/23 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] at 9:13 p.m. with a diagnosis including gastric ulcer with hemorrhage (internal bleed of a stomach ulcer), hypertension (high blood pressure), chronic pain syndrome, overactive bladder, and gastroesophageal reflux disease (heart burn). The physician orders indicated Resident #1 had orders for Morphine Sulfate (medication for pain) by mouth every morning and at bedtime starting 7/06/23 and Hydrocodone (medication for pain) 10-325mg by mouth every 6 hours as needed for pain starting 7/06/23. Record review of the MAR dated July 2023 indicated Resident #1 received her first dose of Morphine Sulfate on 7/06/23 at 7:00 p.m. and was experience pain of 7 out of 10 (0 being no pain and 10 being severe pain) The MAR indicated Resident #1 received her first dose of Hydrocodone on 7/06/23 at 7:30 p.m. and was experience pain of 9 out of 10. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #1 had moderate pain occasionally. Record review of the care plan dated 7/06/23 indicated Resident #1 was on a pain management regimen and takes analgesics routinely or as needed. The care plan indicated interventions included administer medications as ordered, monitor for side effects and effectiveness, and attempt non-pharmacological pain interventions when not contraindicated. Record review of the Admit/Readmit Evaluation dated 07/05/23 at 10:10 p.m. indicated Resident #1 had pain of 9 out of 10 with non-verbal pain indicator of restlessness. The Admit/Readmit Evaluation indicated interventions implemented were narcotics and quiet/relaxation. Record review of the Pain assessment dated [DATE] at 11:39 p.m. indicated Resident #1 reported having pain in her hip and back daily and times it was horrible or excruciating. The Pain Assessment indicated Resident #1 rated her pain as very severe. Record review of the nursing progress noted dated 7/06/23 at 3:06 p.m. indicated, The skilled nurse contacted [the physician] in regards for the need of ordered controlled medications. [The physician] reports ordered medications have been sent to the pharmacy at this time, awaiting arrival . Record review of pain level summary dated 7/06/23 at 7:30 p.m. indicated Resident #1 had a pain level of 9 out of 10. Record review of the pain level summary dated 7/06/23 at 9:24 p.m. indicated Resident #1 had a pain level of 7 out of 10. Record review of pharmacy packing slips dated 7/06/23 indicated Resident #1's morphine sulfate and hydrocodone had been delivered. During an interview on 7/07/23 at 1:20 p.m. Resident #1 said she had been in pain when she admitted to the facility on [DATE]. Resident #1 said did not receive any pain medication until 7/06/23 at 10:50 p.m. During an interview on 7/12/23 at 1:32 p.m. LVN B said she had worked at the facility 2 weeks. LVN B said she worked the 6:00 a.m.-6:00 p.m. shift. LVN B said Resident #1 in pain when she came in for her shift on 7/06/23. LVN B she was told in report about Resident #1' pain medications not being at the facility. LVN B said the order for Resident #1's pain medications had not been sent to the pharmacy. LVN B said she contacted the physician regarding Resident #1's pain medications. LVN B said she had text the physician regarding Resident #1's pain medication on 7/06/23 at 10:02 a.m. but did not chart that she had contacted him at that time. LVN B said she told Resident #1 that she could administer her some Tylenol. LVN B said Resident #1 refused the Tylenol. LVN B said without documentation there was no way to prove medications were given, communication with the physician had taken place, or that Resident #1 had refused Tylenol. During an interview on 7/12/23 at 1:43 p.m. the pharmacy staff said there was not time of delivery for Resident #1's medication on 7/06/23 documented. The pharmacy staff said they did not have the time the controlled medication order was received from the physician. During an interview on 7/12/23 at 2:26 p.m. the DON said when a new admit was coming from the hospital she expected staff to ask the hospital nurse during report to have the hospital doctor send a triplicate with the resident if they have an order for narcotics. The DON said she expected staff to ask the hospital nurse to administer pain medications to a resident with pain prior to them transferring to the facility. The DON said if a resident was admitted with pain 9 out of 10 she expected the nurse to reach out to the physician regarding sending in a controlled medication order if needed and get an order for an as needed pain medication until the pain medication requiring a controlled medication order was available. The DON said if it was after hours the nurses had access to on-call physicians to request an order for pain medication. The DON said the facility's Medical Director had standing ordered for all residents for Tylenol for pain. The DON said when she came into work on 7/06/23 Resident #1 was complaining of pain. The DON said she was called to the Resident #1's room. The DON said Resident #1 complained that she had not yet received any pain medication since she had admitted to the facility on [DATE] and was in pain. The DON said the nurse had been working on getting Resident #1's pain medication all day on 7/06/23. The DON said it was important to manage resident's pain so the residents were pain free. The DON said if something was not charted the only way to prove it had been done would be ask the physician. During an interview on 7/12/23 at 3:41 p.m. the Medical Director said he was familiar with Resident #1. The Medical Director said he had not seen Resident #1 in person yet. The Medical Director said the facility had notified him on 7/06/23 regarding Resident #1's pain. The Medical Director said he could not verify what time he was notified of Resident #1's pain. The Medical Director said he sent the controlled medication order to the pharmacy for Resident #1's morphine sulfate and hydrocodone on 7/06/23. The Medical Director said he could not verify the time the controlled medication orders for these medications was sent to the pharmacy. The Medical Director said the facility had standing orders from him for residents to receive Tylenol for pain. During an observation and interview on 7/13/23 beginning at 12:15 p.m. Resident #1 was lying in the hospital bed resting. Resident #1 said she did not feel good at all. Resident #1 said she did not remember speaking to the surveyor last week or her admission to the facility. During an interview on 7/13/23 at 2:32 p.m. LVN G said she was the nurse who admitted Resident #1 on 7/05/23. LVN G said Resident #1 complained of pain of 9 out of 10. LVN G she had 3 admissions the night that Resident #1 was admitted to the facility. LVN G said the ADON had assisted with inputting orders on 7/05/23. LVN G said her admission assessments for Resident #1 were not completed until 7/6/23, but she had dated them for the night Resident #1 admitted on [DATE]. LVN G said she gave Resident #1 pain medication on 7/06/23. LVN G said the night that she admitted Resident #1 had said she was in pain around midnight and asked for her pain medicine. LVN G said Resident #1 said she was always in pain. LVN G said on 7/05/23 she offered Resident #1 Tylenol and that Resident #1 accepted the Tylenol, but that she did not document giving her Tylenol. LVN G said LVN B gave her report on 7/06/23. LVN G said the LVN B told her in report that she had to contact the pharmacy after the first pharmacy run regarding Resident #1's pain medication and reached out to the physician regarding sending the controlled medication order to the pharmacy. LVN G said that she assumed in the facility's EMR it could be seen when the assessments had been completed. LVN G said she actually never completed the admission evaluation and locked it due to not having Resident #1's height and weight. LVN G said there was no way to prove she had administered Tylenol to Resident #1 due to it not being charted. LVN G said when she came on shift 7/05/23 at 6:00 p.m. the day shift nurse had already taken report from the hospital on Resident #1. LVN G said the report sheet it indicated Resident #1's narcotics order had already been sent to the pharmacy. LVN G said she did not contact the physician regarding Resident #1's pain medication due to being told in report it had been sent to the pharmacy. LVN G said she did not call the pharmacy to verify the narcotics orders were there because she had 3 admissions (3 new residents transferred to the facility from home, the hospital, or another nursing facility) and did not have the time. LVN G said it was important to administer scheduled pain medication to help keep their pain under control and not let it get to an excruciating level. Record review of the facility's Pain Management Policy dated 10/24/2022 indicated, The facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences .The facility will utilize a systemic approach for recognition, evaluation, treatment, and monitoring of pain. Pain evaluation are completed on admission, quarterly, with a significant change of condition, and as needed .Based on professional standards of practice, an assessment or evaluation by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate the following information, as applicable to the resident: History of pain and its treatment .Asking the patient to rate the intensity of his/her pain using a numeric scale, a verbal or visual indicator that is appropriate and preferred by the resident .Reviewing the resident's current medical conditions .Impact of pain on quality of life .Current prescribed pain medications .Based on the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission . The Administrator was notified on 7/13/2023 at 11:55 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/13/2023 at 11:57 a.m. The facility's Plan of Removal was accepted on 7/14/2023 at 7:35 a.m. and included: 1. Immediately Resident # 1 discharged to hospital on 7/11/23. A Pain User defined assessment will be completed on 100% of all residents in center by the DON/designee to identify if any other residents are experiencing pain. This will be completed today 7/13/23 at 6:00 pm. DON or designee will notify the physician of any resident experiencing unrelieved pain with current pain regimen. This will be completed 7/13/2023 at 6:00 pm if applicable DON or designee will provide all license nurses education on Pain Management Policy this will be completed 7/13/23 at 6:00 pm. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Notification of Change in Condition Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Medication Administration Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. 2. Identification of Residents Affected or Likely to be Affected: DON/Designee will complete a Pain assessment on 100% of all residents in center to identify if any other residents experiencing pain. This will be completed 7/13/2023 at 6:00 pm, and Physician notification will be completed by charge nurse of resident, for any resident identified with pain. 3. Actions to Prevent Occurrence/Recurrence: DON/Designee will Provide all nurses with education on Pain Management Policy. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. DON/Designee will Provide all nurses with education on Notification on Change of Condition. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. DON/Designee will Provide all nurses with education on Medication Administration Guidelines. This will be completed by 7/13/2023 at 6:00 pm. No nurse will be allowed to work until this education has been completed. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. DON/Designee completed 100% audit on 7/13/2023 at 4:00 pm and validated that all residents who receive pain medication, have medication available. DON/Designee started education with all license nurses on Control Substance Prescriptions Guidelines (which includes back up procedures for new admissions, including notifying physician and telehealth physician after hours for orders.). This education will be completed on 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. 4. Monitoring: DON or designee will monitor daily the 24hr sheets to identify any residents with unrelieved pain with physician notified of any identified. DON or designee will complete the QAPI pain monitor tool daily x 30 days, to validate no resident are experiencing unrelieved pain. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 7/13/2023 The facility's Medical Director was notified of the immediate jeopardy at 1:41pm on 7/13/23 by the administrator. On 7/13/23 4:00 pm an ad hoc QAPI meeting was conducted including medical director to discuss findings and sustained compliance. On 7/14/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 7/14/23 between 10:53 a.m. and 11:25 am (LVN A, LVN B, RN C, LVN D, LVN E, LVN F) were performed. All staff interviewed were able to name types of non-verbal pain indicators, non-pharmacological pain interventions, when to notify the physician, how to obtain pain medication for newly admitted residents, what information should be documented in the resident EMR, and proper medication administration and documentation. A random sample of resident EMR's were reviewed to ensure pain assessments had been completed on 7/13/23. Record review of QAPI meeting sign-in sheet dated 7/13/23 indicated appropriate staff in attendance. Record review of the DON's signed statement indicated pain medication audit and verification had been completed on all residents receiving pain medication. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 2 of 3 resident reviewed for quality of care. (Resident #1 and Resident #2) The facility failed to ensure Resident #1 and #2 were thoroughly assessed over a period of 3 days. RN A did not obtain vital signs during assessment of Resident #1 and #2 four times each over a course of three days;she documented vital from the previous day. The facility failed to consult Resident #1's physician and document a change in his condition when he vomited. Resident #1 and Resident #2 died on the same day at the facility, approximately 5 hours apart, after not receiving thorough assessments. These failures could place residents at risk for not receiving necessary care and services to meet their needs, serious impairment, and death. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: 1. Review of Resident #1's face sheet with a print date of [DATE] indicated Resident #1 admitted on [DATE] and discharged on [DATE]. He was [AGE] years old and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's baseline care plan dated [DATE] addressed the resident had a potential for falls, potential alteration of skin integrity and activities of daily living. The care plan did not address the resident's gallbladder issues, risks associated with heart failure, kidney failure or diabetes. Review of Resident #1's MDS dated [DATE] indicated he had adequate hearing, clear speech, understood others, was also understood, and had intact cognition. He required the extensive assistance of two staff members with bed mobility and toilet use. Review of Resident #1's physician Order Summary Report with a print date of [DATE] indicated Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 3:45 p.m. Resident #1's family member said her family member fell at home and broke his hip on [DATE] and had surgery on [DATE]. She said the resident admitted to the facility on [DATE]. She said the resident would have to push his call light multiple times before facility staff would respond. She said on the morning of [DATE], family members walked into the resident's room and he had thrown up on himself. She said the family members had to go find someone to clean him up and change his clothes. She said RN A came into the room, did not introduce herself or explain what she was doing and checked his blood sugar. She said facility staff did not take any other vital signs throughout the weekend, while she was there throughout the days of [DATE] and [DATE], other than his blood sugar. She said the resident was complaining about back pain on Saturday [DATE] and Sunday [DATE] when she visited. She said the family had recently discovered the resident had gallstones, but he could not have surgery due to his heart being too weak. She said she thought of this after leaving the facility, at approximately 3 p.m. on [DATE]. She said she contacted RN A to let her know he had gallstones and might need to be seen by his doctor. She said at around 7 p.m. she called the facility to see if RN A had spoken to the doctor and the nurse said she had not. Facility staff found the resident unconscious at around 3:30 a.m., on [DATE] and they worked on him for 30 minutes but were unable to resuscitate him. Review of a progress note dated [DATE] at 8:57 a.m. indicated Resident #1 had been seen by his physician, via a telemedicine visit. The resident notified the physician of his continued back pain and inability to relieve it. The physician indicated he believed it was related to the resident laying in a hospital bed for an extended period. The progress note also indicated the resident had been taking [MEDICATION(S)] 875mg/125mg (an antibiotic) twice a day for a gallbladder infection. Review of a nurse's note dated [DATE] at 4:08 a.m. indicated LVN B had assessed Resident #1 and obtained vital signs. Resident #1's blood pressure was ,d+[DATE] (normal ,d+[DATE]) at 4:10 a.m. His pulse was 68 at 4:10 a.m. His respiration rate was 18 at 4:10 a.m. His temperature was 97.1 at 4:09 a.m. His oxygen saturation was 95% at 4:10 a.m. His pain level was an 8 out of a 10 at 4:11 a.m. Interventions included dimming lights, turning/repositioning the resident. LVN B documented the resident was alert and oriented to person, place and time. His pulses were regular and palpable, and his pupils were reactive to light. She said he was resting in bed with his eyes closed and was easily aroused when spoken to. Review of a nurse's note dated [DATE] at 10:09 a.m. indicated RN A had assessed Resident #1 and included vital signs from [DATE]. His blood pressure was ,d+[DATE] at 4:10 a.m. on [DATE]. His pulse was 68 at 4:10 a.m. on [DATE]. His respiration rate was 18 at 4:10 a.m. on [DATE]. His temperature was 97.1 at 4:09 a.m. on [DATE]. His oxygen saturation was 95% at 4:10 a.m. on [DATE]. His pain level was a 3 at 10:10 a.m. on [DATE]. RN A documented the resident was alert and oriented to person, place and time. His pulses were regular and palpable, and his pupils were reactive to light. She said he was sitting up in bed. Review of a nurse's note dated [DATE] at 4:22 a.m. indicated Resident #1 had been assessed and included vital signs from [DATE]. His blood pressure was ,d+[DATE] at 4:10 a.m. on [DATE]. His pulse was 68 at 4:10 a.m. on [DATE]. His respiration rate was 18 at 4:10 a.m. on [DATE]. His temperature was 97.1 at 4:09 a.m. on [DATE]. His oxygen saturation was 95% at 4:10 a.m. on [DATE]. His pain level was a 3 at 10:10 a.m. on [DATE]. The nurse documented the resident was alert and oriented to person, place and time. His pulses were regular and palpable, and his pupils were reactive to light. The nurse said he was resting with no distress and no other problems. Review of a nurse's note dated [DATE] at 7:41 a.m. indicated RN A had assessed Resident #1 and included vital signs from [DATE]. His blood pressure was ,d+[DATE] at 4:10 a.m. on [DATE]. His pulse was 68 at 4:10 a.m. on [DATE]. His respiration rate was 18 at 4:10 a.m. on [DATE]. His temperature was 97.1 at 4:09 a.m. on [DATE]. His oxygen saturation was 95% at 4:10 a.m. on [DATE]. His pain level was a 2 at 7:42 a.m. on [DATE]. Interventions included turning and repositioning the resident. RN A documented the resident was alert and oriented to person, place and time. His pulses were regular and palpable, and his pupils were reactive to light. She said he was sitting up in bed. During an interview on [DATE] at 12:36 p.m. RN A said she worked double weekend shifts, 5:45 a.m. to 10:15 p.m. on Saturday's and Sunday's. She said she did not remember Resident #1. She said she was not aware that she had carried over vital signs from [DATE] into [DATE] and [DATE]. She said she would not have intentionally done that. She said she thought the CNAs obtained her vital signs for her during her shifts and did not realize they did not. She said she did not recall Resident #1 or that he had vomited or that the family had requested she call the physician. She said she performed finger stick glucose checks, assessments and administered pain medications for residents during her shifts. She said the nursing staff cleaned the residents if there were no aides available. Review of a nurse's note dated [DATE] at 3:35 a.m. indicated LVN B was called into Resident #1's room by a CNA. The nurse responded to the room with the crash cart and AED and requested other staff members assistance. The resident was found unresponsive and CPR was started by staff. EMS arrived and assisted with CPR. The resident was pronounced dead by EMS personnel at 3:05 a.m. During an interview on [DATE] at 9:04 a.m. LVN B said she had not been notified Resident #1 had possibly vomited on the day shift, when she received report that night from RN A. She said RN A told her in report that they needed to get in touch with the physician on Monday regarding his gallbladder at the family's request. She said nurses are supposed to get resident vital signs on their personal equipment and then input it into the computer system. She said they were supposed to get resident vital signs every shift. She said they should not have been using vital signs from previous shifts for their documentation. She said she had no reason to believe anything was wrong with the resident when she came on shift. She said when she came on shift, she never noticed anything may have been wrong with him and that she was shocked when he expired. She said the CNAs were doing rounds when Resident #1 was found at around 2:30 a.m. on [DATE]. During an interview on [DATE] at 11:42 a.m. CNA C said Resident #1 was in his bed at 11:59 p.m. on [DATE] and he was lying in bed watching tv. She said at 2:00 a.m. he was found unresponsive. She said she had not been told in report about him being sick earlier in the day or that anything was wrong with him. She said she and other aides would have to notify RN A that a resident needed medication, and 30 minutes later she would have to ask the aide -who it was that needed medicine. She said RN A also had to be told multiple times a resident was requesting something before she would get up to do it. During an interview on [DATE] at 11:51 a.m. LVN B said she would have seen Resident #1 at around 10 p.m. during shift change. She said the aides would have seen him around 11 p.m. on their rounds and then again at 2:00 a.m. on another round. During an interview on [DATE] at 4:39 p.m. Resident #1's physician said he had been caring for the resident for many years and the resident had multiple issues such as poorly controlled diabetes, kidney failure, and heart failure. He said the resident was in the facility for a broken hip. He said the broken hip and medications were exacerbating his chronic kidney failure and the hospital stay for his hip was extended due to that. He said the resident had gallstones and was receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the resident was not a candidate for gallbladder surgery due to his heart problems. He said he did a telehealth visit with the resident on ,d+[DATE] after his admission to the facility and that was the last time he heard about the resident until the facility contacted him to let him know the resident had expired. He said he was never notified of any changes with the resident. He said his nurse practitioner may have been notified of any changes with the resident, or the after-hours company the facility contracts with. During an interview on [DATE] at 4:49 p.m. the nurse practitioner said she was not notified of any changes with Resident #1 on the weekend of [DATE] through [DATE]. She said she did not work on the weekends. During an interview on [DATE] at 5:25 pm the DON said she did not remember ever being notified of Resident #1 vomiting. She said if he did vomit, she would expect the nurses to first assess him for constipation and bowel sounds. She would expect they take vital signs, and if the findings were abnormal, they should notify the doctor. She said if a family member requested staff call the physician, she would think the nurse should do so. She said the computer system pulled stuff that the nurses could use but didn't intend to use, such as old vitals, so it may not have been intentional when they used the old vital signs in their charting. She said she did not think the nurses had to get their own vital signs, because in her opinion, there were medication aides she trusted very much. She said she was going to see if she could override their electronic charting system to where it would not automatically pull over old vital signs. During an interview on [DATE] at 11:31 a.m. CNA D said she worked over the weekend of [DATE] and [DATE] but was never asked to come to Resident #1's room or to change his clothes after vomiting. During an interview on [DATE] at 11:33 a.m. CNA E she worked over the weekend of [DATE] and [DATE] but did not ever recall being asked to change Resident #1's clothes or being told he had vomited. During an interview on [DATE] at 11:48 a.m. HA F said she did remember going into Resident #1's room to answer his call light and deliver a meal tray, but she did not ever recall being asked to change his clothes or do anything else for him. During an interview on [DATE] at 12:45 p.m. the DON said there was not an afterhours call for Resident #1 on [DATE] or [DATE] but there was one for Resident #2 on [DATE] to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of Resident #2's face sheet with a print date of [DATE] indicated Resident #2 admitted on [DATE] and discharged on [DATE]. He was [AGE] years old and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's baseline care plan had not yet been completed Review of Resident #2's MDS dated [DATE] indicated he had adequate hearing, unclear speech, usually understood others, and was usually understood. He had short and long-term memory problems and had severely impaired decision-making skills. He had continuous inattention and required the extensive assistance of 2 staff members with bed mobility and toilet use. Review of Resident #2's physician Order Summary Report with a print date of [DATE] indicated Resident #2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a nurse's note dated [DATE] at 5:48 a.m. indicated LVN B had assessed Resident #2 and obtained vital signs. His blood pressure was ,d+[DATE] at 5:50 a.m. on [DATE]. His pulse was 98 at 5:50 a.m. on [DATE]. His respiration rate was 22 at 5:50 a.m. on [DATE]. His temperature was 97.6 at 5:50 a.m. on [DATE]. His oxygen saturation was 100% at 5:51 a.m. on [DATE]. LVN B indicated the resident was oriented to person, his pulses were regular and palpable, and his pupils were reactive to light. The nurse said he was confused and had behavioral issues throughout her night shift. Review of a nurse's note dated [DATE] at 11:19 a.m. indicated RN A had assessed Resident #2 and included vital signs from earlier in the day on [DATE]. His blood pressure was ,d+[DATE] at 5:50 a.m. on [DATE]. His pulse was 98 at 5:50 a.m. on [DATE]. His respiration rate was 22 at 5:50 a.m. on [DATE]. His temperature was 97.6 at 5:50 a.m. on [DATE]. His oxygen saturation was 100% at 5:51 a.m. on [DATE]. His pain level was a 0 at 11:20 a.m. on [DATE]. RN A documented the resident was alert and oriented to person. His pulses were regular and palpable, and his pupils were reactive to light. The nurse said he was sitting up in bed. Review of a nurse's note dated [DATE] at 4:31 a.m. indicated Resident #2 was assessed by the nurse and included vital signs from [DATE]. His blood pressure was ,d+[DATE] at 5:50 a.m. on [DATE]. His pulse was 98 at 5:50 a.m. on [DATE]. His respiration rate was 22 at 5:50 a.m. on [DATE]. His temperature was 97.6 at 5:50 a.m. on [DATE]. His oxygen saturation was 100% at 5:51 a.m. on [DATE]. His pain level was a 0 at 11:20 a.m. on [DATE]. The nurse documented the resident was alert and oriented to person. His pulses were regular and palpable, and his pupils were reactive to light. The nurse said he was resting and was very confused and yelling. Review of a nurse's note dated [DATE] at 8:26 a.m. indicated RN A assessed Resident #2 and included vital signs from [DATE]. His blood pressure was ,d+[DATE] at 5:50 a.m. on [DATE]. His pulse was 98 at 5:50 a.m. on [DATE]. His respiration rate was 22 at 5:50 a.m. on [DATE]. His temperature was 97.6 at 5:50 a.m. on [DATE]. His oxygen saturation was 100% at 5:51 a.m. on [DATE]. His pain level was a 0 at 8:32 a.m. on [DATE]. The nurse documented the resident was alert and oriented to person. His pulses were regular and palpable, and his pupils were reactive to light. The nurse said he was sitting in the floor on his mat in his room. Review of a nurse's note dated [DATE] at 8:46 a.m. indicated LVN G assessed Resident #2 and found he had low blood pressure. She said she left the room to call the physician when CNA H called for her to come back to the resident's room. She said the resident had been talking to CNA H and then went unresponsive. She said the resident had shallow breaths and confirmed he had a pulse but was unresponsive to all stimuli. She said she called for the crash cart, called 911, and when hanging up the phone, realized the resident no longer had a pulse. She began CPR until EMS arrived, and 46 minutes after EMS arrived, the resident was pronounced deceased . During an interview on [DATE] at 2:38 p.m. LVN G said the nurses were supposed to get resident vital signs when the residents were on follow up for antibiotics, new medications, or when they were on the skilled hall. She said when she saw the resident had low blood pressure at around 7:50 a.m. on [DATE], she left his room to call the doctor. The aide was in the room with the resident when she left, and when she was almost to the nurse's station to call the doctor, the aide called her back to the resident's room and said he was unresponsive. She said she was telling management that the residents were not having their lights answered in a timely manner, but she said no one listened to her. During an interview on [DATE] at 10:15 a.m. CNA H said she gave Resident #2 his medications the morning of his expiration. She said he was alert and mumbling which was normal for him. She said as she went to the next room, she heard a resident yelling HEY! but was unsure which resident it was. One of the therapists went into Resident #2's room and told CNA H he looked blue. CNA H said she looked in, and said he looked blue to her as well. She said he was still breathing and had a pulse. CNA H got LVN G to come down and assess the resident. She said LVN G went to get the crash cart and CNA H called 911. During an interview on [DATE] at 12:55 p.m. Resident #2's physician said he had not yet seen Resident #2. He said he was on his way into the facility when they called a code blue for the resident and then was informed the resident had expired. During an interview on [DATE] at 1:15 pm ADON J said vital signs should be taken every shift for the skilled nursing halls and staff should not reuse vital signs. Some of the nurses were good about uploading resident vital signs into the electronic charts and some nurses were not good about it. She said the only other staff member who would get resident vital signs would be the medication aide, but they only obtained blood pressures in order to administer medications and did not get full sets of vitals. She said she did not agree that the medication aides or CNA's should get vital signs in place of the nurses. During an interview on [DATE] at 4:45 p.m. Hospitality Aide K said her co-workers on the weekends were not attentive to the residents. She said if she requested help on weekend shifts, no help could be found. She said when residents would ask for medications on the weekends, the nurses could take up to an hour to bring the medication. She said she believed staff on the weekends did not get vital signs every shift as they were supposed to. During an interview on [DATE] at 9:38 a.m. Hospitality Aide L said she believed weekend staff did not get vital signs throughout the weekend and she had been asked by the nurses to get their vital signs. She said she refused when she was asked to get vital signs because she was not supposed to do that. During an interview on [DATE] at 10:20 a.m. Resident #3 said the nurses did not get his vital signs on the weekend shifts. He said he rarely saw his nurse on the weekends and usually only saw the medication aide. During an interview on [DATE] at 10:26 a.m. Resident #4 said she did not recall if the nurses got her vital signs on the weekends. She said she thought they might, but she was not sure. She said she did not see staff very often. During an interview on [DATE] at 10:30 a.m. Resident #5 said she only saw the medication aide on the weekends and throughout the week, not the nurses. She said she only saw her nurse when she would request a pain pill. She said they would sometimes get her vital signs but not always. During an interview on [DATE] at 11:40 a.m. Resident #6 and Resident #7 both said they never see anyone on the weekends. They said they were both ambulatory and used the restroom without assistance. They both said they had to wait at least an hour on the weekends for their call lights to be answered, if they were ever answered at all. During an interview on [DATE] at 11:50 a.m. the DON said she could not provide the facility 24-hour reports for the weekend of [DATE] to [DATE] because their corporate office said the reports were internal documents and could not be copied. She said she would see if she could provide the documents if they were not copied. During an interview on [DATE] at 2:30 p.m. the DON said they no longer had 24-hour reports from [DATE]. She said they were only kept for a month since they were not needed for permanent records. An undated Recognition of Change of Condition policy indicated: 1. Criteria: Resident . .Roommate, family or other observer expresses concern that resident is looking/sounding funny . .3. Assess the Resident -Take vital signs . .4. Contact the attending physician or designee. If the attending MD fails to respond within 5 minutes, contact again. If still no response, contact, Medical Director. If no response from Medical Director. If no response from Medical Director within 5 minutes, send resident to the nearest E.R. to be evaluated. Have the chart to provide this checklist of information when MD responds: . .-vital signs . .-vomiting, diarrhea, constipation if present . .5. Receive orders from physician or designee 6. Implement order 7. Provide nursing care 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours. The administrator and DON were notified on [DATE] at 5:52 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on [DATE] at 3:56 p.m. and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility took the immediate actions to ensure that all residents received a comprehensive assessment to prevent any potential adverse outcomes. (Completion Date: __[DATE]____) On [DATE] the DON/Designee immediately reviewed and evaluated all residents including obtaining vital signs to identify any signs or symptoms that would require notification and intervention changes by the physician. As Indicated, The DON/Designee notified the physician of any resident with signs or symptoms and new orders for interventions were obtained and implemented. Any resident identified through this process was placed on q shift charting by the DON/Designee. 2. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the concerns identified in the IJ template: (Completion Date: _[DATE]__) The staff nurses will evaluate residents during their shift to identify resident signs or symptoms that require physician notification, intervention and documentation. The nurse documents on the 24-hour report any residents that have signs/ symptoms that require physician notification or intervention. The DON/designee audits the 24-hour report daily and completes walking rounds to validate the effectiveness of new interventions. The DON/Designee works with the nurse to discuss with the physician additional interventions to promote positive resident outcomes as indicated. The MDS Nurse/Designee will audit the care plans to validate that the healthcare information necessary to properly care for the resident has been implemented. 3. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or systems to prevent an adverse outcome from occurring or recurring, and when those actions were completed. (Completion Date: __[DATE]___) All licensed nurses were educated using Relias Learning System on the following topics: -- PCC ECourse: Weights/Vitals -- PCC ECourse: Assessment -- Post Test were completed The DON/Designee educated all nurse on the facility policy and procedure for Documentation in Medical Record. All nurses will complete the Documentation in Medical Record Post Test. The DON/Designee educated Nurse aides to report changes of condition and resident behaviors to the charge nurse Staff members who were not educated by end of day on [DATE] will not be permitted to work a shift until education was completed. New hires (licensed nurses) will be educated on PCC ECourse: Weights/Vitals, PCC ECourse: Assessment, and Documentation in medical Record. Post Test will be completed The DON/ Designee will educate New hires (nurse aides) on their job duties which include reporting changes of condition and resident behaviors to the charge nurse The DON/Designee will review and discuss with the IDT team residents that required physician notification or changes of interventions in the morning meeting and afternoon meeting. The Regional MDS Nurse/Designee will educate on care plans with posttest to validate that the healthcare information necessary to properly care for the resident has been implemented. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Facility's Checklists and Monitoring tools used to verify compliance, frequency, how long and responsible person. The DON/designee will complete chart audits using the Acute Condition Change QAPI Audit Tool on residents that have signs or symptoms that require physician notification or change in intervention to validate that comprehensive assessments were performed. The chart audits will include a review of the PCC assessment documentation, care plans, and a validation that the vital signs are current and accurate as follows: Five residents daily for one week then; Three residents weekly for four weeks then; Two residents weekly for two weeks then; Two residents a month for two months. The DON/Designee will submit and review all audits with the Quality Assurance Performance Improvement Committee monthly for three months. The QAA committee will monitor for consistent substantial compliance and make recommendations for changes as indicated. The facility medical director was notified on [DATE]. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of resident assessments. Starting on [DATE] all residents were assessed except for one resident who refused because he was being discharged later in the day. Assessments included current vital signs. Interviews with 6 CNAs on the ,d+[DATE] shift and ,d+[DATE] shift indicated they had received in-services from the facility regarding communicating change in resident condition to the nurse and to escalate concerns up the chain of command to the ADON and DON if the nurse does not respond. Interviews with 3 LVNs indicated they had received the required in-services. An interview with DON indicated required trainings with staff were being completed, that she was conducting morning meetings and reviewing the 24-hour report for any changes or new problems, conducting the daily rounds and auditing the 24-hour reports for effectiveness of interventions. Record review of 24-hour report indicated appropriate documentation of changes and significant resident information. Changes were found and addressed during the assessment of all residents in the facility the doctor was notified. During an interview on [DATE] at 12:30 p.m. LVN M said she had been in-serviced that morning regarding documentation, assessment and vital signs. She said she was told who needed vital signs regularly and how and where to document them. She said she was told to put any changes on the 24-hour report and vital signs she was monitoring. During an interview on [DATE] at 1:50 p.m. HA N said she was in-serviced that morning. She said she was to notify the nurses if there was a problem with a resident, such as anything different, more confused, or a change in what they can do. During an interview on [DATE] at 1:55 p.m. CNA O said she was in-serviced that morning on communicating with the nurse if there were changes in behavior or physical status of the residents. She said they were to notify the nurse verbally and in writing. During an interview on [DATE] at 2:01 p.m. CNA P said she was in-serviced on telling the nurse if something different was going on with the resident. She said if the nurse did not respond, they would need to tell the DON or ADON. She said different could be any change in mental status or mental confusion. She said the report would be a face to face verbal report. During an interview on [DATE] at 2:03 p.m. CNA Q said she was in-serviced on resident changes. She said if they saw a change in a resident, they were to report it to the nurse and then to the ADON or DON if they were not responding. She said changes could be something physical or anything different or not normal for them. She said the report would be verbal and written in case they forget. During an interview on [DATE] at 2:05 p.m. CNA R said she was in-serviced on residents having changes in condition and who to tell. She said changes could be behavior, or physical. She said notification to the nurse could be verbal or written. During an interview on [DATE] at 2:08 p.m. HA S said she had been in-serviced that morning concerning if something was not normal with the resident, she should tell the nurse, the DON, or the ADON. During an interview on [DATE] at 2:25 p.m. LVN T said she had done the computer-based training on weights and vital signs, how to chart in the computer, how to do an assessment and how to record it in in the system. She said changes made to her 24-hour report included a resident with a shear on her buttock that was identified last night. Another resident had nausea and vomiting, and they got medication for him. She said another resident they were watching her blood pressure and they were encouraging fluids. She said she should notify the physician of any change in condition, requests, or critical labs, be sure to document it and be sure to put in on the 24-hour report. During an interview on [DATE] at 3:05 p.m. LVN U said he did the required in-services last night. He said the in-services were over documentation, vital signs, and assessments. He said he had received in-services with the quality control nurse from their corporate staff, on care plans, how to use it, time frames, etc. He said notification to the physician regarding changes was covered in one of the in-services. He said he was told to document any pertinent data on the

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents were provided for 1 of 4 residents reviewed for accidents. (Resident #1) The facility did not implement effective interventions to prevent Resident # 1 from sustaining injuries from falling out of the bed. Resident #1 who had a history of [REDACTED]. This failure could place residents with history of falls at risk of injury. Findings included: 1. A face sheet printed 09/12/20 indicated Resident #1 was a [AGE] year-old female readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was not available for interview as she was still in the hospital and visitation was not allowed due to COVID-19. A fall risk assessment dated [DATE] indicated Resident #1 had a score of 17 (a score above 10 represents high risk). The MDS dated [DATE] indicated Resident #1 had clear speech; usually made herself understood; had impaired vision; had moderately impaired cognition; required extensive assistance of 2 staff for bed mobility and transfers; was always incontinent of bladder and bowel; and had no falls since admission, reentry, or prior assessment. A care plan initiated on 07/01/20 indicated Resident #1 was at risk for falls related to a fall risk score of greater than 10 with goal to reduce the risk of injury related to falls over the next 90 days and the following interventions: * on 06/29/20-therapy to evaluate and treat, rearrange personal items in reach, and place grabber device at bedside; * on 07/01/20-anticipate and meet the resident's needs, place items frequently used by the resident within easy reach when in the room, ensure resident is wearing appropriate footwear when ambulating or mobilizing in her wheelchair, and Fall Risk Screening upon admission and quarterly to identify risk factors; * on 07/07/20-assist resident with all meals, resident up in chair for meals; and * on 07/21/20-floor mat. 1.An incident report dated 08/21/20 indicated Resident #1 was found lying on her stomach and right side on the floor next to her bed with a moderate amount of bleeding from her right forehead. She was not able to inform the facility and EMS staff of what exactly happened due to her mental status. She was transported to the local hospital and treated. An Interdisciplinary Post-Fall assessment dated [DATE] indicated Resident #1 rolled out of bed, she had a laceration to her forehead, and recommendations for ER evaluation and a fall mat at the bedside. A nursing note dated 08/21/20 indicated Resident #1 returned from the ER with a [DIAGNOSES REDACTED]. The note indicated she had 4 sutures to her right forehead. 2. An incident report dated 08/24/20 indicated Resident #1 was found sitting on the floor mat leaned against the bed, she was assessed, and no injuries noted. An Interdisciplinary Post-Fall assessment dated [DATE] indicated Resident #1 rolled out of the bed, she had no injuries, and recommendations for low bed and fall mat in place. A nursing note dated 08/24/20 indicated Resident #1 was found sitting on the floor mat leaned against the bed, she was assessed, and no injuries noted. The care plan initiated on 07/01/20 indicating Resident #1 was at risk for falls had a revision on 08/24/20 to include an intervention to keep her bed in the lowest position when not providing care. 3. An incident report dated 09/04/20 indicated at 01:00 p.m., the charge nurse noticed Resident #1 was lying in her bed with her trunk in her bed and her feet dangling off the side of the bed, at 01:30 p.m., it was reported by therapy to the charge nurse Resident #1 was on her fall mat beside the bed, she was assessed, and she had no injury. An Interdisciplinary Post-Fall assessment dated [DATE] indicated Resident #1 rolled out of the bed, she had no injuries, and recommendations for low bed, fall mat in place, and encourage activity. A nursing note dated 09/04/20 indicated it was reported by therapy to the charge nurse Resident #1 was on her fall mat beside the bed, she was assessed, and she had no injury. The care plan initiated on 07/01/20 indicated Resident #1 was at risk for falls had a revision on 09/04/20 to include an intervention to encourage her to participate in activities that promote exercise, physical activity for strengthening and improved mobility. A Fall Risk assessment dated [DATE] indicated Resident #1 had an increase in her score from 17 to 19 (a score above 10 represents high risk) due to 3 or more falls in the last 3 months. 4. An incident report dated 09/07/20 for Resident #1 indicated she was found on the floor on her left side with a large amount of blood coming from her nose, 911 was called, and she was transported to the ER. An Interdisciplinary Post-Fall assessment dated [DATE] indicated Resident #1 rolled out of the bed onto the floor, she had a nose bleed, and recommendations for ER evaluation and a scoop mattress (mattress with the sides slightly elevated to help prevent rolling out of the bed). A nursing note dated 09/07/20 indicated Resident #1 was found lying on the floor on her side with a large amount of blood coming from her nose; pressure was applied to the nose; 911 was notified; her vital signs were blood pressure 96/59 (low), pulse 112 (elevated), respirations 18 (normal), and oxygen saturation 99% (normal); and she was transferred to the ER. A hospital Trauma Admission History and Physical for Resident #1 dated 09/07/20 indicated Chief Complaint/HPI: .HPI (history of present illness) Patient presents to ER as transfer from (town) after GLF (ground level fall) at nursing home. Patient reported to have rolled out of bed and landed face down on floor. Unknown LOC (level of consciousness). Was evaluated by ER and found to have a very small SDH (subdural hemorrhage (brain bleed)), nasal bone fx (fracture) Assessment and Plan: 1) Subdural Hemorrhage, Present on Admit Yes, Clinical Status New, Admit to medical surgical unit 2) Closed Fracture of Nasal Bones, Present on Admit Yes, Clinical Status New A hospital Radiology Report dated 09/08/20 for Resident #1 indicated Procedure: CT Head (cat scan) WO (without) Contrast (a special dye) .REASON FOR EXAM: Trauma TBI ([MEDICAL CONDITION]) Additional Clinical Information: TRAUMA GLF SDH NASAL FX .COMPARISON: 09/07/20 FINDINGS: There is subdural hemorrhage layered on the tentorium (structure of the brain) on the left. There is no evidence of mass, mass effect, or midline shift. Ventricles (cavities filled with fluid in the brain) and sulci (indentation or depression in the brain) are normal. Basilar cisterns (space that surrounds the structures lying on the floor of the skull) are patent. Air-fluid level again seen at the left maxillary antrum (a sinus cavity). IMPRESSION: 1. Stable thin acute subdural hemorrhage layered on tentorium on the left. A written statement completed by MA A dated 09/08/20 indicated she was asked at approximately 02:00 p.m., to assist HA D to lay Resident #1 back into bed. She indicated PTA C assisted with laying Resident #1 down. She indicated HA B entered the room and she left. She indicated Resident #1's bed was elevated and there was no fall mat on the floor. An undated phone interview by the DON with HA B indicated she helped HA D with changing Resident #1. She indicated she left the room just prior to Resident #1's fall. She indicated the bed was in the raised position and no fall mat was in place. A written statement dated 09/08/20 PTA C indicated on 09/07/20 he transferred Resident #1 from her wheelchair to her bed with the assistance of MA A. He indicated he left the room leaving MA A with Resident #1. He indicated Resident #1's bed was in the low position, but the fall mat was not in place. An undated phone interview by the DON with HA D indicated he and HA B changed Resident #1. She indicated she left the room just prior to Resident #1's fall. He indicated the bed was in the low position and the fall mat was in place. During an interview on 09/12/20 at 01:54 p.m., the DON indicated from the investigation they were not sure if the bed was in the low position and the fall mat were in place. She said the scoop mattress was put into place after the incident on 09/07/20 when Resident #1 sustained the fractured nose and brain bleed. When asked if the scoop mattress should have been put into place prior to the incident on 09/07/20 due to Resident #1's four falls from rolling out of the bed, the DON said probably. She said the resident was able to reposition herself in the bed from working with therapy. She said she was aware of the resident being found with her feet hanging off the bed at least one time. A Fall Management System policy revised 01/03/17 indicated Policy: It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs Procedure: B. Analysis of Assessment and Implementation of Preventive Measures: 2. The identifying factors will be provided to staff, and the individualized resident care plan will be developed with appropriate goals and interventions utilizing the Fall Management 5. Preventive interventions are reviewed, evaluated, and implemented to reduce the reoccurrence of falls 6. Nursing Administration/designee will be responsible for validation and re-evaluation residents at risk for falls and effectiveness of interventions for Fall Management Program E. Investigation and follow-up of accidents involving falls 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable (e.g., placing a chair alarm, removing obstacles out of path to (bathroom), placing resident on a low bed, etc.). 3. Further investigation may be necessary and findings documented on the Investigation Synopsis by the Administrator or Director of Nursing

Based on observation, interview, and record review, the facility failed to ensure each resident received assistive devices to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #2) Resident #2 did not have a fall mat in place when she had a fall and sustained 4 fractured ribs. This failure could place 15 residents with orders for fall mats at risk for injury. Findings included: The face sheet indicated Resident #2 was [AGE] years old and admitted to the facility 12/30/13 with [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 was cognitively intact; had delirium with inattention and disorganized thinking; required extensive assistance of 2 staff members for bed mobility; required extensive assistance of one staff member for transfers; and had no falls since admission. During a telephone interview on 04/03/15 at 8:45 a.m., Resident #2's family member said the resident was known to have falls at home prior to admission to the facility. Physician orders [REDACTED].#2 had an order to keep a floor mat beside the bed for safety and check every shift for placement with a start date of 01/30/15. A care plan dated 01/15/15 indicated Resident #2 had the potential for falls related to cognitive impairment with interventions that did not include the use of a fall mat. An Incident/Accident Report dated 03/30/15 indicated the nurse was called to Resident #2's room when the resident was found on the floor. The report indicated the resident said she attempted to see something on the floor and slid out. There was no indication a floor mat was in place at the time of the fall. A nursing note dated 03/30/15 for Resident #2 indicated no documentation there was a fall mat in place at the time of the incident. During an interview on 04/03/15 at 12:40 p.m., the DON said Resident #2 was reaching for a chocolate bunny on the bedside table next to the bed when she rolled out of the bed and on to the floor. She said the resident was sent to the emergency room and found to have 4 fractured ribs. She said an different air mattress with bolsters was placed on the bed, the bed was replaced with a low bed frame, U bars were placed on the bed to help the resident turn, and fall mats were put in place. She acknowledged the physician order [REDACTED]. She acknowledged the nursing note entry and Incident/Accident Report with no indication of a fall mat in place and said she could not say for sure the mat was in place at the time of the fall. A hospital discharge instruction sheet dated 03/30/15 indicated Resident #2 was seen in the emergency department for a ground level fall and x-rays indicated 4 fractured right side ribs (#s 9, 10, 11, &12). During an observation and interview on 04/03/15 at 8:20 a.m. Resident #2 was sitting in her wheelchair in her room. The resident's bed was a low bed, U bars were in place on the bed to assist with turning/repositioning, a fall mat was in place on the floor next to the bed, and an air mattress with bolsters was in place. She said she fell to the floor reaching for her candy on the table. She said she just rolled out of bed. She said she did not remember a cushion on the floor. During an interview on 04/03/15 at 1:03 p.m., the DON said she contacted CNA B who was on duty at the time of the incident. She said CNA B told her the fall mat was not in place at the time Resident #2 fell on [DATE]. During a telephone interview on 04/14/15 at 11:38 a.m., the DON said 15 residents had physician orders [REDACTED].

Based on interview and record review, the facility failed to consult the physician regarding a change in condition for 1 of 4 residents reviewed for physician notification. (Resident # 1) Resident #1 experienced increased pain and a swollen scrotum area over a period of 5 days and the physician was not notified. The resident was sent to the hospital; diagnosed with [REDACTED]. (a tube that drains urine from your bladder. It is inserted into your bladder through a small hole in your belly.) This failure could place 10 residents who resided on the same hall with Resident #1 (Hall 100) at risk of delay in medical attention, decline in condition, and increased pain. Findings included: Physician orders [REDACTED]. An MDS dated [DATE] indicated Resident #1 ' s cognitive status was modified independence with some difficulty in new situations only and could make his needs known to staff. He was frequently incontinent of urine and always incontinent of bowel. A care plan dated 1/20/14 indicated Resident #1 had stress bladder incontinence and self-care deficits related to a history of a stroke. The interventions included staff to assist the resident to the toilet as needed and monitor for signs and symptoms of urinary tract infections. The resident was to maintain his current level of functioning with toilet use. Staff were to monitor and notify the charge nurse of any decrease or improvement in Resident #1's ADLs function. A nursing note for Resident #1 indicated on 5/8/14 at 10:20 a.m. Resident # 1 refused breakfast and was resting in bed. Resident #1 nodded his head when asked if he was in pain, but could not specify the location of the pain. The resident ' s vital signs were taken. The NP was contacted and ordered labs and a urine culture. The 24 hour nursing communication report for Resident #1 indicated on 5/8/14 Resident #1 had increased confusion. He received a new order for labs and a urine sample to be collected. During an interview on 6/18/14 at 5:12 p.m., LVN B said on 5/8/14 Resident #1 had a change in condition. LVN B said the resident stayed in bed and did not eat breakfast which was unusual behavior for him. Resident #1 said he was in pain, but could not describe the location of the pain. LVN B said she took Resident #1 ' s vital signs, but did not make observations of his body. She said they repositioned the resident to relieve his pain. She said she called the NP and new orders for labs and a urine sample were received. LVN B said she tried to collect the urine by in and out catheter but was unsuccessful. During an interview on 6/18/14 at 10:35 p.m., CNA D said Resident #1 had swelling underneath his scrotum about the size of an orange. She said Resident #1 complained of pain in that area. CNA D said she reported it to the nurse (LVN B) and the nurse said they were aware The 24 hour nursing communication report for Resident #1 indicated on 05/9/14 during the night shift Resident #1 exhibited increased confusion and the nurse attempted to collet urine. During an interview on 6/18/14 at 10:30 p.m., LVN C said on 5/9/14 Resident #1 had swelling underneath his scrotum about the size of a quarter. She said his testicles were hard and swollen. LVN C said they had orders to get a urine culture from Resident #1, but she could not collect any urine. She did not inform the physician of the swelling to Resident #1 ' s scrotum. A nursing note for Resident #1 indicated on 5/10/14 at 9:30 a.m. Resident #1 voided freely. At 11:15 he was in bed grimacing with pain to the lower abdomen. He was given [MEDICATION NAME] 200 mg. At 7:00 p.m., Resident #1 voided freely and was in bed with complaints of pain to his lower abdomen. The 24 hour nursing communication report for Resident #1 indicated on 5/10/14 during the evening shift, the on call physician was paged due to Resident #1 ' s abnormal labs and complaints of lower abdominal pain. A Physician Communications and Progress Note dated 5/10/14 written by LVN H indicated Resident #1 had abnormal labs. Since 5/8/14 Resident #1 had swelling in his prostate and testicles and constant pain which worsened with palpitation. He had pain in his lower abdomen and a decrease in the intake of solids and fluids. During an interview on 6/19/14 at 10:20 a.m. LVN H said on 5/10/14 she contacted the on call physician because she noted swelling under Resident #1 ' s scrotum area. The area was raised and hard measuring about 1.5 inches wide and about 2 inches long. LVN H said on the 24 hour report the night nurse noted Resident #1 was grimacing in pain. She said although the on-call physician was notified of a resident ' s change in condition, the staff were to notify a resident ' s primary physician. She did not know if there was any follow up with Resident #1 ' s primary physician. A nursing note for Resident #1 indicated on 5/11/14 at 5:00 a.m. Resident #1 complained of right sided pain. The nurse noted his scrotum area was hard. At 9:05 a.m., swelling to his scrotum area was noted, but the resident denied pain. At 11:45 a.m., swelling was seen to the resident ' s scrotum area and the nurse was unable to collect urine via condom catheter. The resident would remove the condom catheter. The 24 hour nursing communication report for Resident #1 indicated on 5/11/14 during the night shift, Resident #1 had hardened spot at his scrotum area. The day shift reported the resident was up in his wheelchair for meals and swelling was noted to his scrotum. The evening shift reported the resident had no complaints of pain and swelling was noted to his scrotum area. During an interview on 6/19/14 at 7:35 a.m., LVN E said Resident #1 was very independent. LVN E said CNA F informed her of Resident #1 ' s swelling in his scrotum area. She said she looked at the resident ' s scrotum area, but did not access it or call MD. LVN E said she did not administer Resident #1 pain medication. She was unable to provide any specific details During an interview on 6/19/14 at 7:45 a.m. CNA F said had a grapefruit sized knot under his scrotum. CNA F said the resident was in pain and would say "Ooh! " when touched near his scrotum. He said he informed LVN E of the resident ' s scrotal swelling and pain. CNA F said LVN E said they were aware. A nursing note for Resident #1 indicated on 5/12/14 at 2:00 p.m. the physician requested the resident have an appointment with a hematologist related to abnormal labs. He had new orders for [MEDICATION NAME] possible urinary tract infection. At 10:15 p.m. swelling to the resident ' s scrotum area was noted. The 24 hour nursing communication report for Resident #1 indicated on 5/12/14 during the night shift, Resident #1 had swelling to the scrotum area, but he denied pain. The nurse needed to get a urine sample. The day shift reported Resident #1 had a swollen prostate and he was non-compliant with a condom catheter. The physician [MEDICATION NAME] 10 days, [MEDICATION NAME], and labs. During an interview on 6/19/14 at 10:00 a.m. the NP said she was not aware Resident #1 had any swelling in his scrotum area. She said on 5/12/14 she was at the facility and visited Resident #1, but staff did not notify her of the resident ' s scrotal swelling. The 24 hour nursing communication report for Resident #1 indicated on 5/13/14 during the evening shift Resident #1 was admitted to the hospital. A hospital history and physical dated 5/13/13 indicated Resident #1 was found to have significant scrotal swelling, increased lethargy, and a decline in his overall status. According to the nursing (home) staff, Resident #1 was more lethargic and had felt worse over the last couple of days. A cat scan of the pelvis showed an abscess measuring 6 cm x 14 cm x 9 cm from around the base of the penis and into the scrotum and perineal area. A preoperative [DIAGNOSES REDACTED]. The procedure required incision and drainage of the scrotal abscess, debridement of the wound, and a suprapubic catheter tube placement. During an interview on 6/19/14 at 2:26 p.m. Resident #1 ' s primary physician said Resident #1 did not complain of pain often. The physician said he was not informed the resident having swelling to the scrotum area before Resident #1 was hospitalized . The primary physician said he was at the hospital when Resident #1 was admitted and the area was large. During an interview on 6/19/14 at 10:27 a.m. the ADON said she was not at the facility during those days and she was not aware if the former DON was aware of the condition or not. The ADON said it was normal procedure if they contacted the on call physician to follow up with the primary physician. According to her this did not occur with Resident #1. During an observation and interview on 6/18/14 at 3:18 p.m. Resident #1 was living at a different facility. He was able to make his needs known and said he was going to bed. He had just transferred his self to bed form the wheel chair. Resident #1 had a suprapubic catheter and communicated no problems. He was unable to voice concerns about the previous facility. A census report dated 6/18/14 indicate there were 9 residents that resided on the 100 hall.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to maintain the highest level of wellbeing, in accordance with the comprehensive assessment and plan of care, for 1 of 4 residents reviewed for change in condition. (Resident #1) Resident #1 complained of increased pain and had increased swelling in his scrotum area over a period of 5 days. The facility did not assess the resident or notify his physician. Resident #1 required surgery and a suprapubic catheter (a tube that drains urine from your bladder. It is inserted into your bladder through a small hole in your belly.) This failure could place 10 residents who resided on the same hall (Hall 100) with Resident #1 at risk of a decline in condition and increased pain. Findings included: Physician orders [REDACTED]. An MDS dated [DATE] indicated Resident #1 ' s cognitive status was modified independence with some difficulty in new situations only and could make his needs known to staff. He was frequently incontinent of urine and always incontinent of bowel. A care plan dated 1/20/14 indicated Resident #1 had stress bladder incontinence and self-care deficits related to a history of a stroke. The interventions included staff to assist the resident to the toilet as needed and monitor for signs and symptoms of urinary tract infections. The resident was to maintain his current level of functioning with toilet use. Staff were to monitor and notify the charge nurse of any decrease or improvement in Resident #1's ADLs function. A nursing note for Resident #1 indicated on 5/8/14 at 10:20 a.m. Resident # 1 refused breakfast and was resting in bed. Resident #1 nodded his head when asked if he was in pain, but could not specify the location of the pain. The resident ' s vital signs were taken. The NP was contacted and ordered labs and a urine culture. The 24 hour nursing communication report for Resident #1 indicated on 5/8/14 Resident #1 had increased confusion. He received a new order for stat lab, a UA to be collected. During an interview on 6/18/14 at 5:12 p.m., LVN B said on 5/8/14 Resident #1 had a change in condition. LVN B said the resident stayed in bed and did not eat breakfast which was unusual behavior for him. Resident #1 said he was in pain, but could not describe the location of the pain. LVN B said she took Resident #1 ' s vital signs, but did not make observations of his body. She said they repositioned the resident to relieve his pain. She said she called the NP and new orders for labs and a urine sample were received. LVN B said she tried to collect the urine by in and out catheter but was unsuccessful. During an interview on 6/18/14 at 10:35 p.m., CNA D said Resident #1 had swelling underneath his scrotum about the size of an orange. She said Resident #1 complained of pain in that area. CNA D said she reported it to the nurse (LVN B) and the nurse said they were aware The 24 hour nursing communication report for Resident #1 indicated on 05/9/14 during the night shift Resident #1 exhibited increased confusion and the nurse attempted to collet urine. During an interview on 6/18/14 at 10:30 p.m., LVN C said on 5/9/14 Resident #1 had swelling underneath his scrotum about the size of a quarter. She said his testicles were hard and swollen. LVN C said they had orders to get a urine culture from Resident #1, but she could not collect any urine. She did not inform the physician of the swelling to Resident #1 ' s scrotum. A nursing note for Resident #1 indicated on 5/10/14 at 9:30 a.m. Resident #1 voided freely. At 11:15 he was in bed grimacing with pain to the lower abdomen. He was given [MEDICATION NAME] 200 mg. At 7:00 p.m., Resident #1 voided freely and was in bed with complaints of pain to his ower abdomen. The 24 hour nursing communication report for Resident #1 indicated on 5/10/14 during the evening shift, the on call physician was paged due to Resident #1 ' s abnormal labs and complaints of lower abdominal pain. A Physician Communications and Progress Note dated 5/10/14 written by LVN H indicated Resident #1 had abnormal labs. Since 5/8/14 Resident #1 had swelling in his prostate and testicles and constant pain which worsened with palpitation. He had pain in his lower abdomen and a decrease in the intake of solids and fluids. During an interview on 6/19/14 at 10:20 a.m. LVN H said on 5/10/14 she contacted the on call physician because she noted swelling under Resident #1 ' s scrotum area. The area was raised and hard measuring about 1.5 inches wide and about 2 inches long. LVN H said on the 24 hour report the night nurse noted Resident #1 was grimacing in pain. She said although the on-call physician was notified of a resident ' s change in condition, the staff were to notify a resident ' s primary physician. She did not know if there was any follow up with Resident #1 ' s primary physician. A nursing note for Resident #1 indicated on 5/11/14 at 5:00 a.m. Resident #1 complained of right sided pain. The nurse noted his scrotum area was hard. At 9:05 a.m., swelling to his scrotum area was noted, but the resident denied pain. At 11:45 a.m., swelling was seen to the resident ' s scrotum area and the nurse was unable to collect urine via condom catheter. The resident would remove the condom catheter. The 24 hour nursing communication report for Resident #1 indicated on 5/11/14 during the night shift, Resident #1 had hardened spot at his scrotum area. The day shift reported the resident was up in his wheelchair for meals and swelling was noted to his scrotum. The evening shift reported the resident had no complaints of pain and swelling was noted to his scrotum area. During an interview on 6/19/14 at 7:35 a.m., LVN E said Resident #1 was very independent. LVN E said CNA F informed her of Resident #1 ' s swelling in his scrotum area. She said she looked at the resident ' s scrotum area, but did not access it or call MD. LVN E said she did not administer Resident #1 pain medication. She was unable to provide any specific details During an interview on 6/19/14 at 7:45 a.m. CNA F said had a grapefruit sized knot under his scrotum. CNA F said the resident was in pain and would say "Ooh! " when touched near his scrotum. He said he informed LVN E of the resident ' s scrotal swelling and pain. CNA F said LVN E said they were aware. A nursing note for Resident #1 indicated on 5/12/14 at 2:00 p.m. the physician requested the resident have an appointment with a hematologist related to abnormal labs. He had new orders for [MEDICATION NAME] possible urinary tract infection. At 10:15 p.m. swelling to the resident ' s scrotum area was noted. The 24 hour nursing communication report for Resident #1 indicated on 5/12/14 during the night shift, Resident #1 had swelling to the scrotum area, but he denied pain. The nurse needed to get a urine sample. The day shift reported Resident # 1 had a swollen prostate and he was non-compliant with a condom catheter. The physician [MEDICATION NAME] 10 days, [MEDICATION NAME], and labs. During an interview on 6/19/14 at 10:00 a.m. the NP said she was not aware Resident #1 had any swelling in his scrotum area. She said on 5/12/14 she was at the facility and visited Resident #1, but staff did not notify her of the resident ' s scrotal swelling. The 24 hour nursing communication report for Resident #1 indicated on 5/13/14 during the evening shift Resident #1 was admitted to the hospital. A hospital history and physical dated 5/13/13 indicated Resident #1 was found to have significant scrotal swelling, increased lethargy, and a decline in his overall status. According to the nursing (home) staff, Resident #1 was more lethargic and had felt worse over the last couple of days. A cat scan of the pelvis showed an abscess measuring 6 cm x 14 cm x 9 cm from around the base of the penis and into the scrotum and perineal area. A preoperative [DIAGNOSES REDACTED]. The procedure required incision and drainage of the scrotal abscess, debridement of the wound, and a suprapubic catheter tube placement. During an interview on 6/19/14 at 2:26 p.m. Resident #1 ' s primary physician said Resident #1 did not complain of pain often. The physician said he was not informed the resident having swelling to the scrotum area before Resident #1 was hospitalized . The primary physician said he was at the hospital when Resident #1 was admitted and the area was large. . During an interview on 6/19/14 at 10:27 a.m. the ADON said she was not at the facility during those days and she was not aware if the former DON was aware of the condition or not. The ADON said it was normal procedure if they contacted the on call physician to follow up with the primary physician. According to her this did not occur with Resident #1. During an observation and interview on 6/18/14 at 3:18 p.m. Resident #1 was living at a different facility. He was able to make his needs known and said he was going to bed. He had just transferred his self to bed form the wheel chair. Resident #1 had a suprapubic catheter and communicated no problems. He was unable to voice concerns about the previous facility. A census report dated 6/18/14 indicate there were 9 residents that resided on the 100 hall.