Every finding on record at Avir at Fredericksburg

Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for two of six residents (Resident #1 and Resident #2) reviewed for clinical records. The facility failed to ensure Resident #1 and Resident #2 medical records included provider, psychiatric referrals, and visits following physical aggression incidents.The facility failed to ensure Residet #1's and Resident #2 medical record included quarterly Interdisciplinary Team Meeting (IDT) with the PASARR Service Coordinator regarding their current mental status and service needs. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included:1.Record review of Resident #1's admission Record, dated 06/25/2026 revealed a [AGE] year-old male admitted [DATE].Record review of Resident #1's Medical Diagnoses, undated and accessed 06/24/2026 at 4:48 p.m., revealed diagnoses including anxiety disorder (mental health condition characterized by excessive uncontrollable worry about everyday issues, affecting daily functioning and quality of life), depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional physical problems), and attention deficit hyperactivity disorder (neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity that can affect daily functioning and development).Record review of Resident #`1's quarterly MDS, dated [DATE] and signed 05/28/2026 as completed, reflected a BIMS score of 11, indicating moderate cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including physical and verbal symptoms directed toward others. Resident #1's functional abilities were documented as requiring supervision or touching assistance to independent assistance.Record review of Resident #`1's care plan, undated, revealed Resident #1 had behavior problem causing public disruption during meal times r/t Life experiences of years in group home for intellectually disabled, Paranoia, head injury, Sensory overload, physical aggression. The interventions included Intervene as necessary to protect the rights and safety of others. The care plan focus was created and initiated on 10/18/2025 and revised on 02/08/2026.Record review of Resident #1's progress notes dated 01/01/2026 to 06/01/2026 revealed no documentation of quarterly interdisciplinary meetings with the PASARR Service Coordinator regarding resident's current mental status and service needs. No other documentation was presented.Record review of Resident #1's progress notes dated 01/01/2026 to 06/01/2026 revealed no documentation of referral to provider, psych services or progress notes written by a physician or MD regarding resident's behavioral incidents on 02/24/2026 he raised his fist toward the resident, 02/22/2026 swung at staff, and 2/10/2026 Resident swung his ball cap toward a visitor's backside. No other documentation was presented.Record review of Resident #1's progress notes dated 01/01/2026 to 06/01/026 revealed no documentation written by Social Services regarding resident's behavior symptoms and PASRR specialized services. 2.Record review of Resident #2's admission Record, dated 06/25/2026 revealed a [AGE] year-old male admitted [DATE].Record review of Resident #2's Medical Diagnoses, undated and accessed 06/25/2026 at 4:01 p.m., revealed diagnoses including cerebral palsy (affects the nervous system), seizure disorder (chronic brain disorder), and depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional physical problems).Record review of Resident #`2's quarterly MDS, dated [DATE] and signed 03/23/2026 as completed, reflected a BIMS score of 13, indicating cognition intact. Resident #2 was documented as having exhibited verbal behavioral symptoms. Resident #2 was documented as having not exhibited any behavioral symptoms, including physical symptoms directed toward others. Resident #2's functional abilities were documented as requiring supervision or touching assistance to independent assistance.Record review of Resident #`2's care plan, undated, revealed Resident #1 had Potential to be verbally or physical aggressive toward a specific resident r/t poor impulse control, unpredictable situations/without provocation where I my [may] intentionally instigate an altercation. The interventions included, Initiate referral to Licensed Behavior Analyst through PASARR (Preadmission Screening and Resident Review) Program for comprehensive behavioral assessment and recommendation. The care plan focus was created and initiated on 02/25/2026 and revised on 05/28/2026.Record review of Resident #2's Social Service Note dated 02/19/2026 reflected Resident was approached regarding reports of verbal aggression toward peers in the dining room and common areas, including yelling and making demeaning comments. Resident initially minimized behavior, stating, They bother me first, but later acknowledged becoming frustrated easily. Resident denied intent to harm others but admitted to losing temper. Further review of the social service note revealed there was no referral to provider or psych services was documented. No other documentation was presented. Record review of Resident #2's Social Service Note dated 03/06/2026 reflected Social Worker wants an order from [Medical Director] for Psychological Services. to reduce symptoms of Depression. [Medical Director] will be here today and will notify him of request. Further review of the social service note revealed there was no referral to provider or psych services was documented. No other documentation was presented. Record review of Resident #2's Social Service Note dated 03/10/2026 reflected Social Services and Nursing met with resident and his [family member]/POA to address recent unacceptable behaviors observed in the dining and common areas. Behaviors discussed included verbal aggression toward others, yelling at peers to get out of his way, striking his fist on dining tables, and hitting out toward others. The purpose of the meeting was to review concerns, ensure resident understanding, and collaborate on strategies to reduce behavioral triggers. Further review of the social service note revealed there was no referral to provider or psych services was documented. No other documentation was presented. Record review of Resident #2's Document Habilitative assessment dated [DATE] reflected Local Intellectual and Developmental Disabilities Authorities (LIDDA) - Section 5, Outcome Action Plan documents It would be optimal for [Resident #2] to have access to transportation and a day habilitation. program so that he could socialize with individuals outside of the NF setting. Further review of the assessment revealed there was no documentation as to why day-habilitation services outside of the NF setting were not being provided. No other documentation was presented. During an interview on 06/26/2026 at 5:25 p.m., the Social Worker revealed that he was tasked with coordinating the PASARR care plan meetings and he was unsure as to why care plan meeting notes and email correspondence between NF and Local Authority regarding PASARR specialized services were not present in Resident #1's and Resident #2's medical record, but that he would be printing out his emails to add to the chart today. He stated he was unable to locate the psych progress notes and follow-up visit documentation for both Resident #1 and Resident #2 and the NF would need to reach out to psych provider to obtain for investigation. He stated that when medical records are not accessible it could seem as if they were not receiving services.During an interview on 06/26/2026 at 6:35 p.m., the Administrator stated that psych NP discontinued care at NF in December 2025.She stated psych NP provided services regularly for Resident #1 and Resident #2. She stated she cannot reach psych provider to provide documentation of Resident #1's and Resident #2's regular visits and was unsure as to why documentation was not available in resident's medical records. She stated she had reached out by phone and was waiting for a call back. She stated that after the psych NP discontinued care at NF that psych services were being provided by the Medical Director.During a phone interview on 06/26/2026 at 7:09 p.m., the Medical Director revealed that there had been several provider visits with Resident #1 that were not documented in resident's medical record. The Medical Director stated after reviewing his records he identified a routine progress note on 01/22/2026 that he documented that Resident #1's mental health and mood was stable and no concerns were noted, therefore no changes to current medication regimen. He stated another routine progress note on 03/13/2026 he documented that Resident #1's mood had been stable, and he was not making changes to his medication regimen. The Medical Director stated after reviewing his records he identified a progress note on 03/06/2026 that he documented that Resident #2's visit was following a minor altercation where Resident #2 admitted he had been somewhat depressed, not mentally well and he felt he was lashing out and he increased his Sertraline. He stated he documented a routine progress note on 04/02/2026 that Resident #2 seemed to be doing much better and he documented no change to his medication. Medical Director stated he visited Resident #2 shortly after on 04/17/2026 following an incident in that the story was much more unclear, multiple variations of the story, had Resident #2 placed on one-to-one supervision. He stated that he visited with Resident #2 for a long period, and he did not seem to be a threat to anyone at this time, he seemed calm and he lifted the supervision and did not see it necessary to change his medication.During an interview on 06/26/2026 at 7:22 p.m., the Administrator stated moving forward she and ADON would work together to update resident medical records. She stated the impact of not having complete medical records accessible could cause runaround and wait times for provider call backs to provide pertinent information. She stated that when staff cannot access medical records it could also cause delays in resident care.During an interview on 06/26/2026 at 8:02 p.m., the MDS Coordinator stated she attended a quarterly PASARR care plan meeting with the Local Authority on 06/02/2026, which discussed Resident #1's behaviors and the behavior management specialist services that would be implemented. She stated she was unsure why the care plan meeting documentation was not present in Resident #1's medical record, but that she could download it today and make it available for review. Requested a policy for Complete and Accurate Records and the Administrator stated they had no policy and they followed State regulations regarding records.

Based on interviews and record reviews, the facility failed to ensure that Resident #1 was free of significant medication errors for 1 of 3 residents (Resident #1) reviewed for medication errors. - LVN A administered Resident #2's medications to Resident #1. Resident #1 had a change of condition (slow respirations and low oxygen saturation levels) and was sent to the hospital via 911 EMS where she was diagnosed and treated for opioid overdose.- LVN A did not administer Resident #2's daily 4:00 PM prescriptions. A past non-compliance Immediate Jeopardy (IJ) was identified at 1:50 p.m. on 5/27/2026. The immediacy began on 5/24/2026 and ended on 5/25/2026. While the immediacy was removed on 5/25/2026, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ due to the need to evaluate the effectiveness of the corrective systems. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for medication errors.Findings included: A record review of Resident #1's admission record, dated 5/26/2026, revealed an admission date of 5/15/2026 and a discharge date of 5/24/2026 with diagnoses which included atherosclerotic heart disease (fatty deposits called plaque clog the arteries supplying blood to the heart), myocardial infarction (heart attack - blood flow to a section of the heart muscle is blocked, depriving it of oxygen), and aortocoronary bypass graft (the surgical repair of a blocked heart artery). A record review of Resident #1's admission MDS assessment, dated 5/25/2026, revealed Resident #1 was an [AGE] year-old female admitted for rehabilitation after a heart attack and heart bypass surgery. A record review of Resident #1's physicians orders, dated 5/26/2026, revealed Resident #1 was not prescribed to receive medications in the afternoon nor was Resident #1 prescribed to receive any opioids (a class of medications which dulls the senses, relieves pain, and induces sleep or profound lethargy) or benzodiazepines (central nervous system depressants). A record review of Resident #1's care plan, dated 5/26/2026, revealed Resident #1 was a full Code status and wished to receive cardiopulmonary resuscitation if she became unresponsive without breaths or heartbeats. A record review of Resident #1's nursing progress notes, dated ??, revealed on 5/24/2026 at 6:53 PM the ADON documented that Resident #1 was not responding and assessed with a blood oxygen saturation of 65% (dangerously low blood oxygen levels. This is a medical emergency and requires immediate medical attention), EMS 911 was called, and Resident #1 was transferred to the hospital. A record review of Resident #1's hospital emergency room admission records, dated 5/24/2026, revealed Resident #1 was brought in by EMS and was assessed by Dr. P with low blood oxygen levels, poor respirations and Resident #1 was not responding to treatments. Dr. P administered naloxone (a life-saving medication used to rapidly reverse an opioid overdose by blocking the effects of opioids on the brain and restoring normal breathing). Dr. P ordered a urine drug screen laboratory report which revealed Resident #1 had methadone, opioids, and benzodiazepines in her body; . Urinary drug screen tested positive for methadone, opioids, and benzodiazepines, none of which are on patients' medication list. Emergency department medical doctor at bedside. A record review of Resident #2's admission record, dated 5/26/2026, revealed an admission date of 9/29/2025 with diagnoses which included malignant neoplasm of intra-abdominal lymph nodes (the spread of growing cancer tumors in the abdomen of the lymph nodes [small, bean-shaped structures that act as the body's primary defense filters]). A record review of Resident #2's quarterly MDS assessment, dated 4/13/2026, revealed Resident #2 was a [AGE] year-old male admitted for LTC with supports for ADL under hospice services (hospice services provide comfort care for those with a life expectancy under 6 months). A record review of Resident #2's care plan, dated 5/26/2026, revealed Resident #2 was receiving pain medications with nursing interventions to monitor Resident #2 for respiratory depression, respiratory rates, depth of respirations, and respiratory efforts after administration of medications. A record review of Resident #2's physicians orders, dated 5/26/2026, revealed the physician prescribed for Resident #2 to receive daily, between 4:00 PM and 5:00 PM, the following drugs:- Methadone (a powerful, long-acting synthetic opioid medication) 10mg 2 tablets.- Morphine sulfate (a strong pain-relieving medication that completely activates the opioid receptors in the brain and central nervous system to produce the maximum possible pain relief) extended release 60mg 1 tablet.- Alprazolam (a potent, fast-acting prescription medication used to treat anxiety disorders, panic disorders, and severe anxiety associated with depression) 0.5mg 1 tablet. A record review of the facility's Medication Audit Report, dated 5/26/2026, revealed LVN A documented on 5/24/2026 at 5:15 PM she administered the following medications to Resident #2:- Methadone 10mg, 2 tablets.- Morphine sulfate extended release 60mg, 1 tablet.- Alprazolam 0.5mg, 1 tablet. A record review of the United States of America's National Library of Medicines' website: https://www.ncbi.nlm.nih.gov/books/NBK560654/accessed 6/1/2026 titled, Nursing Rights of Medication Administration, dated 9/4/2023, revealed, Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include:'Right patient' - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. This is best practiced by nurses directly asking a patient to provide his or her full name aloud, checking medical wristbands if appropriate for matching name and ID number as on a chart. It is advisable not to address patients by first name or surname alone, in the event, there are two or more patients with identical or similar names in a unit. Depending on the unit that a patient may be in, some patients, such as psychiatric patients, may not wear wristbands or may have altered mentation to the point where they are unable to identify themselves correctly. In these instances, nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence. During an interview on 5/25/2026 at 2:20 PM the Administrator and the DON stated LVN A had failed safe medication administration expectations during her 6:00 A.M. to 6:00 PM shift on the facility's 100 and 200-halls when around 5:00 PM she was passing medications and administered Resident #2's medications to Resident #1 and had not administered Resident #2's medications to Resident #2. The Administrator and the DON stated Resident #2's medications included opioids. The Administrator and the DON stated Resident #1 was not prescribed opioids. The Administrator and the DON stated Resident #1 had an adverse reaction to receiving Resident #2's medications and required emergency hospitalization where she received naloxone to reverse the adverse effects from receiving Resident #2's medications. The Administrator and the DON stated they reported the allegation of abuse to the State Agency and suspended LVN A pending the investigation and began assessing all the residents LVN A passed medications to on halls 100- and 200. The Administrator and the DON stated all residents who were served by LVN A, were assessed without injuries, which included Resident #2. The Administrator and the DON stated Resident #2 received pain medications 4 times a day and had not reported any signs and or symptoms of pain during the afternoon. The Administrator and the DON stated the incident was caused by LVN A when she was pre-pouring medications, for several residents, into small plastic pill cups and writing residents' names on the cups. The Administrator and the DON stated LVN A mistakenly then administered Resident #2's medications to Resident #1. The Administrator and the DON stated they began an in-service for not pre-pouring medications and basic medication administration for the 10 facility nurses and the 1 facility medication aide, and no one could take a shift unless they received the in-service. The Administrator and the DON stated they had scheduled an ad hoc QAPI (quality improvement and performance improvement) meeting to address the failure (ad-hoc meeting which was spontaneously to tackle a specific, pressing issue). During an interview on 5/25/2026 at 7:00 PM, RN F stated she was a hospital emergency room nurse when Resident #1 was brought in by EMS 911. RN F stated Resident #1 was treated by Dr. P and diagnosed with respiratory distress, low blood oxygen saturation, needed oxygen, had low respirations, 6 per minute, and was unresponsive to Dr. P's treatments until Dr. P prescribed naloxone for Resident #1, twice. RN F stated that Dr. P ordered a urinary drug screen which revealed Resident #1 had opioids and benzodiazepines in her blood stream. RN F stated per Resident #1's records, Resident #1 was not prescribed to receive those drugs. During an interview on 5/25/2026 at 7:10 PM, Dr. P stated she re-enforced RN F's interview and supported RN F's account of events. Dr. P stated Resident #1 had ingested opioids and benzodiazepines which were not in line with her previous prescribed medications and caused her a life threating incident of lethargy and respiratory depression. During an observation and interview on 5/25/2026 at 7:20 PM, Resident #1 was in her hospital room in the hospital's intensive care unit. Resident #1 stated, the last thing I remember was taking my pills from the nurse, but the pills looked different. During an interview on 5/26/26 at 9:02 A.M., LVN A stated on 5/24/2026 she was assigned to care for residents on the 100-200 hall and was administering the 4:00 PM to 5:00 PM medications when she felt there was a potential to run late with the medication administration and began to Pre-pour medications, I dispensed the medications for Resident #2 and placed his name on the small plastic pill cup. LVN A stated on the morning of 5/25/2026 she learned from the Administrator and the DON that Resident #1 had been sent to the emergency room due to lethargy. LVN A stated she reported to the Administrator and the DON that she may have been responsible because she pre-poured medications for Resident #2 during the afternoon medication pass and may have erroneously given Resident #2's medications to Resident #1, they both have similar names and Resident #1 does not take medications at 4PM. During an interview on 5/27/2026 at 1:20 PM, the Administrator and the DON stated nursing staff were expected to administer medications, per professional standards, by administering medications to 1 resident at a time and to follow the rights of medication administration which included verifying the resident's identification and medications with the physicians' orders. The Administrator and the DON stated failure to follow these guidelines could place residents at risk for not receiving the intended effects of their medications. The Administrator and the DON stated LVN A had not reported to the Administrator and the DON that she was pre-pouring medications on her shift and denied the DON the opportunity to intervene for safe medication administration practices. A record review of the facility's Administering Medications policy, dated April 2019, revealed, Policy interpretation and implementation: . medications are administered in accordance with prescribers' orders, including any required time frame. The individual administering medications verifies the resident's identity before giving the resident his or her medications. Methods of identifying the resident included: checking identification bands; checking photographs attached to the medical record; and if necessary, verifying resident identification with other facility personnel. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and write method of administration before giving the medication. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The immediacy existed from 5/24/2026 to 5/25/2026. The facility corrected the noncompliance before the survey began. This was determined to be a past non-compliance Immediate Jeopardy (IJ) on 5/27/2026 at 1:50 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 5/27/2026 at 1:50 p.m. A record review of the facility's Plan of Removal for Immediate Jeopardy, dated 5/25/2026, revealed, Summary of details which led to outcomes. Lab results confirm medication administration incident involving a resident who tested positive for benzodiazepines, opioids, and methadone despite no physician orders or history of administration within the facility. Plan:1. Immediate Actions Implemented:a. Nurse involved immediately suspended pending an investigation.b. Medication cart access / security review initiated to confirm only 1 nurse had access during the identified shift.c. Facility initiated nursing license verification for all licensed nursing staff.d. Medication carts, narcotic storage areas, and keys secured and audited immediately.e. Attending physicians, pharmacy, facility leadership, and HHSC notified as indicated.f. All Residents that nurse provided care to were assessed for physical / emotional adverse reactions.2. Audits:a. Facility conducted immediate narcotic reconciliation and audit for all controlled substances including methadone, opioids, and benzodiazepines.b. Facility verified current physician orders against medication administration records documentation and medication inventory.c. Any discrepancies identified were immediately escalated to the Administrator, the director of nursing, consultant pharmacist, and regional leadership.d. Facility initiated a review of all residents receiving controlled substances to identify any additional concerns, omissions, or adverse reactions.e. Facility implemented management oversight of all medication passes until investigation completion.3. Education:a. Facility wide nursing in-services initiated regarding documentation, following position orders, resident rights, abuse neglect and exploitation, add medication administration.b. All education includes signature verification and verbal competency validation to ensure understanding.c. Nursing staff educated regarding timely reporting expectations and immediate escalation of medication discrepancies or adverse events.4. Monitoring / compliance plan:a. Narcotic reconciliation audits to be completed by the director of nursing and or his designee daily for 14 days then every two weeks for two months then once a month for two months. Random audits will be conducted to ensure compliance.b. 100% medication pass observations to be conducted for all licensed nurses for a minimum of 14 days by the director of nursing and/or his designee.c. Findings to be reviewed during quality assurance performance improvement meetings to ensure ongoing compliance and sustained correction actions. Past non-compliance verification During an interview on 5/26/26 at 9:02 A.M., LVN A stated she was suspended and was not assigned any shifts at the facility pending the results of the investigation. A record review of the Texas Unified Licensure Information Portal's website, accessed 5/26/2026 revealed a facility reported allegation of neglect on behalf of Resident #1 on 5/25/2026 at 12:06 PM. Record reviews of the facility's census dated 5/24/2026 revealed LVA A served 25 residents on her 6:00 A.M. to 6:00 PM shift on 5/24/2026, as follows:1. Resident #12. Resident #23. Resident #34. Resident #45. Resident #56. Resident #67. Resident #78. Resident #89. Resident #910. Resident #1011. Resident #1112. Resident #1213. Resident #1314. Resident #1415. Resident #1516. Resident #1617. Resident #1718. Resident #1819. Resident #1920. Resident #2021. Resident #2122. Resident #2223. Resident #2324. Resident #2425. Resident #25 A record review of medical records for Residents #2 through Resident #25, dated ??, revealed all were assessed physically and emotionally without injuries or adverse effects. A record review of Resident #2's medical record, dated ??, revealed the ADON documented her assessment of Resident #2 on 5/24/2026, Resident alert with no signs or symptoms of distress. No signs or symptoms of adverse reactions to medications. A record review of Resident #2's medical record revealed the SW assessed Resident #2 and documented on 5/25/2026, Resident seen by Social Services for follow-up assessment related to medication error reported on previous date. Resident was alert and able to communicate needs and concerns appropriately during visit. Social Worker assessed resident's emotional status and coping response. Resident stated he is doing fine and denied any change in mood or emotional distress related to incident. Resident also denied pain, nausea, or other adverse symptoms at this time. No signs of acute emotional distress observed during visit. Support and opportunity for discussion provided. Resident encouraged to notify staff of any concerns or changes in condition. No further social service interventions indicated at this time. A record review of the facility's, Medication Cart Monitoring/Order, MAR, inventory reconciliation check auditing worksheet tool, revealed the DON checked the medication carts and observed medication administration without incidents on the following dates and times:- 5/25/2026 PM- 5/26/2026 AM- 5/26/2026 PM- 5/27/2026 AM A record review of the facility's Quality Assessment and Performance Improvement Plan 2026 dated 5/25/2026 revealed the following leadership attended the QAPI meeting:- The Administrator- The DON- The Medical Director- The ADON A record review of the facility's ANE, following physicians' orders, medication administration (no pre-pouring), opioid overdose response in-service, dated 5/25/2026, revealed 12 nursing staff received the in-service from the DON and the ADON: which included:During an interview on 5/27/2026 at 10:13 A.M., RN O stated she was the charge nurse for 300-hall and some of 200-hall and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. During an interview on 5/25/2026 at 6:10 PM, RN G stated she was the weekend RN supervisor who picked up the PRN holiday shift on 5/25/2026 and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. During an interview on 5/25/2026 at 6:22 PM, the ADON stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications for 1 resident at a time. During an interview on 5/25/2026 at 4:32 PM, LVN N stated she was the charge nurse for 300-hall and some of 200-hall and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. During an interview on 5/25/2026 at 6:14 PM, LVN B stated she was the charge nurse for 300-hall and some of 200-hall and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. During an interview on 5/25/2026 at 4:21 PM, LVN M stated she was the charge nurse for 300-hall and some of 200-hall and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. LVN M stated she had not practiced pre-pouring medications and as a professional standard administered medications to 1 person at a time. During an interview on 5/26/2026 at 4:47 PM, MA K stated she was a Medication Aide for the facility and had worked evening shifts. MA K stated she received an in-service from the DON which included teaching on the rights of medication administration specific for not pre-pouring medications. MA K stated she had not practiced pre-pouring medications and as a professional standard administered medications to 1 person at a time. During an interview on 5/27/2026 at 9:05 A.M., RN L stated she was a nurse for the facility and had worked evening shifts. RN L stated she received an in-service from the DON which included teaching on the rights of medication administration specific for not pre-pouring medications. RN L stated she had not practiced pre-pouring medications and as a professional standard administered medications to 1 person at a time. During an interview on 5/26/2026 at 6:07 PM, LVN J stated she was a nurse for the facility and had worked evening shifts. LVN J stated she received an in-service from the DON which included teaching on the rights of medication administration specific for not pre-pouring medications. LVN J stated she had not practiced pre-pouring medications and as a professional standard administered medications to 1 person at a time. During an interview on 5/25/2026 at 6:18 PM, LVN C stated she was the charge nurse for 100-hall and some of 200-hall and stated she received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications 1 resident at a time. During an interview on 5/26/2026 at 9:00 A.M., RN D stated he received an in-service for medication administration and ANE prevention and reporting and did not practice pre-pouring medications and administered medications to 1 resident at a time. During an interview on 5/26/2026 at 5:22 PM, LVN I stated she was a nurse for the facility and had worked evening shifts. LVN I stated she received an in-service from the DON which included teaching on the rights of medication administration specific for not pre-pouring medications. LVN I stated she had not practiced pre-pouring medications and as a professional standard administered medications to 1 person at a time. The noncompliance was identified as PNC. The IJ began on 5/24/2026 and ended on 5/25/2026. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was completed in a timely manner and included pain he experienced, code status, ADL functional status, bladder/bowel incontinence, cognitive loss, skin risk, diet orders, or psychotropic drug use. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #1's admission record, dated 12/04/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses including secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes (cancer cells that have spread to the lymph nodes located in the abdominal area), secondary malignant neoplasm of bone (bone cancer), chronic obstructive pulmonary disease (lung and airway disease that restrict breathing), drug introduced constipation, nicotine dependence, depression, anxiety disorder, other chronic pain, esophagitis unspecified without bleeding (swelling and irritation of the tissue that line of the esophagus), abnormal weight loss, adverse effect of other opioids, and malignant neoplasm of prostate (prostate cancer). The advance directive section showed he was DNR status. Record review of Resident #1's admission MDS assessment, dated 10/11/25, revealed Resident #1's cognition was severely impaired. Section H revealed he was occasionally incontinent with bladder. Section J revealed the resident received pain medication and used tobacco. Section M revealed the resident was at risk for pressure ulcers. Section N revealed he was taking antianxiety, diuretic, opioid, and anticonvulsant. Section O revealed the resident received hospice services. Section V Care Area Assessment (CAA) summary revealed cognitive loss/dementia, visual function, communication, ADL functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Pressure Ulcer, Psychotropic Drug Use, and Pain were triggered. Record review of Resident #1's Comprehensive Care Plan, initiated on 10/09/25, last revised on 10/12/25, only contained an area for fall risk and functional discharge goals. No other focus areas or interventions were listed on the comprehensive care plan. Record review of Resident #1's physician order summary, dated 12/04/25, revealed orders for: -Code status DNR, start date 9/30/25 -Nasal Cannula 2-5 L as needed, start date 9/29/25, no end date. -buspirone tablet (mild antianxiety medication) 15 mg, start date 9/30/25, and no end date. -clonazepam (antianxiety medication) tablet 1 mg, start date 9/30/25, and no end date. -duloxetine (antidepressant medication) 30 mg tablet, start date 11/27/25, end no end date. -Gabapentin (anticonvulsant, can treat seizures or nerve pain) 300 mg capsule, start date 9/30/25, and no end date. - Ipratropium-Albuterol Inhalation Solution (combination medication used to treat and prevent symptoms of chronic COPD) 0.5-2.5 (3)MG/3ML (Ipratropium-Albuterol) 1 inhalation inhale orally every 4 hours as needed for SHORTNESS OF BREATH, start date 9/29/25, and no end date. -Lasix (diuretic) oral tablet 40 mg, give 1 tablet by mouth in the morning for edema, with start date of 11/26/25, and no end date. -Methadone hcl (pain medication) oral tablet 10 mg, give 10 mg by mouth at bedtime for pain management, start date 10/22/25, and no end date. -Morphine sulfate oral solution (pain medication)20 mg/5mL give 1 mL by mouth every hour as needed for pain, with a start date of 10/06/25, and no end date. During an interview on 12/04/25 at 12:13 p.m. the DON stated he started at the facility as a floor staff nurse in September and his first day as DON was 12/04/25. The DON stated he was being trained on how to complete care plans by the regional MDS but was not yet trained. The DON stated the previous DON was responsible for the care plans and he was now responsible for the care plans. The DON stated it was important that the resident's comprehensive care plan was completed to manage his care and to implement and meet the resident's goals. Record review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, dated 03/2022, stated Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This failurecould place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Record review of the staff roster revealed DM's hire date was 6/24/2024. In an interview on 6/17/2025 at 11:19 AM, the DM reported to the SSA that he was not currently certified as a food services manager. He stated he was enrolled in an educational program to obtain certification. He stated his prior professional experience helped him to prepare for his role as the current DM. The Admin confirmed the DM was not a certified food services manager during an interview on 6/20/2025 at 8:34PM. She stated she was aware of the certification requirement for food services managers and had been cited for the deficiency in a prior survey. She felt that because the DM was currently working towards being certified and because this was accepted in a prior plan of correction, the DM's position was acceptable. She reported the potential harm to the residents was inaccurate dietary procedures.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services to meet the needs for 5 of 9 residents (Residents #4, #5, #9, #15, and #134), and the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconcilitation for 1 of 9 residents (Resident #4) reviewed for medication administration. 1. The facility failed to ensure accurate documentation of medications administered to Resident #134. 2. The facility failed to ensure Residents #4, #5, #9, and #15 received medications as ordered by the physician. 3. The facility failed to prevent the loss of 2 tablets of Resident #4's hydrocodone-acetaminophen, a narcotic pain medication. 4. The facility failed to discard expired insulin for Resident #15. These failures could lead to inaccurate administration of medications, ineffective therapeutic effects, and injury or illness. Findings included: 1. Record review of Resident #134's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with relevant diagnoses including type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels resulting from the body's inability to self-regulate glucose) and chronic pulmonary embolism (a blood clot in the lung). Record review of Resident #134's admission MDS, submitted on [DATE], indicated a BIMS score could not be assessed due to the cognitive status of the resident. Record review of Resident #134's EMR contained the following medication orders: a. Insulin lispro injection solution 100 unit/mL, inject as per sliding scale . subcutaneously before meals and at bedside related to type 2 diabetes mellitus with hyperglycemia (order date [DATE]) b. Eliquis oral tablet 2.5mg (apixaban), given 1 tablet via PEG-tube every morning and at bedside related to chronic pulmonary embolism (order date [DATE]) Record review of Resident #134's MAR revealed no documentation on [DATE] for 8:00 PM administration of medication Eliquis and 8:00 PM administration of subcutaneous insulin. In an interview on [DATE] at 4:00 PM, LVN E stated he was responsible for administering the above listed medications. He stated Resident #134 received both medications, and the missing documentation was the result of a computer error. LVN E reported potential the possible harm of incorrect medication documentation was potential overdose or other staff not knowing what medications a resident had received. 2. Record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. Record review of Resident #4's EMR contained the following physician's order: Divalproex sodium DR 125 mg tab, given 1 tablet orally two times a day related to unspecified dementia (order date [DATE]) While observing routine medication administration on [DATE] at 7:32 AM, the DON was observed crushing the divalproex DR tablet before mixing it with pudding to administer to Resident #4 orally. In a telephone interview on [DATE] at 8:20 AM, the RPh stated Resident #4's divalproex DR should not be crushed prior to administration, as crushing it would affect the absorption and cause the medication to become absorbed more quickly. The RPh also stated that he was unaware Resident #4 required medications to be crushed, and if he would have known, he would have contacted the facility to recommend a different formulation of the medication. The RPh then stated the potential harm to Resident #134 by receiving the medication crushed inappropriately was ineffective therapeutic effect due to quicker absorption. The DON was interviewed on [DATE] at 14:20. She stated the divalproex DR should not have been crushed. She then stated the divalproex had been discussed with the RPh, and the order was modified to the alternate formulation appropriate for crushed medications. She reported the potential harm to Resident #4 from receiving the improperly crushed medication was the resident not getting the intended therapeutic effect or seizures. Record review of Resident #5's facesheet, printed [DATE], reflected a [AGE] year-old male, originally admitted to the facility on [DATE], and with a relevant diagnosis of drug induced subacute dyskinesia (a movement disorder that develops as a result of starting or increasing the dosage of certain medications). Record review of Resident #5's quarterly MDS, submitted [DATE], revealed a BIMS score of 9, indicating moderately impaired cognition. Resident #5's EMR contained the following order: Austedo XR oral tablet extended release 24 hour 6mg (Deutetrabenazine) give 6mg by mouth at bedtime for tardive dyskinesia related to unsteadiness on feet (order state [DATE] 20:00 [8:00 PM]) Review of Resident #5's MAR for [DATE], printed [DATE], reflected the following documentation for Austedo XR: a. [DATE] 8:00 PM: no documentation/blank b. [DATE] 8:00 PM: code 9 documented by LVN C c. [DATE] 8:00 PM: code 9 documented by CMA A d. [DATE] 8:00 PM: code 9 documented by LVN C e. [DATE] 8:00 PM: documented as administered by LVN C f. [DATE] 8:00 PM: code 9 documented by CMA A g. [DATE] 8:00 PM: code 9 documented by CMA A h. [DATE] 8:00 PM: code 9 documented by CMA A i. [DATE] 8:00 PM: code 9 documented by LVN C j. [DATE] 8:00 PM: code 9 documented by LVN C k. [DATE] 8:00 PM: code 9 documented by ADON l. [DATE] 8:00 PM: code 9 documented by ADON The code key for the MAR revealed 9 indicated other/see progress notes. Record review of Resident #5's progress notes for [DATE] did not reveal any documentation related to the administration of the Austedo XR. CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #5 on [DATE]. She explained the Austedo XR was not able to be administered to Resident #5 because it was not available in the facility and did not arrive until [DATE]. She explained if a medication is not in stock, the process was to inform the charge nurse or the ADON or DON, if they were available. She stated she informed the charge nurse and the DON of the need for the Austedo XR and the pharmacy told the staff it would be delivered. She was unsure why the administration scheduled for 8:00 PM on [DATE] did not contain any documentation, as the facility policy for medications not administered was to use code 9 and type a progress note, if needed. In an attempted interview on [DATE] at 5:29 PM, LVN C was contacted by telephone but there was no answer, and the voicemail recording indicated the mailbox was full. The ADON was interviewed on [DATE] at 5:15 PM. She stated she noticed on [DATE] the medication was not in stock, so she contacted the pharmacy personally to request the medication. She said the pharmacy was unaware of the new order, and they delivered it on [DATE]. An interview on [DATE] at 5:20 PM revealed the DON was not aware that Resident #5 had not received 11 doses of the Austedo XR. She did not recall being notified by any staff member during that time. She stated Austedo XR was not contained with the facility emergency stock of medications, so the documentation of Resident #5 receiving the medication on [DATE] was likely charted in error. She then said her expectation of staff was they would notify her and the Admin of any medications that were out of stock. Record review of Resident #9's face sheet, printed [DATE], reflected a [AGE] year-old male, initially admitted to the facility on [DATE], with a relevant diagnosis of cognitive impairment of uncertain or unknown etiology. Record review of Resident #9's quarterly MDS submitted on [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. Record review of Resident #9's EMR revealed the following physician's order: Memantine HCl oral tablet 5mg, give 5mg by mouth at bedside related to mild cognitive impairment of uncertain or unknown etiology for 7 days (start date [DATE] 20:00 [8:00 PM]). Record review of Resident #9's [DATE] MAR, printed [DATE], revealed the following documentation for Memantine HCl: a. [DATE] 8:00 PM: no documentation/blank b. [DATE] 8:00 PM: no documentation/blank c. [DATE] 8:00 PM: no documentation/blank d. [DATE] 8:00 PM: no documentation/blank CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #9 on [DATE] and [DATE]. She stated the order for administration of the Memantine HCl was not present on [DATE] or [DATE], as she did not remember seeing an alert. Per the staffing schedule, LVN C was responsible for administering Resident #9's medications on [DATE] and [DATE]. LVN C was contacted by telephone on [DATE] at 5:29 PM, but there was no answer, and the voicemail recording indicated the mailbox was full. Record review of Resident #15's facesheet, printed [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of schizoaffective disorder, bipolar type (a chronic mental health condition that causes difficulty distinguishing reality with frequent mood swings). Record review of Resident #9's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. Record review of Resident #15's EMR revealed the following physician's order: Quetiapine fumarate oral tablet, give 12.5 mg by mouth in the morning related to schizoaffective disorder, bipolar type for 7 days (start date [DATE] 08:00 [AM]). Record review of Resident #15's [DATE] MAR, printed [DATE], reflected the following documentation for Quetiapine: a. [DATE] 8:00 AM: no documentation/blank b. [DATE] 8:00 AM: no documentation/blank Per the staffing schedule, LVN D was responsible for administering Resident #15's Quetiapine on [DATE] and [DATE]. LVN D was contacted by telephone on [DATE] at 4:20 PM, and a voicemail with contact information was left to obtain an interview. LVN D did not contact the state survey team prior to exit. In an interview with the ADON on [DATE] at 5:33 PM, she explained that Resident #9 did not receive the ordered Memantine HCl and Resident #15 did not receive the ordered Quetiapine because the electronic orders were pending confirmation from the nursing staff administering the medication in the EMR. She further explained that both orders were confirmed late (after the ordered start date), so the MARs populated with the missed doses. She reported the potential harm to residents as missed doses of medication. She reported there was no formal process for confirming medication orders and that this needed to be addressed by herself and the DON. Record review of the facility's policy titled Administering Medications (2001, revised [DATE]) revealed the following: a. Medications are administered in accordance with prescriber orders, including any required time frame b. If a drug is withheld . the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 3. As noted previously, record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. Record review of Resident #4's EMR revealed the following physician's order: Hydrocodone-acetaminophen oral tablet 10-325mg Give 1 tablet by mouth four times a day related to pain, unspecified (Order date [DATE]) Record review of the facility's investigation report included copies of the individual narcotic record dated [DATE] through [DATE], in which 2 tablets of the medication were not dated or signed as administered by nursing staff. During an observation of medication administration on [DATE] at 7:00 AM, Resident #4's hydrocodone-acetaminophen tablets (45) were verified to match the documentation on the individual narcotic record (45). LVN E was interviewed on [DATE] at 12:26 PM,. she stated a discrepancy of 4 tablets was discovered during the routine narcotic count on the [DATE] morning shift handoff between LVN F and herself. She stated she counted the actual tablets present, and LVN F read the number she recorded in the book during her overnight shift, and the numbers did not match. She reported signing the paper to indicate the number of tablets on hand and notified the DON later that day. She stated Resident #4 did not appear to be in pain during her shift or to have suffered any harm because of the missing medication. LVN E denied knowledge of the missing hydrocodone-tablets. LVN F was interviewed on [DATE] at 2:06 PM. She reported no medication was missing on the handoff that occurred on the morning of [DATE], and she was unsure why she was questioned about the missing tablets, as the handoff was recorded by herself and the oncoming nurse which indicated a proper count of actual tablets versus recorded amount. She denied any knowledge of Resident #4's misappropriated hydrocodone-acetaminophen. She stated she was no longer employed at the facility. In an interview with the DON on [DATE] at 9:03 AM. She explained the process for narcotic counts at shift change was the off-going and oncoming would review the narcotics and the documentation in the binder containing the individual narcotic records to verify the documentation was correct. The two nurses would then sign the front page of the binder to indicate mutual verification. When asked about Resident #4, she explained initially four tablets of the hydrocodone-acetaminophen were missing, but her investigation and audit revealed two of the four tablets were administered by LVN F on the PM shift of [DATE] and not documented properly . She reported 2 tablets were not able to be reconciled, despite the investigation. Record review of the facility's policy titled Controlled Substances (dated 2001, revised [DATE]) revealed the following: The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. 4. Record review of Resident #15's facesheet, printed [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of type 2 diabetes mellitus without complications (inability of the body to regulate blood glucose levels.) Record review of Resident #15's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. Record review of Resident #15's EMR contained the following physician's order: Insulin lispro infection solution 100 unit/mL . subcutaneously before meals and at bedside related to Type 2 diabetes mellitus without complications (order date [DATE]) In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, two multi-dose insulin vials affixed with pharmacy labels for Resident #15 were observed in the drawer. Both multi-dose vials were labeled as opened on [DATE]. LVN B explained during this observation that the facility process was to discard insulin after 29 days and Resident #15's insulin should be thrown away. LVN B had just arrived for his shift and was unsure if Resident #15 had been administered the expired insulin. LVN B reported the potential harm to residents receiving expired insulin was hyperglycemia as the expired insulin may be less effective. In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to keep insulin for 28 days after removing from the fridge. The DON stated unlabeled insulin in the medication cart should be discarded and not administered. Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following: Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and that were not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #29) reviewed for freedom from physical and chemical restraints. The facility failed to ensure Resident #29 was free from physical restraint when nursing staff physically restrained her for medication administration on 06/02/25, 06/04/25, and 06/17/25. These deficient practices could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). The findings include: Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. It further reflected a focus of Behavior Management, initiated on 06/10/25, with interventions to include educated resident/representative on necessity of care attempted to provide .ensure the safety of resident and others. Resident #29's care plan further reflected a focus of risk for harm: self-directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. It further reflected a focus of The resident has a behavior problem (schizoaffective disorder (mental health condition)) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Record review of Resident #29's care plan did not reflect anything about Resident #29 needing a therapeutic hold for medication administration. Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML. Inject 5 mg intramuscularly one time only related to Disorganized Schizophrenia, with start date 06/02/25, was given on 06/02/25 at 07:10 PM by LVN B. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to Disorganized Schizophrenia, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00 PM. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG. Inject 50 mg intramuscularly every day shift every 14 day(s) related to Disorganized Schizophrenia, with start date 06/17/25, was blank on 06/17/25 Day. Record review of Order Granting Leave to Resign and Appointing Succesor Guardian of the Person, dated 06/18/20, reflected [Resident #29's RP] is appointed as the successor guardian of the person of [Resident #29], an Incapacitated Person. [Resident #29] is found to be incapacitation and lacks the necessary capacity to care for herself as a reasonable prudent person would do, and a full guardianship of the person is hereby granted with all the rights, duties, and powers granted to a successor guardian by law. [Resident #29] is declared fully incapacitated without the authority to exercise any rights or powers over herself. Record review of nurse's note, dated 06/17/25 at 10:30 PM and authored by LVN C, reflected [Resident #29] informed of ordered IM Risperidone 50mg injection, increased agitation noted, resident quickly stated, no you will not! Get out of my room! Several attempts to educate the resident regarding the medication were unsuccessful, four employees assisted to ensure safety and protect the resident from hurting herself or others. Safety techniques effectively applied by staff, IM Risperidone 50mg administered to the right upper outer gluteal quadrant without incident. Resident voiced frustration and yelled, I said get out of my room, staff exited room, visual safety checks applied and continued monitoring throughout the night to ensure safety and monitor for any possible side effects Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer Haldol. The DON revealed she tried to explain to Resident #29 the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in a chair to receive the injection. The DON revealed they tried to give the medication when Resident #29 was in the chair, but the resident physically swung. The DON revealed the psychiatric NP and attending physician said the nursing staff could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, 1 staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety and Resident #29 sustained no injuries. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. He revealed when the shot was wearing off for Resident #29, Resident #29 did not have reason and was combative. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. He further revealed he had been in contact with her psychiatrist, and they were all in agreeance that this helped the resident. He was okay the facility had to physically restrain her because it was for her benefit, health wise. Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and there was no assessment to show the need for physical restraints for the resident. She revealed the use of restraints was a verbal order from the doctor, but it needed to be signed and entered into the resident's medical record. She revealed when they entered the doctor's order, they would add what health condition it was used for in the additional comments. She revealed it was important for resident safety because restraints could lead to injury. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 12:57 PM, the DON revealed there was not an assessment available to complete for using restraints on Resident #29 for medication administration. She revealed the facility had created an assessment so they could complete this assessment before doing a therapeutic hold on Resident #29 for medication administration. She revealed when they used a therapeutic hold on Resident #29 on 06/17/25 and monitored Resident #29 every 5 to 15 minutes. The DON revealed she sat with Resident #29 for about 2 hours to ensure resident safety. She revealed after each therapeutic hold for medication administration, Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he was called before the nursing staff held Resident #29 down for medication administration. He revealed Resident #29 was on a special psychiatric medication and she has had, on more than one occasion, been held because she was yelling and throwing items. He revealed the facility called and asked him if this was appropriate to hold Resident #29 for medication administrator. He revealed for resident's comfort and well-being, medication was vital because there could be an emergency room trip if she had not received these medications. He revealed Resident #29 was not harmed in anyway, because the medication was administered in a respectful and non-violent manner. He revealed his orders were done verbally because the medication administration needed to be done quickly. He revealed there should be a doctor's order afterward. He revealed his order would have read: With familial consent and doctor approval, okay to hold patient for medication administration to improve uncontrolled symptoms of aggression and allow time for new medication to take effect. He revealed he may revise this order and have it read more eloquently. He revealed this should be a one-time thing and if the facility wanted to do it again, he would be contacted. He revealed this was not a long-term solution. He revealed they might need to adjust Resident #29's medication regimen to have Resident #29 be participate with staff more. He revealed Resident #29 had a psychiatric disturbance with aggressive behaviors. He revealed there needed to be monitoring after a therapeutic hold for medication administration for Resident #29 to watch the resident for any injuries every few hours or every shift. He revealed it was important for these components to be in place so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:20 PM, the DON revealed form 3713 (consent for antipsychotic or neuroleptic medication treatment) should be completed for Haldol. She revealed it was important because it went back to resident safety and resident rights. She revealed before they went into Resident #29's room they had a safety plan if resident was not cooperative with receiving the shot. She revealed each staff member were all assigned an extremity to hold. She revealed they did not practice. She revealed she instructed the nursing staff to hold the resident to make sure they would not cause a fracture. She revealed on June 17th Resident #29 sat on the edge of bed and this was all Resident #29 would comply. She revealed they tried non-pharmacologically interventions first. She revealed Haldol was given on June 2nd and RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Interview with LVN B was attempted. A voicemail was left on 06/20/25 at 05:16PM for LVN. Record review of the facility's, undated, policy, Restraint Policy, reflected The use of restraints is expressly forbidden unless it is prescribed as a measure of treatment for the resident and issued by the treating physician. Physical Restraint is any method or device used to restrict the movement or to keep a resident in a certain position while sitting or lying down . A restraint may only be placed on a resident if it has been determined by the Licensed Staff and the Treating Physician that it is medically necessary and the order is include in the Care Plan of a resident . The LVN or RN may receive a verbal order and consent from the physician and approval by the resident's responsible party but for a period not to exceed 24 hours. A written order must be received by the facility before the 24-hour period expires.

Based on record review, interview and observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 1 of 1 facility reviewed. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. The findings were: Record review of the Mealtimes, undated, reflected: Dining Room: Breakfast 07:45 AM, Lunch 11:45 AM, and Supper 05:45 PM; Hall Trays: Breakfast 07:30 AM, Lunch 11:30 AM, and Supper 05:30 PM. Record review of the snack times, undated, reflected 09:30 AM, 02:30PM, and 07:00 PM. Confidential interviews during the Resident Meeting on 06/18/25 at 01:03 PM revealed the facility did not offer snacks at bedtime and they would like to be offered snacks at bedtime. Interview on 06/19/25 at 07:05 PM, the ADM revealed the facility did not have a nourishment room to keep items from the kitchen like snacks to give out to the residents at night. She revealed there were three times a day when the facility gave out snacks to include a 7PM snack. She revealed for the 7 PM snack the kitchen staff would leave the snacks on ice, in the dining room, for the nursing staff to pass out. She revealed there were items to make peanut butter and jelly sandwiches at the nurse's station, if residents wanted a snack, because when they did offer bedtime snacks for residents, they would have to discard snacks that were not used. Interview on 06/19/25 at 07:15 PM, Resident #13 revealed she had not received a snack tonight and had not been offered snacks at night. She revealed she would like to be offered a snack and would probably accept a snack at times but did not need a snack tonight. Interview on 06/20/25 at 04:08 PM, the Dietary Manager revealed the kitchen had not been preparing snacks for bedtime snacks. He revealed this was due to their budget, but they stocked up snacks for the residents from dry food storage. He revealed it was important for residents to have snacks, especially diabetics so they can maintain their blood sugars. Interview on 06/20/25 at 05:29 PM, CNA L revealed she worked doubles Friday to Sunday and had never seen snacks passed out for bedtime. She revealed she had only seen snacks passed out to residents one time. Interview on 06/20/25 at 06:07 PM, the ADM revealed she was not aware that bedtime snacks were required to be offered at night. She had not heard of any resident complain about not having nighttime snacks. Observation on 06/19/25 at 07:18PM revealed there were no snacks left on ice to be passed out, in the dining room. The kitchen appeared to have the lights off with no staff in the kitchen. There was a sign posted right outside of the kitchen that revealed there was a snack time at 7 PM. Record review of facility's policy, Food and Nutrition Services, revised October 2017, reflected 4. Reasonable efforts will be made to accommodate resident choices and preferences . 10. Nourishing snacks are available to residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label the drink containers in the dining room, which were used by residents for hydration. 2. The facility failed to store raw protein food items below fully cooked foods in the freezer. 3. The facility failed to not store personal beverages in the food preparation area. These failures could place residents at risk for food borne illness. The findings included: 1. Interview and observation on 06/17/25 at 11:19 AM, the drink containers in the dining room were not labeled. The DM revealed the kitchen staff knew to date and label kitchen items, but he had to keep reminding them because they tended to forget. 2. Interview and observation on 06/17/25 at 11:19 AM, there were raw proteins (chicken and beef patties) stored in a freezer above biscuit dough. The DM revealed raw proteins should be stored below fully cooked items. 3. Interview and observation on 06/17/25 at 09:56 AM, there was a personal water bottle in a carton of potatoes. [NAME] M revealed she knew her personal beverage should not be put here. During this same interview on 06/17/25 at 09:56 AM, The DM revealed he oversaw personal beverages being stored in their designated spot, foods being stored properly like the raw proteins, and drink containers being labeled appropriately. He revealed it was important for labeling the drink containers, so they knew when the beverages were no longer good to drink. Dietary Aide N joined the interview and revealed she knew to date and label the drink containers. Combined interview on 06/20/25 at 04:08 PM, Dietary Staff O, Dietary Staff P, and the CDM revealed raw protein food items needed to be stored below fully cooked food items to prevent cross contamination and food poisoning. They revealed it was important to label foods and beverages, so they knew when to discard these items so that it was good when the resident ate or drank it. They revealed it was important to not have personal beverages in the food preparation area so there would not be contamination. Record review of facility's policy, Food Receiving and Storage, revised November 2022, reflected 4. Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage areas at all times .9. Uncooked and raw animal products and fish are stored separately in drop-proof containers and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for 2 of 3 staff members (CNA G and CNA I) reviewed for pre-employment TB screenings, 3 of 3 staff members (CNA G, CNA I, and LVN E) reviewed for pre-employment vaccinations, and 2 of 2 residents (Resident #5 and Resident #134) reviewed for transmission-based precautions. 1. The facility failed to screen staff members CNA G and CNA I for TB prior to hire, per CDC guidelines. 2. The facility failed to offer a vaccination for hepatitis B upon hire to staff members CNA G, CNA I, and LVN E per OSHA and CDC guidelines. 3. The facility failed to utilize proper PPE procedures during TBP for Resident #5 and Resident #134. These failures could result in the development and spread of infection or illness. Findings included: Record review of employee files revealed the following: a. CNA G: hire date of 4/21/2025 and a copy of a chest x-ray dated 4/19/2021 for listed indication screening examination for pulmonary tuberculosis b. CNA I: hire date of 4/29/2025 and a form documenting negative results of a TB skin test dated April 2024. c. LVN E: hire date of 4/18/2025 and a TB screening form dated 3/26/2025 No documentation of the hepatitis vaccination being offered to these staff members was in the employee files. An interview with the Admin was conducted on 6/20/2025 at 12:04 PM. She was unsure if the staff members had been offered the hepatitis B vaccination. In an interview with the DON on 6/20/2025 at 4:27 PM, she reported newly hired staff members wereposed to have a TB skin test within the previous year prior to hire. She was unsure if the facility should perform an additional screening questionnaire of newly hired staff members. The DON stated the importance of screening staff for TB before hire and annually was to prevent transmission of infection. She reported the risk of transmission in the nursing facility setting was higher and would be catastrophic. She was unsure if the staff members had been offered the hepatitis B vaccination. In an interview with the ADON on 6/20/2025 at 12:40 PM, she stated CNA G and CNA I were not screened for baseline TB risks using the facility form prior to employment. She explained that when CNA G and CNA I provided the TB testing documentation, she accepted the documents to meet the pre-employment requirement. She was not aware a baseline screening questionnaire should have also been performed. She agreed that CNA G and CNA I could have been exposed to or contracted TB since their testing performed prior to hire and should have been screened. The ADON also stated she had not offered the hepatitis B vaccination to CNA G, CNA I, or LVN E while performing her responsibilities in the hiring process. She provided documentation at that time of TB screenings for CNA G and CNA, as well as hepatitis B vaccination status for CNA I, all documents dated 6/20/2025. Record review of the facility document titled New Employee Orientation Checklist (not dated) revealed TB test agreement and results as an item listed under tasks to be completed prior to day 1. Additionally, the item hepatitis vaccine was listed under the section titled Day 1 onboarding forms: employee logs onto [system] and completes the following forms on day 1. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE], and with a relevant diagnosis of benign prostatic hyperplasic without lower urinary tract symptoms (enlargement of the prostate gland that can cause difficulty or the inability to urinate). Record review of quarterly MDS, submitted 5/21/2025, revealed a BIMS score of 9, indicating moderately impaired cognition. Record review of Resident #5's active physician orders, date printed 6/17/2025, included: a. Catheter care every shift (start date 5/9/2025) b. Check foley catheter tubing secure device placement every shift (start 5/9/2025) c. Change foley the 11th of every month (start date 5/19/2025) d. EBP precautions for duration of catheter (start 5/9/2025) e. Contact precautions (start 6/11/2025) In an observation on 6/17/2025 at 1:58 PM, the DON was observed entering Resident #5's room without donning PPE. The DON was interviewed on 6/20/2025 at 2:20 PM. She stated any staff or visitor entering a resident's room with contact precautions should don a gown and gloves prior to entering, regardless of whether or not direct care is providing to the resident. She acknowledged she entered Resident #5's room without donning PPE, and she reported the potential risk of not appropriately donning PPE was the transmission of infection. Record review of Resident #134's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of encounter for attention to gastrostomy (a surgical opening in the stomach allowing for the intake of nutrition and medication). Record review of the admission MDS, submitted on 3/29/2025, indicated a BIMS score could not be assessed due to the cognitive status of the resident. Record review of Resident #134's active physician orders, date printed 6/18/2025, included resident to be on enhanced barrier precaution (start 4/17/2025). In an observation of routine medication administration on 6/19/2025 at 7:59 AM, the DON was observed donning a disposable gown and gloves and administering one medication to Resident #134 via the gastrostomy tube. The DON was then observed maintaining the same pair of gloves to remove additional medications from the medication cart and perform documentation on the laptop affixed to the top of the cart. The DON then administered additional medications to Resident #134's gastrostomy tube while wearing the same pair of gloves. In an interview with the DON on 6/18/2025 at 8:10 AM, the DON stated she should have changed her gloves and performed hand hygiene before accessing Resident #134's gastrostomy tube and before accessing the medication cart. The DON reported the potential harm to residents of not changing gloves or performing hand hygiene was transmission of infection. Record review of the facility policy titled Isolation- Categories of Transmission Based Precautions (dated 2001, revised September 2022) revealed the following: Contact precautions: .Staff and visitors wear gloves (clean, nonsterile) when entering the room . Staff and visitors wear a disposable gown upon entering the room . Record review of the facility policy titled Standard Precautions (dated 2001, revised September 2022) revealed the following: Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. Record review of the CDC guidelines for TB screening and testing of health care personnel, published May 2019, recommend a baseline screen and individual risk assessment at baseline (preplacement) as well as TB testing for new employees. OSHA standard 1910.1030(f)(1)(i) requires employers to make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure . The CDC also published recommendations in 2018 that included offering the hepatitis B vaccination to all adults working in health care settings.

Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29 was prescribed and received the antipsychotic medication Haldol for disorganized schizophrenia without evidence in her medical record of the state consent form 3713. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included: Record review of Resident #29's admission record revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. It further reflected Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences, It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. And it further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML Inject 5 mg intramuscularly one time only related to DISORGANIZED SCHIZOPHRNIA, with start date 06/02/25, was given on 06/02/25 at 07:10PM by LVN B. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 04:20PM, the DON revealed Resident #29 did not have form 3713 completed for the antipsychotic Haldol. She revealed she did not realize it was not signed. She revealed it was important because it went back to resident safety and resident rights. Record review of facility's policy, revised April 2019, reflected 22. The individual administering the medication initials the resident's MAR and the appropriate line after giving each medication and before administering the next ones.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 residents (Resident #10) reviewed for assessment accuracy. The facility inaccurately assessed Resident #10 as not requiring a mechanical lift for transferring in the quarterly MDS submitted on 1/22/2025. This failure could lead to residents not receiving required care. Findings included: Record review of Resident #10's facesheet, printed 6/20/2025, revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Relevant diagnoses included muscle wasting and atrophy (muscle breakdown), other lack of coordination, and other reduced mobility. Record teview of the quarterly MDs submitted 4/24/2025 revealed a BIMS score of 06, indicating severely impaired cognition. Section GG of this MDS was not assessed. The prior quarterly MDS, submitted 1/22/2025, question GG0110 did not include mechanical lift in the assessment of prior device usage. Record review of Resident #10's comprehensive care plan, printed 6/18/2025, revealed care planning for fall prevention as evidenced by the use of the Hoyer lift. Attempted interview with Resident #10 on 6/17/2025 at 11:12 AM and again on 6/18/2025 at 10:30 AM revealed the resident was unable to be interviewed. The COTA indicated during an interview on 6/20/2025 at 09:09 AM, that Resident #10 has required use of the mechanical lift since initial admission to the facility. She also reported Resident #10 is unable to stand or bear weight at all. The ADON, serving as the MDS nurse, was interviewed on 6/20/2025 at 12:44 PM. She stated she was still receiving training for completing MDS assessments and had not completed the prior two MDS submissions for Resident #10. She was unsure why the 1/22/2025 assessment indicated that Resident #10 had not required the use of mechanical lift in the period prior, as she also recalled Resident #10 required the mechanical lift since admission. The ADON indicated potential harm of inaccurate assessments to residents was resident's not receiving required care.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Residents #29) reviewed for care plans. The facility failed to develop care plan interventions to include Resident #29 needing a therapeutic hold for medication administration. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental and psychosocial well-being. The findings include: Record review of Resident #29's admission record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29's had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. It further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and it needed to be care planned for resident rights. The DON did not give a reason why it was not care planned, but it was important for resident care. Interview on 06/20/25 at 01:08 PM, the ADON, who oversaw care plans, revealed Resident #29 needing to be held down for medication administration should be care planned for resident safety and resident rights. Interview on 06/20/25 at 06:14 PM, the DON and ADM revealed care plans should be updated for residents being held down for medication administration, so staff knew how to provide resident care. Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer Haldol. The DON revealed she tried to explain to Resident #29 the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in a chair to receive the injection. The DON revealed they tried to give the medication when Resident #29 was in the chair, but the resident physically swung. The DON revealed the psychiatric NP and attending physician said the nursing staff could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, 1 staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety and Resident #29 sustained no injuries. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. He revealed when the shot was wearing off for Resident #29, Resident #29 did not have reason and was combative. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. He further revealed he had been in contact with her psychiatrist, and they were all in agreeance that this helped the resident. He was okay the facility had to physically restrain her because it was for her benefit, health wise. Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and there was no assessment to show the need for physical restraints for the resident. She revealed the use of restraints was a verbal order from the doctor, but it needed to be signed and entered into the resident's medical record. She revealed when they entered the doctor's order, they would add what health condition it was used for in the additional comments. She revealed it was important for resident safety because restraints could lead to injury. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 12:57 PM, the DON revealed there was not an assessment available to complete for using restraints on Resident #29 for medication administration. She revealed the facility had created an assessment so they could complete this assessment before doing a therapeutic hold on Resident #29 for medication administration. She revealed when they used a therapeutic hold on Resident #29 on 06/17/25 and monitored Resident #29 every 5 to 15 minutes. The DON revealed she sat with Resident #29 for about 2 hours to ensure resident safety. She revealed after each therapeutic hold for medication administration, Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he was called before the nursing staff held Resident #29 down for medication administration. He revealed Resident #29 was on a special psychiatric medication and she has had, on more than one occasion, been held because she was yelling and throwing items. He revealed the facility called and asked him if this was appropriate to hold Resident #29 for medication administrator. He revealed for resident's comfort and well-being, medication was vital because there could be an emergency room trip if she had not received these medications. He revealed Resident #29 was not harmed in anyway, because the medication was administered in a respectful and non-violent manner. He revealed his orders were done verbally because the medication administration needed to be done quickly. He revealed there should be a doctor's order afterward. He revealed his order would have read: With familial consent and doctor approval, okay to hold patient for medication administration to improve uncontrolled symptoms of aggression and allow time for new medication to take effect. He revealed he may revise this order and have it read more eloquently. He revealed this should be a one-time thing and if the facility wanted to do it again, he would be contacted. He revealed this was not a long-term solution. He revealed they might need to adjust Resident #29's medication regimen to have Resident #29 be participate with staff more. He revealed Resident #29 had a psychiatric disturbance with aggressive behaviors. He revealed there needed to be monitoring after a therapeutic hold for medication administration for Resident #29 to watch the resident for any injuries every few hours or every shift. He revealed it was important for these components to be in place so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:20 PM, the DON revealed form 3713 (consent for antipsychotic or neuroleptic medication treatment) should be completed for Haldol. She revealed it was important because it went back to resident safety and resident rights. She revealed before they went into Resident #29's room they had a safety plan if resident was not cooperative with receiving the shot. She revealed each staff member were all assigned an extremity to hold. She revealed they did not practice. She revealed she instructed the nursing staff to hold the resident to make sure they would not cause a fracture. She revealed on June 17th Resident #29 sat on the edge of bed and this was all Resident #29 would comply. She revealed they tried non-pharmacologically interventions first. She revealed Haldol was given on June 2nd and RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Record review of the facility's, undated, policy, Restraint Policy, reflected The use of restraints is expressly forbidden unless it is prescribed as a measure of treatment for the resident and issued by the treating physician. Physical Restraint is any method or device used to restrict the movement or to keep a resident in a certain position while sitting or lying down . A restraint may only be placed on a resident if it has been determined by the Licensed Staff and the Treating Physician that it is medically necessary and the order is include in the Care Plan of a resident

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 8 residents (Resident #18) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received appropriate care and treatment for the indwelling catheter device placed after admission. 2. The facility failed to ensure Resident #5's foley catheter was secured appropriately. This failure could lead to infection or injury. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #5 diagnoses included benign prostatic hyperplasic without lower urinary tract symptoms (enlargement of the prostate gland that can cause difficulty or the inability to urinate). Record review of the quarterly MDS, submitted 5/21/2025, revealed a BIMS score of 9, which indicated moderately impaired cognition. Record review of Resident #5's EMR revealed Resident #5 was evaluated in the local emergency department on 5/7/2025 for weakness. The emergency department physician attributed the resident's symptoms to urinary retention, and the resident had an indwelling foley catheter placed, as well as treatment for a urinary tract infection. Discharge records included an order to change the foley catheter on 6/8/2025. Record review of additional hospital records from an evaluation in the local emergency department on 6/7/2025 reflected Resident #5 had the foley catheter changed while at the hospital. Record review of Resident #5's active physician orders, date printed 6/17/2025, included : a. Catheter care every shift (start date 5/9/2025) b. Check foley catheter tubing secure device placement every shift (start 5/9/2025) c. Change foley the 11th of every month (start date 5/19/2025) d. EBP precautions for duration of catheter (start 5/9/2025) e. Contact precautions (start 6/11/2025) During an observation of Resident #5 on 6/18/2025 at 11:51 AM, no date was seen on the foley catheter bag, tubing, or securement device. Additionally, the foley catheter tubing was not attached to the securement device on the resident's right thigh. In a subsequent observation on 6/20/2025 at 9:20 AM, the foley was again observed not to have a date. CNA J was observed performing catheter care at this time, and the following deficient practices were observed: a. CNA J donned PPE prior to entering Resident #5's room incorrectly by applying gloves prior to donning a disposable gown b. CNA J did not change gloves or perform hand hygiene after repositioning the resident and removing the resident's clothes. CNA J performed care to the catheter wearing the same, used gloves that were applied initially. c. At the completion of care, CNA J then removed the PPE incorrectly by taking off the used gloves, performed hand hygiene by washing her hands in the sink with soap and water, then removed the disposable gown. In an interview with CNA J on 6/20/2025 at 9:40 AM, she incorrectly stated the steps of applying PPE as applying gloves then donning the disposable gown. She stated she had incorrectly removed PPE, and she reported the steps for removal were to remove the disposable gown and then gloves prior to performing hand hygiene. CNA J stated she received training about infection control and PPE through the staffing agency of which she was employed. She stated the potential harm to residents from not properly utilizing PPE or changing gloves was cross contamination. In an interview with LVN E on 6/18/2025 at 12:20 PM, she reported Resident #5 had the foley catheter changed while at the emergency department recently. She was unsure of the exact date it was changed. LVN E stated the foley catheter should be dated so that staff would know when the device was last changed, and she was unaware that the current foley catheter was not dated. She attributed the lack of date to the insertion performed by the emergency department. LVN E was also unaware the foley catheter was not secured to the securement device. She reported potential harm of the unsecured foley catheter was the foley becoming obstructed, infected, or dislodged. The DON was interviewed on 6/19/2025 at 9:15 AM, and she stated the facility policy for foley catheters was the device must be dated when inserted and the tubing always secured to the securement device. The DON reported potential harm of an unsecured foley catheter was dislodgement or transmission of infection. She also reported potential harm of cross contamination by staff not donning PPE properly or changing gloves during care. Record review of the facility's policy titled Catheter Care, Urinary (2001, revised July 2024) revealed the following: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Record review of the facility's policy titled Standard Precautions (2001, revised September 2022) revealed the following: a. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body side to another (when moving from a dirty site to a clean one) b. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident A policy for EBP precautions and general infection control was requested from the DON and the Admin but were not provided to the SSA prior to exit.

Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for all nursing staff in 1 of 1 facilities where therapeutic holds were used. The facility failed to ensure nursing staff were trained to therapeutically hold Resident #29 for medication administration. This failure could place residents at risk for harm due to staff who lack the appropriate skills and competencies to provide and minimize infections. The findings include: Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML Inject 5 mg intramuscularly one time only related to Disorganized Schizophrenia, with start date 06/02/25, was given on 06/02/25 at 07:10PM by LVN B. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to disorganized schizophrenia, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00 PM. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly every day shift every 14 day(s) related to Disorganized Schizophrenia, with start date 06/17/25, was blank on 06/17/25 Day. Record review of nurse's note, dated 06/17/25 at 10:30 PM and authored by LVN C, reflected, [Resident #29] informed of ordered IM Risperidone 50mg injection, increased agitation noted, resident quickly stated, no you will not! Get out of my room! Several attempts to educate the resident regarding the medication were unsuccessful, four employees assisted (unnamed) to ensure safety and protect the resident from hurting herself or others. Safety techniques effectively applied by staff, IM Risperidone 50mg administered to the right upper outer gluteal quadrant without incident. Resident voiced frustration and yelled, I said get out of my room, staff exited room, visual safety checks applied and continued monitoring throughout the night to ensure safety and monitor for any possible side effects Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer the Haldol. The DON revealed she tried to explain to Resident #29 that the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in the chair to receive the injection. The DON revealed they tried to give medication when Resident #29 was in the chair, but the resident physically swung. The DON asked the psychiatric NP and attending physician, and they said they could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, one staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety. Interview on 06/20/25 at 12:57 PM, the DON revealed Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he gave verbal order for a therapeutic hold for medication administration for Resident #29 for Haldol once and Rispiradal consta twice. He revealed the nursing staff therapeutically held Resident #29 for medication administration in a safe manner. He revealed it was important so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke amongst themselves about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. She revealed she was not trained on restraining a resident Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Attempted interview with LVN B on 06/20/25 at 05:16PM was unsuccessful. A voicemail was left for LVN B. There were no trainings done (no records available) to ensure staff knew how to therapeutically hold residents for medication administration.

Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (200-300 halls cart) reviewed for medication storage. The facility failed to label the expiration dates of opened/unrefrigerated insulin stored in the medication cart for Resident #2. This failure could lead to ineffective insulin therapy, hyperglycemia, and illness. Findings included: Record review of Resident #2's facesheet, printed [DATE], revealed a [AGE] year-old female, originally admitted to the facility on [DATE] with a relevant diagnosis of type 2 diabetes mellitus with hyperglycemia (the body's inability to self-regulate blood sugar leading to elevated levels). Review of the quarterly MDS, submitted [DATE], revealed a BIMS score of 8, indicating moderately impaired cognition. Record review of Resident #2's EMR contained the following physician's order: Lantus Solostar 100 unit/mL Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia (Order date [DATE]) In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, an insulin pen affixed with a pharmacy label for Resident #2 was observed in the drawer. The insulin pen was not labeled with any additional dates other than the information printed by the pharmacy. LVN B assisted with the observation and was interviewed concurrently. LVN B was unsure of when Resident #2's insulin pen was removed from the fridge and opened, and he denied administering insulin to the resident using that device on [DATE] as her insulin was not due until the evening. He stated the facility process is to label insulin pens and vials with the date they are removed from the fridge and opened. He also stated the insulin can be kept for 29 days once removed from the fridge and then must be discarded. LVN B had just arrived for his shift and was unsure if Resident #2 had been administered the unlabeled insulin. LVN B reported the potential harm to residents was hyperglycemia as the insulin may expired and may be less effective. In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to apply a date when the insulin is opened and to keep insulin for 28 days after removing from the fridge. Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following: Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29's June MAR did not reflect that RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG was given on 06/04/25 and 06/17/25. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included: Record review of Resident #29's admission record revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. It further reflected Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences, It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. And it further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to DISORGANIZED SCHIZOPHRENIA, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00PM. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly every day shift every 14 day(s) related to DISORGANIZED SCHIZOPHRENIA, with start date 06/17/25, was blank on 06/17/25 Day. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 04:20PM, the DON revealed RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given Record review of facility's policy, revised April 2019, reflected 22. The individual administering the medication initials the resident's MAR and the appropriate line after giving each medication and before administering the next ones.

Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident. These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living. The findings were: Record review of Form 3740 Bed Classifications, completed by the Administrator on 06/18/2025, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room. Room size measurements in 2024 and 2023 of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows: 1. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident 2. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident 3. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident 4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident 5. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 6. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 7. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident 8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident 9. room [ROOM NUMBER] (3-person room - 1 resident in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident Interview on 06/19/2025 at 04:47PM, the Administrator stated the facility will have to continue completing the room waiver for the rooms less than regulation size. The Administrator revealed they were still using the same rooms that needed waivers in the last 2 years, with no changes. The Administrator revealed she had not signed a room waiver. Asked the ADM for confirmation of room sizes during survey and on 06/26/25 at 08:55 AM. The ADM has not confirmed these room sizes.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 (Residents #11, #15, and #18) of 20 residents reviewed for dignity. 1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged. 2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges. 3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. These deficient practices affect residents who rely on facility equipment for mobilization and could result in loss of self-esteem, dignity, and increased lack of self-worth. The findings included: 1. Record review of Resident #11's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: abnormalities of gait and mobility (any deviations from normal walking or gait), thyrotoxicosis (a condition that happens when there is too much thyroid hormone in the body and can cause rapid weight loss and a rapid heartbeat), paroxysmal atrial fibrillation (type of irregular heartbeat), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). Record review of Resident #11's quarterly MDS assessment with an ARD of 04/02/2024 reflected he scored a 10/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair, and he could roll 150 feet once seated in the chair. Record review of Resident #11's comprehensive person-centered plan of care 09/29/2023 reflected Problem, ADL's Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed. Observation on 05/14/2024 at 10:00 a.m., Resident #11 was sitting in his wheelchair and the left armrest vinyl was torn with sharp ragged edges and appeared worn and damaged. During an interview on 05/17/2024 at 1:30 p.m. with Resident #11, he stated he had the wheelchair for as long as he could remember. When asked why he did not ask the staff to repair it, he stated what good would it do? He stated he did not want to bother anyone. He stated the worn and torn armrest made him feel depressed. 2. Record review of Resident #15's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally), dementia (a loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (when full effort does not produce a normal muscle contraction or movement). Record review of Resident #15's quarterly MDS review with an ARD of 03/25/2024 reflected he scored a 09/15 for his BIMS score which signified he was moderately cognitively impaired. He could usually understand and could usually be understood. He required a manual wheelchair, and he could move independently. Record review of Resident #15's comprehensive person-centered care plan dated 03/24/2024 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed. Observation and interview on 05/14/2024 at 10:12 a.m., Resident #15 was sitting in his wheelchair and both the armrests vinyl was torn and worn which caused him to feel a loss of dignity. During an observation and interview on 05/17/2024 at 2:00 p.m. with Resident #15, who was sitting in his wheelchair in the 300 hallway, he had new armrests on his wheelchair which were replaced on 05/16/2024 after the state surveyor spoke with the RNC. He stated the old armrests made him feel bad. When asked why he did not mention the worn and torn armrests to the staff, he stated he did not want to bother anyone. He stated he had the wheelchair since he was admitted to the facility. 3. Record review of Resident #18's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues), weakness (lacking strength), unspecified abnormalities of gait (any deviations from normal walking or gait), and mobility and spinal stenosis (space inside the backbone is too small and can cause pain, tingling, and weakness). Record review of Resident #18's quarterly MDS assessment with an ARD of 03/21/2024 reflected he scored a 10/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood. He required a manual wheelchair and could move independently. Record review of Resident #18's comprehensive person-centered care plan dated 08/14/2023 reflected Problem, ADLs Functional Status/Rehabilitation Potential, Approach, promote dignity, assist with ADL's as needed. Observation on 05/14/2024 at 10:15 a.m. of Resident #18, he was sitting in his wheelchair, and both the armrests had torn and worn vinyl and the left armrest was missing foam which exposed the baseboard. During an interview on 05/14/2024 at 10:17 a.m. with Resident #18, he stated he had the wheelchair since his admission and the vinyl wore and tore. He stated he did not want to bother the staff and did not complain. He stated the torn and worn vinyl and missing foam on the armrests bothered him and made him feel down and not dignified. Observation on 05/17/2024 of Resident #18 at 3:00 p.m. sitting in his wheelchair in the 300 hall, he had new armrests. The new armrests were the result of the state surveyor intervention, who spoke with the RNC on 05/16/2024 about the torn and worn armrests. During an interview on 05/17/2024 at 3:02 p.m. with Resident #18, he stated the new armrests on his wheelchair were soft and comfortable, and he felt much better. During an interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated worn and torn armrests on resident's wheelchairs were a safety and dignity issue. She stated she had been at the facility for less than a year and the company just hired a DON who had not started work. She stated she was not aware and had not noticed the resident wheelchairs needed armrests replaced or repaired. She stated if staff saw something that required repair, they needed to write it down in the Maintenance book at the nurse's station, and she presumed no one had noticed since the residents did not complain. She stated she would get them replaced right away. She stated a resident could feel embarrassed, undignified, or have a lack of self-esteem because of the torn armrests. Record review of the facility policy and procedure titled Quality of Life-Dignity, dated revised August 2009 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, Treated with dignity means that residents will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on interviews and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (residents #21, and #22) of 20 residents reviewed for care plans. 1. Resident #21's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 03/17/24 to reflect she had taken antianxiety medication. 2. Resident #22's comprehensive person-centered care plan was not revised or updated based on the facility policy to not use chair and bed alarms for prevention of fall, but the care plan reflected continually using chair and bed alarms. These deficient practices affect residents who receive assessments and could result in an inaccurate comprehensive person-centered care plan and missed care. The findings included: 1. Record review of Resident #21's electronic face sheet dated 05/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: edema (swelling caused by too much fluid trapped in the body's tissue), acute respiratory failure (occurs when the lungs cannot release enough oxygen into the blood), anxiety (a feeling of worry, nervousness, or unease), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and spinal stenosis (space inside the backbone is too small and can cause pain, tingling and weakness). Record review of Resident #21's quarterly MDS assessment with an ARD of 03/17/2024 reflected she scored a 09/15 for her BIMS score which signified she was moderately cognitively impaired. She could understand and be understood. She required moderate to extensive assistance with her ADL's. Review of Section N0415, High-Risk Drug Classes: Use and Indication. An area checked Is taking and indication noted was antianxiety. Record review of Resident #21's comprehensive person-centered care plan revised dated 04/09/2024 did not reflect Resident #21's antianxiety medication she took three times a day. Record review of Resident #21's Physician Order Report: 03/01/2024 - 04/30/2024 reflected she took an antianxiety medication during the week of 03/12/2024 to 03/17/2024. Ativan (antianxiety medication) 0.5mg TID, with a start date of 02/09/2024. Record review of Resident #21's EMAR dated 03/01/2024 - 03/31/2024 reflected she received Ativan (antianxiety medication) 0.5mg TID, with a start date of 02/09/2024. During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #21's antianxiety medication ordered in February and indicated on the March 17 MDS assessment. This needed to be updated on her care plan and it was not. She stated a resident's care plan was a map of how a resident gets what care they need and without it, they may miss or receive inappropriate care. In an interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she was so busy with MDS's and care plans, she did not know how the psychoactive medication, Ativan, was not updated on the care plan after her quarterly assessment dated [DATE]. Could result in care missed. 2. Record review of Resident # 22's electronic face sheet dated 05/17/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: hypokalemia (low level of potassium in the blood), cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), reduced mobility, abnormalities of gait and mobility (change to walking pattern), history of falling, anxiety disorder (persistent feeling of anxiety or dread), and impaired vision (poor vision to blindness). Record review of Resident #22's quarterly MDS assessment with an ARD of 04/29/2024 reflected he scored an 8/15 for his BIMS score which signified he was moderately cognitively impaired. He could understand and be understood. Record review of Resident #22' comprehensive person-centered plan of care, dated 03/01/2024, reflected Evaluate need for bed/chair alarms for prevention of fall. In an interview with CNA A on 05/16/2024 at 8:14 a.m. she stated, Per our facility policy, we never use chair or bed alarms. In an interview with LVN D on 05/16/2024 at 8:24 a.m. she stated He [Resident #22] did not have chair or bed alarms because we never use chair or bed alarms per our policy. In an interview with MDS consultant RN B on 05/16/2024 at 9:21 a.m. confirmed the facility did not use chair or bed alarms per their policy. Resident #22' comprehensive person-centered plan of care for Evaluate need for bed/chair alarms for prevention of fall should have revised or updated based on the facility policy. She stated it was very important that the care plan was revised or updated correctly to reflect current Resident #22's status because the care plan was the blueprint regarding how to provide correct care to residents. Record review of the facility policy and procedure titled Care Planning - Interdisciplinary Team revised September 2013 reflected A comprehensive care plan is developed within 7 days of completion of the resident MDS assessment .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Record review of the facility policy, titled Quality of Life - Homelike environment, revised 02/2014, revealed The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include Chair and bed alarms. 39049

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 7 of 20 residents (Residents #11, #15, #16, #19, #21, #22, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #11's incontinence was reflected in his care plan. 2. The facility failed to ensure Resident #15's pacemaker information was in his care plan. 3. The facility failed to ensure Resident #16's bowel incontinence was reflected in her care plan. 4. The facility failed to ensure Resident #19's did not have a care plan for handrails in bed. 5. The facility failed to ensure Resident #21's diagnoses, compression stockings, and diuretic were reflected in her care plan. 6. The facility failed to ensure Resident #22's care plan regarding prevention of falls were measurable to meet the resident's current medical, nursing, mental, and psychosocial needs. 7. The facility failed to ensure Resident #29's had handrails care planned. These deficient practices could place residents at risk of not receiving proper care and services. The findings included: 1.Record review of Resident #11's electronic face sheet dated (05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: abnormalities of gait and mobility (any deviations from normal walking or gait), thyrotoxicosis (a condition that happens when there is too much thyroid hormone in the body and can cause rapid weight loss and a rapid heartbeat), paroxysmal atrial fibrillation (type of irregular heartbeat), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). Record review of Resident #11's quarterly MDS assessment with an ARD of 04/02/2024 reflected he scored a 10/15 on his BIMS which signified he was moderately cognitively impaired. He could understand and be understood. He was frequently incontinent of urine and occasionally incontinent of bowel. Record review of Resident #11's comprehensive person-centered plan of care 09/29/2023 failed to reflect he was frequently incontinent of urine and occasionally incontinent of bowel. Observation on 05/14/2024 at 10:00 a.m., Resident #11 was sitting in his wheelchair, and required moderate assistance with his care. During an interview on 05/17/2024 at 1:30 p.m. with Resident #11, he stated he sometimes would be incontinent of urine or bowel. During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #11's incontinence needed to be care planned. She stated the care plan was a tool to communicate care required by the resident, and if it were not care planned, he could receive inaccurate or missed care. In an interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she was so busy with MDS's and care plans, she did not know why Resident #11's incontinence was not care planned. She stated it was important because he could miss care he required. 2. Record review of Resident #15's electronic face sheet dated 05/14/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally), dementia (a loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness (when full effort does not produce a normal muscle contraction or movement), and presence of cardiac pacemaker (small, battery powered device that prevents the heart from beating too slowly). Record review of Resident #15's quarterly MDS review with an ARD of 03/25/2024 reflected he scored a 09/15 for his BIMS score which signified he was moderately cognitively impaired. He could usually understand and could usually be understood. He had an active diagnosis of cardiac pacemaker. Record review of Resident #15's comprehensive person-centered care plan dated 03/29/2023 reflected Problem, Resident has a pacemaker/defibrillator and may be at risk for decreased cardiac output and irregular pulse; and potential for pacemaker/defibrillator malfunction, pace maker type_______, model________, serial #________, insertion date:_________, next operational check________. _________ During an interview on 05/17/2024 at 2:00 p.m. with Resident #15, who was sitting in his wheelchair in the 300 hallway, he stated he had his cardiac pacemaker for 6 years, and had follow-up appointments with his cardiologist. During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #15's pacemaker information needed to be care planned. She stated the care plan was a tool to communicate care required by the resident, and if the cardiac pacemaker information were not care planned, it would be difficult to quickly find information in case of a malfunction. In an interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she was so busy with MDS's and care plans, she did not know why Resident #15's pacemaker information was not completed in his care plan. She stated it was important because he could miss care he required. 3. Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left shoulder, and psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Record review of Resident #16's quarterly MDS assessment with an ARD of 02/24/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. She required extensive assistance with her ADL's. She was always incontinent of bowel and bladder. Record review of Resident #16's comprehensive person-centered care plan dated 09/29/2016 reflected Problem, Urinary Incontinence. Resident #16's bowel incontinence was not reflected in the residents comprehensive person-centered care plan. During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #16's bowel incontinence needed to be in the care plan because it was an important aspect of the resident's care. In an interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she care planned Resident's bladder incontinence, but must have forgotten to care plan her bowel incontinence. She stated it was important to be able to communicate the right care for a resident and to have it in the care plan. 4. Record review Resident #19's face sheet dated 5/16/2024 reflected he was admitted on [DATE], he was [AGE] years old. His diagnoses were multiple sclerosis, need for assistance with personal care, muscle weakness, and depression. Record review Resident #19's Quarterly MDS dated [DATE] reflected he was cognitively intact, required supervision with eating, he was dependent with showers, toileting upper/lower body extremity with dressing, and he used a motorized wheelchair. Record review Resident #19's care plan dated 5/16/2024 revealed no care plan for his handrail. Record review Resident #19's handrail consent/assessment was dated 2/24/2024 for bed mobility and positioning. Observation on 5/14/2024 at 10:40 AM in Resident #19's room revealed he had a handrail on his bed. Observation on 5/14/24 at 5:31 PM in Resident #19's room revealed he had a handrail on his bed. In an interview on 5/14/2024 at 5:32 PM with Resident #19 he stated he had a handrail on his bed to hold on too, while moving in bed. In an interview on 5/16/24 at 09:57 AM RN corporate MDS nurse confirmed the handrail on Resident #19's bed was not in his care plan and she was not sure why it was not in his care plan. The Corporate MDS nurse stated the resident MDS's were completed by the ADON. The corporate MDS nurse stated the ADON was out and was not sure when she would return . 5. Record review of Resident #21's electronic face sheet dated 05/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: edema (swelling caused by too much fluid trapped in the body's tissue), acute respiratory failure (occurs when the lungs cannot release enough oxygen into the blood), anxiety (a feeling of worry, nervousness, or unease), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and spinal stenosis (space inside the backbone was too small and can cause pain, tingling, and weakness). Record review of Resident #21's quarterly MDS assessment with an ARD of 03/17/2024 reflected she scored a 09/15 for her BIMS score which signified she was moderately cognitively impaired. She could understand and be understood. She required moderate to extensive assistance with her ADL's. She was assessed to have an active diagnosis of edema. She was inaccurately coded to be on a diuretic. Record review of Resident #21's comprehensive person-centered care plan did not reflect she had edema as a problem or compression stockings placed twice a day and prescribed a diuretic for interventions. Record review of Resident #21's Physician Order Report: 03/01/2024 - 04/30/2024 reflected she was ordered a diuretic on 04/19/2024 for edema and she had an order for compression hose BLE on in AM, off at HS, for edema with a start date of 03/26/2024. Record review of Resident #21's EMAR dated 04/17/2024 to 05/17/2024 reflected Compression Hose to BLE on in AM off at HS, and was initialed off as having them put on in the AM and taken off in the PM. Observation on 05/14/2024 at 10:30 a.m. of Resident #21 revealed she was sitting in the dining room and had compression hose on both her lower legs. Observation on 05/15/2024 at 10:00 a.m. of Resident #21 revealed she was sitting in her room with her feet on her footrests of the wheelchair and her ankles appeared swollen. During an interview on 05/15/2024 at 10:02 a.m. with CNA A she stated Resident #21 wears special stockings, and she puts them on the resident's lower legs in the morning. During an interview on 05/17/2024 at 11:20 p.m. with Resident #21, she stated she gets special stockings every day, but someone must put them on her. During an Interview on 05/16/2024 at 11:59 a.m. with the RNC, she stated Resident #21's edema needed to be care planned. She stated the edema was an active problem and the resident received medication and compression stockings to treat the swelling. Interview on 05/17/2024 at 05:22 PM with the Corporate MDS Nurse, she stated she was so busy with MDS's and care plans, she did not know why Resident #21's edema was missed. She stated the care plan was a main communication tool about the resident's needs and required care and care could be missed. 6. Record review of Resident # 22's electronic face sheet dated 05/17/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: hypokalemia (low level of potassium in the blood), cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), reduced mobility, abnormalities of gait and mobility (change to walking pattern), history of falling, anxiety disorder (persistent feeling of anxiety or dread), and impaired vision (poor vision to blindness). Record review of Resident #22's quarterly MDS assessment with an ARD of 04/29/2024 reflected he scored an 8/15 on his BIMS which signified he was moderately cognitively impaired. He could understand and be understood. Record review of Resident #22' comprehensive person-centered plan of care, dated 03/01/2024, reflected Problem: Resident was at risk for falls due to poor safety awareness, Goal: Resident will be free of falls, and Approach: for nursing, increased staff supervision with intensity based on resident need. In an interview with CNA A on 05/16/2024 at 8:14 a.m. she stated Resident #22 had high risk of fall because the resident did not use the call light even though teaching every time, so the CNA checked the resident every 30 minutes when the CNA worked on daytime. The facility CNAs generally check residents at least every two hours. In an interview with LVN D on 05/16/2024 at 8:24 a.m. she stated Resident #22 was confused so tried to transfer from the bed to the wheelchair by himself without requesting helps. The facility staff taught the resident every time about using a call light, but the resident forgot. The LVN D just told every CNA checking the resident at least every hour. The LVN D did not know how often the facility CNAs should check the resident per his care plan. In an interview with MDS consultant RN B on 05/16/2024 at 9:21 a.m. confirmed Resident #22's comprehensive person-centered plan of care regarding increased staff supervision with intensity based on resident need was not measurable. It should have been developed measurable, for example, increased staff supervision from every two hour to every one hour, so every staff could provide same supervision to the resident. Further interview with the MDS consultant RN B stated she was so busy with MDSs and care plans, so she did not know it was not measurable, and it affected the resident could not receive proper care and services. 7. Record review of Resident #29's face sheet dated 5/16/2024 reflected he was admitted on [DATE] and he was [AGE] years old. He had a diagnoses of cerebral infarction, muscle weakness, heart failure, and need for assistance with personal care. Record review of Resident #29's Admission MDS dated [DATE] reflected he had moderate cognitive impairment, he had impairment to upper/lower extremity for range of motion, he used a manual wheelchair, he required partial/moderate assistance with eating, he was dependent with showers and toileting, and he required substantial/maximize assistance with upper body dressing. Record review of Resident #29's care plan dated 4/25/2024 reflected no handrail for bed mobility. Record review of Resident #29's handrail consent /assessment was dated 4/2/2024 for bed mobility and positioning. Observation on 5/14/2024 at 10:42 AM reflected he had 2 handrails on his bed. Observation on 5/14/2024 at 12:17 PM reflected he had 2 handrails on his bed. In an interview on 5/14/2024 at 12:18 PM Resident #29 stated he used the 2 handrails to move in his bed. In an interview on 5/16/24 at 9:50 AM with the RN corporate MDS nurse stated there was no care plan for Resident #29's handrail . Record review of the Facility policy Care Plans-Preliminary dated August 2006 revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within 24 hours of admission, 3. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. Record review of the Facility Care Planning- Interdisciplinary Team dated September 2013 reflected Our Facility's Care Planning/Interdisciplinary Team is responsible for the development of an individuated comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed with 7 days of completion of the resident assessment. 28619 39049

Based on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that: The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on [DATE] and [DATE], Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. Aspiration occurs when food, drink, or foreign objects are breathed into the lungs (going down the wrong tube).] An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 05:15 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of IJ and a severity level of J because of the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Residents at risk for death by a blocked airway and secondary pulmonary infection by aspirated food/vomit. The findings included: A record review of Resident #2's Face Sheet, dated [DATE], revealed an admitted [DATE] and [DATE], with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's admission notes, [DATE] to [DATE], failed to reveal any assessments for dentures or oral dentition. A record review of Resident #2's admission MDS, dated [DATE], revealed the Regional MDS LVN prepared the assessment and failed to assess Resident #2 was admitted with and used dentures. Further review revealed Regional DON I signed the MDS. A record review of Resident #2's Care Plan, dated, [DATE], revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. A record review of Resident #2's nursing progress notes revealed LVN H documented on [DATE] at 06:30 PM, Approximately 1730 [05:30 PM] resident was eating dinner in the dining room when she aspirated [inhaled food and/or vomit into lungs] while eating her meal. Writer and staff acted quickly and was able to assist Resident to clear what was caught in her throat. Writer contacted the physician and was told to monitor resident for fever and shortness of breath. Resident [family member] was contacted and let known of the situation. Resident vitals are stable and Resident has been placed back in her bed in high fowlers position to prevent any further aspiration. will continue to monitor. A record review of Resident #2's nursing progress notes revealed LVN A documented on [DATE] at 01:53 PM, To dining room for meals for supervision. Pureed diet served today due to sore and hoarse throat. Resident began coughing on first bite of food. Resident able to clear and then slowly ate pureed food. X-ray ordered with two views. A record review of Resident #2's final X-ray Report, dated [DATE] , revealed, examination: chest . findings: . a metallic foreign body projects over the neck A record review of Resident #2's nursing progress notes revealed the ADON documented on [DATE] at 06:11 PM, Patient presenting increased SOB using ABDM muscles, cold, clammy to touch, pale, diaphoretic [excessive sweating], speech therapist here tried to feed patient at this time patient did not tolerate but one bite of mashed potatoes. Drooling and discharge from nose called. [Resident #2's representative] and doctor [name] on call for [Resident #2's doctor] send to ED for evaluation and treatment . A record review of Resident #2's hospital medical records revealed a History of Present Illness, dated [DATE], authored by Dr. T, chief complaint: altered mental status, low oxygen level, and foreign body (dentures) in esophagus [throat] . is a [AGE] year old white female brought by EMS to [local hospital] hospital emergency roiagnom on the evening of [DATE] for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. The patient is unable to provide any history due to cognitive impairment at baseline. As a result, history is obtained exclusively from review of hard copy medical records provided by the transferring facility. The patient was sent to the outside emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. The patient had one episode of food aspiration on [DATE] and a second episode of food aspiration on [DATE]. Her second episode was more severe and associated with significant coughing and choking. Care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation. Her shortness of breath was worse if she laid flat and improves if she sat up. At the outside emergency room , the patient's initial vital signs were remarkable for blood pressure ,d+[DATE], heart rate 106, respiratory rate 18, temperature 101.4, and 90% oxygen saturation on room air. Labs were remarkable for white blood cell count 25.4, hemoglobin 13.1, hematocrit 40.2, platelet count 270, sodium 138, potassium 4.3, creatinine 0.73, glucose 170, lactic acid 1.35, negative troponin, BNP 37, lipase 22, phosphorus 3.5, magnesium 1.7, TSH 1.06, PT 12.4, INR 1.1, PTT 30.4, and negative urinalysis. The patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, an elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia. CTA of chest was negative for PPE but did show acute findings consistent with bilateral aspiration pneumonia. CT of abdomen and pelvis with IV contrast performed at the outside emergency room showed fecal impaction with wall thickening and adjacent stranding. X-ray of the soft tissues of the neck performed at the outside of emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. As a result of these findings, the patient has been transferred to [out of town specialty hospital] to a higher-level care for further medical management and evaluation, including ear nose and throat specialist consultation. A record review of Resident #2's hospital records revealed a patient assessment document Bedside Swallowing Evaluation, dated [DATE], authored by Dr. U, medical history diagnosis, date of onset: patient is a [AGE] year-old female admitted with hypoxemia, concern for aspiration pneumonia, findings of foreign body and cervical esophagus. her are in, history of renal cancer. chest X-ray ,d+[DATE]: segmental atelectasis vs RRL pneumonia. foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus. per emergency medical record documented dysphasia at nursing facility. During an interview on [DATE] at 10:23 AM, the ADON stated on her 2nd day of employment at the facility, Resident #2 aspirated during the evening dinner on [DATE]. The ADON stated LVN H was assigned to supervise the residents at the evening meal and was absent from his duty. The ADON stated she heard the commotion and calls from the dining room when she ran to the dining room and assessed Resident #2, pale, cyanotic [blue skin], cold, tearing eyes and anxiously attempting to breath. The ADON stated she performed the Heimlich maneuver [performed by wrapping your arms around a person, making a fist with one hand and clasping it with the other. You place your fists between the person's ribcage and belly button and thrust your hands into their abdomen until the object is freed], swept Resident #2's oral cavity and expelled food from Resident #2's oral cavity. The ADON stated she was not familiar with Resident #2 and did not know Resident #2 had dentures. The ADON stated she did not feel or visualize Resident #2's dentures in her mouth. The ADON stated she could not access Resident #2's care plan due to her lack of training on the facility's electronic record. The ADON stated she now understood, even if she had access to Resident #2's care plan there were no interventions to alert anyone to Resident #2's dentures. The ADON stated Resident #2 was assessed with vital signs within normal limits, her physician was given a report and was assisted to bed for the evening. The ADON stated the physician was not given any report regarding her dentures. During an interview on [DATE] at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 to include the dinner meal on [DATE] and [DATE], the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no training or care instructions for Resident #2's denture care. During an interview on [DATE] at 02:00 PM, LVN H stated he was the nurse on duty on [DATE] and that Resident #2 had aspirated and had recovered. LVN H stated he called the on-call physician, gave report of the incident, and received new orders for monitoring Resident #2 for signs and symptoms of aspiration complications . LVN H stated he did not document the SBAR or the new orders received. LVN H stated he was not aware Resident #2 had dentures. LVN H stated Resident #2 was assisted to bed for the evening and was not in distress. LVN H stated he had no knowledge if Resident #2 had her lower dentures lodged in her airway that evening. LVN H stated there was a miscommunication as to his duty to supervise the dining room meal that evening. During an interview on [DATE] at 02:05 PM the ADON stated Resident #2 refused the breakfast meal on [DATE]. The ADON stated Resident #2 was receiving mechanical soft diet and the diet was discontinued on [DATE] and a pureed diet was ordered . The ADON stated Resident #2 was assisted with the lunch meal by LVN A and Resident #2 began to aspirate on pureed foods. The ADON received the report of the 2nd aspiration episode and SBAR'ed the physician and received a new order for a chest x-ray. The ADON stated the image was captured shortly afterward, and the facility awaited the results of the image. The ADON stated Resident #2 was assisted by the SLP with the evening meal on [DATE] when Resident #2 began to aspirate a 3rd time and was sent to the hospital for treatment and evaluation. The ADON stated the facility received the image result of the x-ray at 10:00 PM. The ADON stated the x-ray revealed a foreign object in the airway. During an interview on [DATE] at 02:00 PM the NP stated he was a NP who worked for the PCP responsible for Resident #2. The NP stated he had reviewed Resident #2's medical records to include her admitting nursing assessments and was not aware of Resident #2 using dentures. The NP stated if the nursing staff had assessed and documented Resident #2's dentures he could have had an opportunity to review her assessments, he may have possibly ordered a referral for Resident #2 to see a dentist to assess for Resident #2's dentures for proper fit. The NP stated often, as people age, the lower jaw changed shape and dentures became loose fitting. The NP stated Resident #2 could have died when she was not provided support while eating with dentures, such as proper care for dentures, instructions for wearing dentures, proper supervision for proper fitting dentures prior to meals. The NP stated the danger for aspiration was still in place due to the floor staff not having access to a complete and accurate care plan developed to support Resident #2's nutritional needs, and assistance with meals and dentures. During an interview on [DATE] at 04:32 PM the Administrator stated the ex-DON resigned in [DATE] and since then the corporate regional nursing support staff, to include the Regional DON, Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The Administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The Administrator stated the facility policy was to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which did not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed . A record review of the facility's policy Admission Assessment and Follow Up: Role of the Nurse, dated [DATE], revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 05:17 PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 3:00 PM. Plan of Removal Verification [DATE] Resident # 2 assessed by the RN for any s/s of discomfort/pain or changes in condition, physician was notified of the alleged deficiency on [DATE]. There were no new orders obtained. The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Resident was evaluated by SLP, clarification on diet received, new orders for speech treatment and swallow study ordered by physician. A record review of Resident #2's medical record revealed a progress note authored by the Regional DON, dated [DATE], revealed, resident in the dining room without dentures, oral cavity without signs and symptoms of pain or discomfort. no redness or irritation noted. A record review of the facility's ad-hoc QAPI attendee sign in log, dated [DATE], revealed attendees to include the Regional DON, Medical Director, Administrator, ADON, and RDO A record review of Resident #2's order summary revealed new orders on [DATE], for: the mechanical soft diet to be discontinued and for a pureed diet with thin liquids to begin, denture care to include monitoring daily for comfort and fit, an order for a modified barium swallow test, and an order for speech language to evaluate and treat. A record review of Resident #2's speech therapy notes, dated [DATE], revealed Resident #2 was evaluated by the SLP, clarification on diet received, new orders for speech treatment and a swallow study was ordered by the physician. A record review of Resident #2's progress notes revealed a note authored by the ADON on [DATE], [family member] called and informed there was an active and investigation from state surveyors on the incident with his [Resident #2's] dentures . Residents with dentures were assessed by the RN (Regional DON) on [DATE], the plan of care was updated and POC was updated to reflect patients' dentures utilization. A record review of the facility's daily census report revealed 9 residents (Residents #2, #5, #6, #10, #16, #20, #21, #28, and #88) were assessed for their needs for dentures. A record review of Resident #2's care plan, dated [DATE], revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear. A record review of Resident #5's care plan, dated [DATE], revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear. Residents will be identified on admission, by the charge nurse, if dentures are in place. The ADON will enter the information in the Matrix EMR and Point of Care mechanism. The ADON will also initiate dental care plan. During an interview on [DATE] at 10:33 AM the ADON stated she had reviewed all residents for needs for dentures and has assessed 9 residents with dentures to include Residents #2, #5, #6, #10, #16, #20, #28, and #88. The ADON stated she reviewed their care plans for accurate assessment and nursing interventions for the residents related to their needs for dentures. Staff have been educated on abuse and neglect, changes in condition by the Administrator and ADON starting on [DATE]. IDT has been in-serviced starting on [DATE] by the RNC on Care Planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. Nursing staff has been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on [DATE] by ADON. Staff will not be allowed to work until they receive training. A record review of the facility's in-service titled Change of Condition, dated [DATE], revealed 43 employees were educated for, facility policy title change in the residence condition or status policy statement our facility shall promptly notify the Resident, his or her attending physician, and representative of changes in the Resident's mechanical, mental condition and or status . policy interpretation and implementation; the nurse surveyor charge nurse will notify the resident's attending physician or alcohol physician when there has been . discovery of injuries of unknown source, . a significant change in the residence physical, emotional mental condition . A record review of the facility's in-service titled Abuse and Neglect, dated [DATE], revealed 43 employees were educated for, abuse and neglect clinical protocol the nurse will assess the individual and document related findings, assessment data will include injury assessment, all current medications, vital signs . the nurse who report findings to the physician as needed the physicians well let's ask the resident to verify or clarify such finding . reporting abuse to the facility management, policy statement, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management. A record review of the facility's in-service titled Care Planning IDT, dated [DATE], revealed 43 employees were educated for, policy statement her facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident . policy interpretation and implementation . a comprehensive care plan for each resident is developed within seven days have a completion of the resident assessment MDS. the care plan is based on the resident's comprehensive assessment and is developed by care planning introducing [NAME] team which includes, but it's not necessarily limited to the following personnel: the resident attending physician: the registered nurse who has responsibility for the Resident: the dietary manager dietitian: the social services worker responsible for the Resident: the activity director coordinator: therapist speech, occupational, recreational, etcetera, as applicable: the charge nurse responsible for resident care: nursing assistants responsible for the residents care: and others as appropriate or necessary to meet the needs of the Resident. comprehensive care plan . policy statement; an individualized comprehensive care plan that includes measurable objective objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each Resident. policy interpretation and implementation; are facilities care planning in the disciplinary team in coordination with the Resident, is her family or representative, develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning and resident may be expected to attain . the comprehensive care plan is based on a thorough assessment that includes, but it's not limited to the MDS. A record review of the facility's in-service titled denture Cleaning and Storing, dated [DATE], revealed 43 employees were educated for, the purpose of this procedure are two cleans and freshen the residents mount, to clean the residence dentures, to prevent infections of the mouth, to protect the residents dentures from breakage when dentures are out of the residents mouth, and to store dentures at bedtime . review the residents care plan to assess for any special needs of the Resident. assemble the equipment and supplies needed loose or poor fitting dentures can cause gum sores and prevent the resident from chewing his or her food properly. if a resident is not chewing his or her food thoroughly report it to your supervisor. encourage the resident to keep dentures in his or her mouth as much as possible. when dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly . During an interview on [DATE] at 11:10 AM the Human Resources Manager stated she reviewed the employee roster and compared the roster to the in-service roster and stated it was accurate for all of the facility's employees, to include employees who worked during the IJ up to midnight on [DATE]. Nursing staff received in-service training on documenting physician team contact in the progress notes for each resident as appropriate. Notification to physician of any changes of condition will be noted on the 24-hour report and the facility activity report and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. During an interview on [DATE] at 10:33 AM the ADON stated she received in-service education from the facility's Regional DON to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and would be noted on the 24-hour report and the facility activity report, and would be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated she and the Regional DON provided in-service training education for all of the facility's, 43 staff, to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and will be noted on the 24-hour report and the facility activity report, and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated the weekend RN and the ADON would in-service staff as needed, new staff, since all staff had been in-serviced by [DATE]. Upon reporting to work the appropriate in-service will be given to staff before they can begin work. All staff will complete Abuse/Neglect in-service by the Administrator and verified by the RDO. Nursing staff will also complete denture care, requirement for a nurse to be in dining room during meals, physician notification of change of condition, access to care plan in matrix, and update to Point of Care mechanism for CNA/nurse documentation of denture care from the ADON and verified by the Administrator. During an interview on [DATE] at 10:11 AM, RN K stated she was the facility's weekend RN supervisor and worked from 06:00 AM to 10:00 PM. RN K stated she had received in-service education to include abuse and neglect, residents' changes in condition, care planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. RN K stated she and nursing staff had been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on [DATE] by ADON. RN K stated staff would not be allowed to work until they received training. RN K stated she and the ADON would in service staff as needed, new staff, since all staff had been in- serviced by [DATE]. During an interview on [DATE] at 10:58 AM, the BOM/HR, and MOD as assigned, stated the in-service roster was accurate for employees who worked from the date of the IJ to midnight on [DATE] to include all of the facility's 43 employees. During an interview on [DATE] at 11:18 AM, CNA L stated she assisted residents with dressing, eating, toileting and activities of daily life. CNA L stated she received education/in-services for dentures, clean make sure they have them in, don't fit right, refuse, change of condition, refusal to eat drink, s/s of aspiration, and to report everything. During an interview on [DATE] at 12:30 PM CNA M stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA M stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. During an interview on [DATE] at 3:20 PM LVN N stated she worked the 02:00 PM to 10:00 PM shift and occasionally the 10:00 PM to 06:00 AM shift. LVN N stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the ADON and/or DON any complications and or concerns with residents and their dentures. LVN N stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents and LVN N would inspect the documentation for accuracy and assess residents with dentures prior to and after meals. During an interview on [DATE] at 04:53 PM CNA O stated she worked the 10:00 PM to 06:00 PM shift, received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA O stated the facility's electronic record for resident care now included n area where CNA's could now document denture care for residents. CNA O stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for resident's skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on [DATE] at 04:54 PM CNA P stated worked she worked 02:00 to 10 :00 PM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA P stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents. CNA P stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on [DATE] at 05:01 PM CNA Q stated she worked 06:00 PM to 06:00 AM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA Q stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. CNA Q stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on [DATE] at 06:00 PM LVN R stated she has been in serviced for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for resident denture care. LVN R stated she would assess CNAs for assistance with resident care to include eating and oral care. LVN R stated she had worked double shifts from 06:00 AM to 10:00 PM, but usually worked the 06:00 AM to 2:00 PM shift. During an interview on [DATE] at 06:10 PM LVN B stated she had been in service for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for Resident denture care. LVN B stated she would assess CNAs for assistance with Resident care to include eating, and oral care. LVN R stated she has worked double shifts from 06:00 AM to 10:00 PM, but usually works the 06:00 to 2:00 PM shift. also, in serviced on documenting SBARS and reviewing residents care plans for accuracy, also to report all allegations of suspected ANE and/or mistreatment. During an interview on [DATE] at 06:16 PM CNA E stated she had been in-serviced for has received education in services any changes of conditions and report to the charge nurse, the ADON, and if ANE, mistreatment, and or injuries of unknown origin to the nurse, ADON, and to include the Administrator. CNA E stated the CNA documentation screen for residents now included a care plan for residents who had dentures. CNA E stated she usually worked the 02:00 PM to 10:00 PM shift and had worked the 10:00 PM to 06:00 AM shift. All in-service and training will be completed by ,d+[DATE]. A record review of the facility's in-service records revealed all staff in services were completed by [DATE]. [DATE] the interventions set in place for residents with dentures to assess residents for having dentures, documentation in care plan and POC (Point of Care) dentures utiliza [TRUNCATED]