Every finding on record at Avir at Patriot

Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation for one (Resident #1) of six residents. The facility failed on 08/07/2026 to obtain and maintain documented statements from staff who had access to Resident #1's room while he was out of the facility in an appointment between one and five p.m., failed to document resident safety surveys, failed to document the delegated surveillance-footage review, failed to complete a trauma-informed assessment, and failed to contact law enforcement regarding the reported missing money. These failures resulted in an incomplete investigation that did not thoroughly determine the circumstances surrounding Resident #1's allegation of missing funds.Findings included:Record review of the face sheet revealed Resident #1 was a [AGE] year-old male with an original admission date of 05/17/2021 and a readmission date of 08/02/2021.Record review of Resident #1's quarterly MDS dated [DATE] revealed under Section C, Cognitive Patterns, a BIMS (brief interview for mental status) score of 13 out of 15, meaning the resident was cognitively intact. Resident #1 was able to participate in the interview, repeat three words, identify the year, and recall information with minimal cueing. The assessment reflected Resident #1 was able to make himself understood and understand others. Section I, Active Diagnoses, identified type 2 diabetes mellitus (a condition in which the body has difficulty controlling blood sugar); hyperlipidemia (high levels of cholesterol or fats in the blood); another fracture involving the left patella (a fracture involving the left kneecap); schizophrenia (a mental health disorder that can affect a person's thoughts, perceptions, emotions, and behavior); generalized muscle weakness (overall decreased muscle strength); abnormalities of gait and mobility (difficulty or changes in the way a person walks or moves); benign prostatic hyperplasia (an enlarged prostate that can cause difficulty with urination); gastroesophageal reflux disease, or GERD (stomach acid frequently flowing back into the esophagus, causing heartburn or irritation); hypothyroidism (an underactive thyroid that does not produce enough thyroid hormone); cognitive communication deficit (difficulty communicating because of problems with thinking, memory, attention, or understanding); left knee osteoarthritis (wear-and-tear arthritis of the left knee joint that can cause pain and stiffness); and lack of coordination (difficulty controlling or coordinating body movements).Section GG, Functional Abilities, documented that the resident required setup or clean-up assistance for eating and oral hygiene; partial/moderate assistance for toileting hygiene, showering/bathing, and personal hygiene; supervision or touching assistance for upper-body dressing and for bed mobility, sit-to-stand, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers; and substantial/maximal assistance for lower-body dressing and putting on/taking off footwear. The resident required partial/moderate assistance to walk 10 feet and 50 feet with two turns, and walking 150 feet was not attempted due to medical condition or safety concern. The resident used a manual wheelchair and was documented as independent wheeling 50 feet with two turns and 150 feet.Record review of Resident #1's comprehensive care plan dated 08/02/2026 revealed the resident had an ADL self-care performance deficit related to schizophrenia, with a goal to maintain his current level of function and dignity. Resident #1's care plan directed staff to provide physical assistance limited to transfer by one staff member for showering; limited assistance by one staff member with bed mobility, including turning and repositioning; limited assistance by one staff member with dressing; supervision by one staff member with eating; limited assistance with personal hygiene and setup of oral-care items; limited assistance by one staff member for toileting; and limited assistance with transfers. Resident #1's care plan also directed staff to allow sufficient time for dressing and undressing, assist the resident in choosing simple and comfortable clothing, and praise his efforts at self-care.Record review of the facility's progress notes dated 08/07/2026 revealed that at approximately 9:45 a.m., Resident #1 went to the nurses' station and reported that cash was missing from his drawer. Resident #1 stated he had saved approximately $400.00 for his family member and had only $138.00 remaining. The nurse immediately notified the Administrator. The nurse and Administrator went to the resident's room, where the resident retrieved an envelope from the top drawer. The Administrator counted and verified $138.00 in the envelope. Resident #1 stated that he always kept his cash in the same envelope and drawer.Record review of the facility's progress notes dated 08/07/2026, an Administrator communication note documented that the Administrator and Charge Nurse went to Resident #1's room after receiving the allegation. Resident #1 reported that he counted his money twice a week, had previously kept approximately $400.00 in an envelope in his room, and found only $138.00 remaining. The Administrator verified the amount. The resident reported that he generally remained in his room and had left the facility for a physician appointment on 08/05/2026, which he believed may have provided an opportunity for someone to enter his room. The Administrator advised Resident #1 to use the resident trust fund and keep only a small amount of cash in his room. Resident #1 provided $125.00 for deposit into the trust fund. The Administrator documented that security-camera footage from 08/05/2026 would be reviewed and offered the resident a personal lockbox with a key. Resident #1 liked the lockbox option but elected to deposit the remaining funds into his trust account at that time.Record review of the BOM's note on 08/07/2026 at 9:50 a.m., revealed the BOM documented being notified by the Administrator that Resident #1 had reported money missing from his room. The resident reported that he had been saving his monthly personal-needs allowance and believed he had accumulated approximately $400.00. The BOM documented that the remaining funds were provided for deposit into the resident's (RMFS) Resident Trust Fund account. The BOM attempted to notify the resident's guardian by telephone, left a voicemail when there was no answer, and sent an email requesting contact.Record review of the facility's progress notes dated 08/07/2026 at 10:18 a.m., a BIMS evaluation for Resident #1 documented a score of 15 out of 15. The resident correctly identified the year, month, and day of the week and recalled all three words without cueing, supporting that he was cognitively intact at the time the allegation was reported.Record review of the facility's investigation file on 08/19/2026 revealed the Administrator met with Resident #1 on 08/07/2026 and took the resident's statement. It revealed the Administrator looked into the resident's room to look for the missing funds and the Administrator advising Resident #1 to keep his money in his funds rather than having cash in his room. The facility's investigation file contained the provider investigation report, a copy of Resident #1's funds statement, a copy of the progress notes from the Administrator talking to Resident #1, and a copy of the email the Administrator sent to the legal representative of Resident #1. The facility's investigation file did not include interviews with other residents from the facility, the file did not include interviews with staff who was working on the shift the resident left the facility for an appointment, it did not include a police report, staff in-service records for abuse, neglect and exploitation prohibition nor safety surveys conducted by the staff. There was no evidence in the file of any video footage review.During an interview with CNA A on 08/19/2026 at 11:51 a.m., CNA A stated that she worked on Hallway 100, where Resident #1 resided, and was familiar with his usual behavior and care needs. CNA A stated that Resident #1 had good days and bad days and that she had recently observed an increase in episodes of yelling and screaming. CNA A stated that Resident #1 had never reported to her that money, personal belongings, or other possessions were missing from his room. CNA A stated that she had not received complaints from Resident #1 regarding staff or anyone else taking his belongings. CNA A stated that any allegation from a resident stating something was missing from their room needed to be reported to the Administrator so that he could make an investigation and ensure the resident was safe. CNA A stated that if the facility did not investigate a residents misappropriation allegation could result in them feeling they did not matter and could probably give the wrong message to staff encouraging them to take items from the residents.During an interview with CNA B on 08/19/2026 at 11:56 a.m., CNA B stated that she was assigned to Hallway 100 and routinely worked in the area where Resident #1 resided. CNA B described Resident #1 as having both good and difficult days and stated that he had recently experienced more frequent periods of yelling and screaming. CNA B stated that Resident #1 had not complained to her about missing money or personal property and had never informed her that items had disappeared from his room or that his possessions had been taken. CNA B stated the facility was supposed to investigate any allegation a resident makes about missing items because if they did not, it could potentially make the residents feel unsafe in the facility.During an interview with LVN C on 08/19/2026 at 12:03 p.m., LVN C stated that she was familiar with Resident #1 and described him as alert and oriented. She stated that although Resident #1 had schizophrenia, he was alert and aware of his surroundings. LVN C stated that while she was at the nurses' station, Resident #1 approached her and reported that he had approximately $400 and that some of the money was missing. LVN C stated that the Administrator was walking by at that time and she immediately notified him of the allegation. She stated that she had not known Resident #1 kept money in his room and had never personally seen the money. LVN C stated that Resident #1 reported keeping the money in an envelope in the same location. She stated that she had not heard complaints from other residents in the hallway or in the facility regarding missing money or property. LVN C demonstrated knowledge that suspected or witnessed abuse, neglect, or exploitation was to be reported to the Administrator and the State. LVN C stated that allegations of misappropriation should be taken seriously regardless of a resident's diagnosis or mental condition so that they could feel safe in the facility.During an interview with Resident #1 on 08/19/2026 at 2:22 p.m., Resident #1 stated that approximately one to two weeks earlier, on a Wednesday, he left the facility at approximately 1:00 p.m. for a medical appointment and returned at approximately 5:00 p.m. Upon returning to his room, he noticed that his phone had been moved. Resident #1 checked an envelope where he kept cash and discovered that approximately $350 was missing from approximately $480, he had stored there, with approximately $125 remaining. Resident #1 stated that he initially reported the missing money to a nurse, who notified the Administrator. He stated that the Administrator secured the remaining money. Resident #1 stated that the missing money had not been recovered, police had not spoken with him, and the Administrator had not asked whether he wanted to file a police report. Resident #1 stated that he believed he would want to file a police report.During an interview with the legal guardian on 08/19/2026, at 3:45 p.m., the guardian stated that the facility notified her that Resident #1 had reported money missing from his room. She stated that the facility told her the matter had been resolved and that Resident #1 was fine; however, she was not provided details regarding how the matter had been resolved. The guardian stated that she had not been informed that a police report had been made and recalled being told that the amount involved may have been approximately $70 to $80. She stated that she expected Resident #1's spending money to remain in his resident trust fund and for him to withdraw money as needed rather than keep a large amount of cash in his room. The guardian described Resident #1 as high functioning and aware of money and its value. She stated that she had been working with him to budget his monthly spending money and planned to monitor the issue more closely.During an interview with SW D on 08/20/2026 at 9:36 a.m., SW D stated that she did not participate in any capacity in the facility's investigation regarding Resident #1's allegation of missing money. SW D stated that when there's an allegation of missing money or misappropriation of property, it was the expectation that the abuse prohibition coordinator included the Social Worker so that they could conduct a trauma informed care assessment to make sure the resident was not in distress. SW D stated that if the allegation was not taken seriously and the allegation was not properly investigated, it could potentially result on the resident feeling unsafe in the facility and put them in distress.During an interview with SW E on 08/20/2026 at 9:51 a.m., SW E stated that she had started working at the facility on 08/13/2026 and was still becoming familiar with the facility's processes and responsibilities. She stated that she had not yet participated in a facility self-report investigation but understood that social services were expected to participate in investigations involving allegations of abuse, neglect, exploitation, or misappropriation. SW E identified the Administrator as the facility's Abuse Prohibition Coordinator and stated that allegations involving missing resident money should be reported to the Administrator. She stated that an investigation should include resident safety surveys to determine whether other residents had experienced missing belongings, money, mistreatment, or similar concerns. SW E stated that if the allegation was not properly investigated and documented could lead to a resident not trusting the facility staff any longer and make them feel unsafe and uncomfortable in their own home or room. After reviewing the facility's self-report file, SW E stated that she did not observe documentation of resident safety surveys and identified the need for a trauma-informed assessment and additional evaluation of Resident #1 following the reported loss. SW E stated that, considering the amount of money reportedly missing, law enforcement involvement would have been appropriate. She stated that additional investigative statements could have been obtained, including a separate statement from housekeeping and information identifying which staff members or shifts had access to Resident #1's room during the relevant timeframe. SW E concluded that additional safety surveys, investigative statements, follow-up education, and inquiry could have been completed to determine whether the incident was isolated or represented an ongoing concern.During an interview with ADON F on 08/20/2026 at 10:39 a.m., ADON F stated that she was notified by Resident #1's nurse regarding the allegation that money was missing from his room and that the nurse also notified the Administrator. ADON F stated that regardless of Resident #1's cognitive status, his allegation required investigation. She stated that she spoke with Resident #1, who reported that he kept money in an envelope and maintained that the money had been located where he described. ADON F stated that an investigation involving alleged missing resident property or money should include the Administrator/Abuse Prohibition Coordinator, Social Worker, nurses, CNAs, and other staff members who worked in the affected area. She stated that the Social Worker would be expected to speak with and emotionally assess Resident #1 and determine whether other residents had similar concerns. After reviewing the facility's investigative documentation, ADON F acknowledged that the facility was transitioning between Social Workers during the relevant period. She stated that allegations involving abuse, neglect, exploitation, or misappropriation required investigation and appropriate follow-up. ADON F stated that the documentation reflected that a search of Resident #1's room was conducted and $125 was provided to the Administrator for deposit, but this did not account for the full amount Resident #1 reported having. She emphasized the importance of obtaining appropriate staff statements and completing additional investigative follow-up when resident money was reported missing.During an interview with DON on 08/20/2026 at 11:35 a.m., DON stated that she was not involved in the incident but had been informed about it. She stated that Social Services needed to be involved in the investigation and based on the documentation in the investigative file, it appeared Social Services had not participated. After reviewing the facility's investigation, DON stated that the investigation was incomplete. She acknowledged that the Social Worker had been experiencing personal circumstances during the relevant period but stated that this did not negate the facility's responsibility to complete the investigation. DON stated that the investigative file was missing staff statements, in-service education, a trauma-informed assessment, and resident safety checks. She stated that law enforcement would normally be contacted regarding missing money above the applicable reporting threshold and that a police report should have been generated regardless of whether law enforcement responded to the facility. Based on the contents of the investigative file presented to her, DON stated that the investigation was incomplete and unacceptable.During an interview with BOM G on 08/20/2026 at 12:07 p.m., BOM G stated that Resident #1 had a legal guardian who primarily managed his finances. BOM G stated that her involvement with Resident #1's personal funds was limited to maintaining funds deposited into his facility trust fund account. She stated that the guardian periodically provided checks for Resident #1's spending money, which were deposited into his trust account, and that Resident #1 generally received approximately $50 in spending money at a time. BOM G stated that she was aware of Resident #1's allegation that money had been stolen from a drawer in his room. She stated that $125, representing money remaining after the alleged loss, was returned for deposit into Resident #1's facility trust account. BOM G stated that her involvement in the matter was limited to depositing the funds and that she did not conduct or participate in additional investigative activities. She stated that she believed an allegation involving stolen resident money should be reported to law enforcement but was unsure of the specific reporting requirements because she had not previously encountered this type of situation.During an interview on 08/20/2026 at 12:40 p.m., The Administrator stated that Resident #1's money was generally kept in a facility trust account. He stated that he became aware of an allegation that more than $400 was missing from an envelope in Resident #1's room. The Administrator went to the room and located an envelope containing approximately $135. He stated that he could not independently verify how much money Resident #1 originally had and recommended that the remaining money be deposited into the facility trust account for safekeeping. Resident #1's legal guardian was notified.The Administrator stated that staff searched Resident #1's room and asked personnel whether additional money had been located, but no additional money was found. He acknowledged that, as the facility's Abuse Prohibition Coordinator, he was responsible for investigating allegations of misappropriation. However, he did not provide formal safety-survey forms, signed interview statements, progress notes, or other written documentation showing the investigative interviews and follow-up actions. He also stated that surveillance footage was delegated to the maintenance department director for review. The Administrator stated that law enforcement was not contacted because no alleged perpetrator had been identified and the amount of money reported missing could not be verified. He acknowledged that he was unsure of the facility's policy requirements for reporting alleged misappropriation to law enforcement. He further acknowledged that the Social Worker did not complete a trauma-informed assessment or documented follow-up, and that portions of the investigation were conducted verbally without supporting documentation. The Administrator acknowledged that additional investigative actions could have been completed. Record review of the facility's policies and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised on April 2021, revealed in part: Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:I. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies; f. family members;g. legal representatives;h. friends;I. visitors; and/orJ. any other individual.2. Develop and implement policies and protocols to prevent and identify:c. theft, exploitation or misappropriation of resident property.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.Record review of the facility's policies and procedures titled Resident Rights, revised on February 2021, revealed in part:Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:c. be free from abuse, neglect, misappropriation of property, and exploitation;r. manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes);.

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 3 (Resident #8) residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days. The LTC online portal was subsequently reopened on 06/27/2026 to allow the facility to resubmit documentation reflecting the 04/16/2026 IDT meeting; submission remained incomplete and was not closed. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.Record review of Resident #8's face sheet dated 07/21/2026 revealed a [AGE] year-old female with an initial admission date of 09/22/2023 with a readmission date on 09/20/2024. Resident #8's Diagnoses included Spastic Quadriplegic Cerebral Palsy (severe, lifelong stiffness and tight muscles affecting both arms, both legs, the body's trunk, and the face, caused by an early brain injury), Anxiety Disorders (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry about everyday situations), Depressive Disorders (a common but serious mental health condition), Severe Intellectual Disabilities (the most severe level of intellectual disability) Speech and language development delay due to hearing loss (struggles to learn, understand, or say words clearly because they cannot hear sounds well or consistently), Attention deficit hyperactivity disorder (a brain condition that makes it hard to control attention, impulses, and energy levels), Contracture unspecified joint (a stiff, tight joint that cannot move or straighten all the way, but the medical record does not name which specific body part or joint is affected), Neuromuscular Scoliosis (a sideways curve of the spine caused by an underlying nerve or muscle problem). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but the resident was marked as severely impaired (never/rarely made decisions) under the cognitive skills for daily decision making. Record review of Resident #8's PASRR Level 1 Screening Summary dated 04/17/2026 revealed a positive response for a known or suspected diagnosis of intellectual disability. Record review of Resident #8's PASRR Evaluation dated 04/19/2024 revealed she was identified as having an intellectual disability and required specialized services. Record review of Resident #8's PCSP dated 04/21/2026 revealed the IDT meeting was held on 04/16/2026. Attendees included the resident, the PASRR Habilitation Coordinator, Local Authority for IDD, Licensed Social Worker, MDS Coordinator RN, Qualified Intellectual Disability Professional, Legal Guardian, and nursing facility representatives. The following NFSS were identified and confirmed: Durable Medical Equipment. The comments summary revealed Currently not on therapy services. Habilitation coordinator and guardian recommending specialized PT and OT assessments services to be initiated. Director of therapy will evaluate. The Local Authority for IDD confirmed the selected specialized services. Record review of Resident #8's PT and OT evaluation and plan of Treatment revealed start of care specialized services started on 04/19/2026. During an observation on 07/21/2026 at 10:00 a.m., Resident #8 was observed lying in bed. The resident was nonverbal but intermittently vocalized by yelling. The resident did not appear to be in distress. The call light was observed to be within reach. In an interview on 07/21/2026 at 2:35 p.m., the MDS Coordinator stated she had started employment at the facility the previous day on 07/20/2026. She reported having worked as a PASRR coordinator for approximately four years at another facility. The MDS Coordinator stated that the Level II PASRR evaluation for Resident #8 had been completed on 04/17/2024 and the PASRR Level II determination had been completed on 04/19/2024. She explained that PASRR evaluations were not required to be recertified unless there was a significant change in condition after approximately 30 days. She stated the resident had been admitted to the facility on [DATE]. The MDS Coordinator reported that occupational therapy and physical therapy services were monitored through therapy staff and caseload reviews. She stated the MDS staff were responsible for monitoring required timelines. She stated that if special services were requested, the facility would need to begin processing the NFSS request. She reported the NFSS had been submitted on 07/15/2026 and stated she was unfamiliar with the facility's policy regarding required timelines because she had not yet received facility-specific training. In an interview on 07/23/2026 at 10:12 a.m., the MDS Coordinator opened the LTC Simple system and verified submission dates for Resident #8. She stated the request had been submitted on 04/16/2026 and reviewed on 04/21/2026. She further stated the NFSS was submitted on 04/21/2026 and approved the same day. The MDS Coordinator reported that the facility was responsible for initial and annual submissions, while quarterly reviews and significant changes were submitted by the Mental Health Provider. She stated additional verification with Mental Health Provider was needed because the NFSS reflected a scheduled date of 06/27/2026; however, no PCSP had been submitted through the LTC simple portal. In an interview on 07/21/2026 at 3:21 p.m., the Administrator stated he had been employed at the facility since December 2021 and stated a new PASRR-related meeting had not been rescheduled for Resident #8. The Administrator reported uncertainty regarding the circumstances but believed Mental Health Provider had been unable to attend a scheduled meeting and had requested rescheduling. The Administrator stated no meeting was currently scheduled. He stated the resident had been preparing for discharge to the community and believed this contributed to delays in the process. The Administrator stated there had not been adequate follow-up regarding the meeting and reported the resident remained on rehabilitation services and stated there had been no delay in NFSS services. The Administrator stated the resident had been seen by PT and OT on the day of the interview on 04/16/2026 and had been actively participating in therapy and there had been no delay in care. In an interview on 07/21/2026 at 3:59 p.m., Case Worker V with Mental Health Provider, stated she was not at her desk and could not immediately verify scheduling information. She stated it was the facility's responsibility to submit the NFSS documentation. Case worker V stated a previously scheduled meeting had been canceled because the resident's anticipated discharge location was not ready, resulting in the guardian seeking alternative placement options. She reported the April 2026 meeting had been the last care plan meeting conducted. Case Worker V stated she was responsible for entering the PCSP into the system and reported that no information could be entered if a meeting had not occurred. Upon reviewing emails, she verified that she had initially scheduled a meeting for 06/26/2026 regarding a potential community discharge. She stated the meeting was subsequently canceled due to unresolved community placement arrangements and was later rescheduled for 07/22/2026. Case Worker V reported she entered the information into the system and maintained responsibility for submitting the PCSP. In an interview on 07/21/2026 at 4:09 p.m., DOR J stated he had been employed at the facility for approximately four years and had assumed the DOR position in June 2026. DOR J reported he became involved in the PASRR process the previous week on 07/13/2026 while assisting the MDS staff with submission requirements. He stated the former DOR had managed those responsibilities and he had not previously received instruction regarding required timelines. DOR J stated he had sought assistance from the MDS staff because it was his first time completing the process and he did not initially have system access so was unsure if it was completed or not for June 2026. Regarding Resident #8, he stated some required physician documentation remained pending from his understanding but was unsure. DOR J described the process as requiring therapy evaluations, completion of NFSS documentation, physician and administrator signatures, and submission through the LTC Simple system. He stated he was unfamiliar with required timelines because they had never been communicated to him. DOR J reported that therapy services were not discontinued while authorizations were pending and stated the facility would continue services and seek alternative payment arrangements when necessary. He stated no residents had gone without therapy services due to authorization delays. In an interview on 07/23/2026 at 9:33 a.m., Social Worker E stated she had been employed at the facility for approximately three years. Social Worker E reported attending PASRR meetings and confirmed she attended Resident #8's April 2026 meeting. She stated participants typically included therapy staff, nursing leadership, Mental Health Provider representatives, and the resident's guardian. Social Worker E reported she was not responsible for submitting PASRR-related documentation and had never entered information into the resident's electronic profile. In an interview on 07/23/2026 at 1:22 p.m., former MDS Coordinator B stated responsibility for PASRR-related submissions was shared between the MDS Coordinator and the DOR. MDS Coordinator B explained that MDS staff entered meeting-related information and coordinated submissions, while the DOR was responsible for therapy evaluations, NFSS documentation, obtaining physician signatures, and ensuring submission of required documentation. MDS Coordinator B stated the resident's therapy services had remained active throughout the process. She reported that Mental Health Provider requested an additional meeting and permission to reopen the case due to documentation issues for the submission on 04/16/2026. Former MDS Coordinator B stated she reopened the submission and modified information to allow continued services instead of one-time therapy treatment. She reported the submission remained pending when she left employment with the facility. Former MDS Coordinator B stated she had informed facility leadership and the DOR of the pending status and instructed them to complete the submission process to prevent any interruption in therapy services. She further reported that a meeting had been scheduled for 06/26/2026 at 2:30 p.m. but was canceled on 06/25/2026 and rescheduled due to discharge planning issues involving community placement and case management services. Former MDS Coordinator B stated she no longer had access to the LTC Simple system and could not verify the exact dates of subsequent actions. In an interview on 07/23/2026 at 3:25 p.m., the Administrator stated the June 2026 meeting had not been conducted because it was associated with discharge planning for the resident's anticipated return to the community. The Administrator reported the resident's guardianship status required additional assessments and coordination. The Administrator stated former MDS Coordinator B had informed facility leadership that documentation remained pending from the DOR; however, no specific follow-up assignment had been made after former MDS Coordinator B departure from the facility on 05/29/2026. The Administrator acknowledged the facility failed to adequately follow up on the pending submission and stated no individual had been designated to continue the process. The Administrator reported rehabilitation services continued without interruption and stated therapy services had not been suspended or delayed during the period in question and believes there would not have been a risk since services continued. Record review of the facility's PASRR policy dated 01/20/2026 revealed 2.) The facility will initiate the request for specialized services within 20 business days of the IDT meeting, implemented specialized services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWX and/or DME withing 5 business days of receiving approval from HHSC in the online portal. 3.) The MDS Coordinator or designee, will document the IDT minutes and all specialized services into the online portal on the PCSP within 3 business days after the IDT meeting and annual thereafter. Nursing facility specialized services; Habilitative physical, speech or occupational Therapy. Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-professional revealed: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures).

Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 13 residents (Resident #1) reviewed for quality of care.-The facility failed to immediately notify the physician and/or nurse practitioner on [DATE] at 6:06 p.m. when the laboratory called to report WBC critical results for Resident #1. -The facility failed to immediately notify the physician on [DATE] of Resident #1's worsening condition, continued abdominal pain, elevated blood glucose at 563 and became unresponsive. Resident #1 was transferred to the hospital emergency room and expired on [DATE].-The facility failed to monitor blood glucose on Resident #1 when she as admitted to the facility on [DATE] and was taking multiple oral hypoglycemic medications to treat Diabetes Mellitus.An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:47 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for minimum harm, due to the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of delayed treatment/intervention, decline in health and/or death.Findings included:Record review of Resident #1's Face Sheet dated [DATE] revealed and original admission date of [DATE].Record review of Resident #1's Hospital ED Triage Note dated [DATE] at 4:28 p.m. revealed Chief Complaint: Unresponsive. Diagnoses: Altered Mental Status. Vitals: Pulse Rate 91, blood pressure 87/60. At 4:13 p.m. EMS Blood Glucose Check 561, SPO2 less than 90%, pt arrived being bagged by EMS, chest compressions were performed; 4:50 p.m. family member revoked hospital DNR/DNI over the phone. Emergent intubation at this time. While preparing for intubation pt pulse is no longer palpable, CPR started; 4:43 p.m. Patient intubated due to respiratory failure. At 5:00 p.m.; 4:59 p.m. EKG Post ROSC has hyperkalemia (low levels of potassium in the blood), severe acidosis (A life-threating condition where the body fluids or blood contain too much acid, overwhelming the body's ability to balance its pH), and hypoxia (a dangerous condition where the body's tissues and organs do not receive enough oxygen to function properly); 5:45 p.m. patient noted to have agonal respirations (a sign of cardiac arrest and severe lack of oxygen) and a faint pulse is placed back on ventilator. At 5:28 p.m. patient is becoming bradycardic (having a slow heart rate), no pulse felt at this time, witnessed arrest. Family members wished to discontinue CPR and resuscitation efforts at this time. Time of death 5:45 p.m.Record review of Medical Visit dated [DATE] at 10:29 a.m. written by attending physician revealed Reason for Visit follow up: c/o Abd pain and diarrhea. History: new Abd pain and diarrhea with low appetite ordered amylase and lipase and Pepto started. No other medical concerns reported DOS [DATE]. Summary of Findings: Abdominal pain diarrhea. Plan: Start Bentyl & Zofran PRN.Record review of Medical Visit dated [DATE] written by attending physician revealed: Reason for Visit: New c/o Abd pain and diarrhea. History: reporting new Abd pain and diarrhea with low appetite today. Plan: us Abd, basic labs including amylase and lipase ordered Lomotil.Record review of Resident #1's Radiology Report dated [DATE] revealed: Date of Exam: [DATE]. History: Unspecified abdominal pain. KUB X-Ray Kidney, Ureter, Bladder: Findings: There is no evidence to suggest bowel obstruction. Impression: No bowel obstruction or ileus. Reported to MD & NP [DATE] at 6:45 p.m.Record review of Radiology Report dated [DATE] for Resident #1 revealed, Date of Exam: [DATE]. History: abdominal discomfort. US Abdomen Impression: No acute process. Reported to MD & NP [DATE] at 6:45 p.m.Record review of Resident #1's admission MDS dated [DATE] revealed: Date of admission [DATE] from acute hospital. BIMS Summary Score: 15 Cognitively Intact. Active Diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, Post Procedural Pain, Aftercare following surgical amputation, left below knee amputation High-Risk Drug Classes: Opioid. Discharge Plan already occurring for the resident to return to the community.Record review of Resident #1's Care Plan dated [DATE] revealed: -The resident has Diabetes Mellitus. Approaches: Diabetes Medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate resident/family as to the correct protocol for glucose monitoring. Monitor/document/report PRN any signs/symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor for signs and symptoms of infection to any open areas: redness, pain, heat, swelling, or pus formation.-The resident is on pain medication therapy. Administer Analgesic medications as ordered by the physician. Monitor/Document side effects and effectiveness Q Shift. Monitor/Document/Report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention. Review. For pain medication efficacy. Therapeutic regiment followed, but pain control not adequate, changes required.-The resident has potential for pain r/t Amputation Left leg below knee. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify previous responses to analgesia, including pain relief, side effects, and impact on function. Monitor/Document for side effects of pain medications. Observe for constipation, new onset of increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Monitor/Record/Report to nurse loss of appetite, refusal to eat and weight loss. Monitor/record/report to Nurse resident complaints of pain or request for pain treatment. Notify physician if interventions are unsuccessful or a recurrent complaint is a significant change from residents past experience of pain.Record review of Physician Order Summary dated [DATE] for Resident #1 revealed: Order Date: [DATE] CBC w/Diff, Comprehensive Panel, Lipase, Amylase Order Date: [DATE] Abdominal Ultrasound; Order Date: [DATE] KUB; Order Date: [DATE] Stool Culture. Pain assessment to be completed every shift. Pharmacy: Order Date: [DATE] Dicyclomine HCL 20 mg Give one tablet by mouth two times a day for GI. Order Date: [DATE] Hydrocodone-Acetaminophen 7.5-325 mg Give one tablet by mouth every six hours as needed for pain. Order Date: [DATE] Insulin Glargine Subcutaneous Solution 100 unit/ml Inject 10 units subcutaneously at bedtime for DM. Order Date: [DATE] Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 10 units; 351 - 399 = 12 units. If >400 administer 14 units and notify MD, subcutaneously before meals and at bedtime for DM. Order Date: [DATE] Metformin HCl 500 mg give 1 tablet by mouth two times a day for DM. Order Date: Ondansetron HCl 4 mg give 1 tablet by mouth every 6 hours as needed for nausea. Order Date: [DATE] Pepto Bismol Oral Suspension give 30 ml by mouth every 6 hours as needed for upset stomach and loose stools. Order Date: [DATE] Pioglitazone HCl 30 mg give 1 tablet by mouth one time a day for DM. Order Date: [DATE] Sitagliptin 25 mg give 1 tablet by mouth one time a day for DM.Review of Medication Administration Record dated [DATE] for Resident #1 revealed, Order Date: [DATE] Pioglitazone HCl 30 mg give 1 tablet by mouth one time a day at 9:00 a.m. for DM. Order Date: [DATE] Sitagliptin 25 mg give 1 tablet by mouth one time a day at 9:00 a.m. for DM. Order Date: [DATE] Metformin HCl 500 mg give 1 tablet by mouth two times a day at 9:00 a.m. and 5:00 p.m. for DM.Review of Medication Administration Record dated February 2026 for Resident #1 revealed, Order Date: [DATE] Pioglitazone HCl 30 mg give 1 tablet by mouth one time a day at 9:00 a.m. for DM. Order Date: [DATE] Sitagliptin 25 mg give 1 tablet by mouth one time a day at 9:00 a.m. for DM. Order Date: [DATE] Metformin HCl 500 mg give 1 tablet by mouth two times a day at 9:00 a.m. and 5:00 p.m. for DM. Record review of Resident #1's Laboratory Lab Monitoring Sheet, not dated, filed in the 200 Hall Lab Binder revealed, Resident #1 CBC, CMP, Lipase and Amylase collected [DATE] with lab staff initials. Review of Lab Results Report dated [DATE] for Resident #1 in the resident's clinical record revealed: Collection Date: [DATE] 8:19 a.m. (Eastern Time); Date Reported: [DATE] at 22:45 p.m. (Eastern Time) Clinic Information: Status: Completed Flag: Red Octagon (Report contains critical results in red text). CBC w/Diff - WBC Result: CRITICAL HIGH 30.9 Unit: K/uL Ref. Range: 3.8-10.8 Flag HH Final. There was no documentation on the lab report that results had been reported to MD and/or NP on [DATE].During an interview and record review on [DATE] at 10:30 a.m., of the 24-Hour Report Sheets dated [DATE] through [DATE] with DON and ADON LVN C on [DATE] at 10:30 a.m. revealed the following-[DATE] at 1:07 p.m. LVN C had not documented in the 24-Hour Report sheet new order for CBC w/Diff, Comprehensive Panel, Lipase, and Amylase were ordered [DATE] for Resident #1. -[DATE] LVN C on 6-2 shift had not documented follow up on labs ordered on [DATE] for Resident #1.-[DATE] LVN D on 2-10 shift had not documented follow up on labs ordered on [DATE] for Resident #1.-[DATE] LVN H on the 10-6 had not documented labs were done in the morning for Resident #1.-[DATE] LVN C on the 6-2 shift had not documented labs were completed on [DATE] 8:19 a.m. (Eastern Time) for Resident #1 and were pending results.-[DATE] LVN D on the 2-10 shift had not documented labs drawn in a.m. for Resident #1 and were pending results.Record review of Resident #1's Nurse Note dated [DATE] at 1:35 p.m. written by DON revealed: spoke to resident's family member by weekend supervisor family wants to leave AMA. Family was informed we could provide the care in-house and agreed for resident to be treated in the facility. DON then spoke to Medical Director over the phone with RN weekend supervisor per physician, initiate orders for blood glucose checks prior to meals and bedtime. Resident to be place on a medium dose insulin sliding scale. DON to report morning fasting glucose levels over next 24-48 hours for further review. Record review of Resident #1's Nurse Note dated [DATE] at 2:55 p.m. written by LVN B revealed: Upon doing rounds, pt was crying and stating pain to abdomen area, PRN Hydrocodone administered, pt stated pain decreased but 30 minutes later increased to 8/10. Family arrived, pt showed to be agitated and irritable. BS checked with reading of 473 mg/dl Family stated wanted to have pt leave AMA, notified DON and spoke to pt family and informed that if leaves AMA not able to come back. Family agreed to have pt. stay in facility. Notified attending physician by phone and ordered BS checks ac and Hs, with moderate sliding scale and to give Lispro 10 units STAT. Administered 10 units to back of left arm. Pt tolerated well. Rechecked BS 45 minutes later and BS increased to 515 mg/dl Pt clammy, and stated feels sleepy. Notified attending physician and ordered to D/C moderate sliding scale and start patient on high sliding scale and to give 14 units of Lispro STAT, and to give the Lantus 10 units as well. Administered both to back of right arm. Pt tolerated well. Educated family on purpose of each insulin. Will continue to monitor.Record review of Resident #1's Nurse Note dated [DATE] at 3:35 p.m. written by DON revealed LATE ENTRY: Informed by weekend supervisor labs pending review from Friday have not been reported to physician, DON informed RN to inform MD for further evaluation and review. CN reported lab values to physician and is awaiting orders. Resident's Glucose continues to trend up and is now 567, informed to encourage oral fluids, as per weekend supervisor resident has received 14 units of lispro and 10 units of Lantus, as per MD order. Resident to be encouraged to increase oral fluid intake.Record review of Resident #1's Nurse Note dated [DATE] at 3:45 p.m. written by DON revealed: LATE ENTRY: DON received a call from weekend supervisor, stating the resident's condition is starting to deteriorate aeb fixed pupils and resident is increasingly lethargic with little improvement, as per weekend supervisor attempts made to notify physician and NP, with no answer. DON notified supervisor to send resident out to the ER due to change in condition.Record review of Resident #1 eINTERACT SBAR Summary dated [DATE] at 4:00 p.n. written by LVN B revealed: Situation: Abdominal pain/Altered mental status. Pulse: 194, Respirations 12, Blood Glucose 563, Relevant Medical History: Diabetes. Review and Notify: Primary Care Clinician Notified: Yes [DATE] at 4:00 p.m.Record review of Resident #1's Nurse Note dated [DATE] at 4:03 p.m. written by LVN B revealed: Upon further assessment pt became unresponsive, clammy, HR elevated to 194, family at bedside, notified attending physician by phone, with no answer, sent group message to attending physician and FNP, no response, EMS activated via 911, decision to be sent to hospital based on symptoms above. Family concurred with decision to be sent to hospital. Review of Administration Note dated [DATE] at 5:56 a.m. for Resident #1 written by LVN H revealed PRN Administration was: Effective. Follow-up Pain Scale was: 0Review of Administration Note dated [DATE] at 5:09 a.m. for Resident #1 written by LVN H revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of Nurses Notes dated [DATE] at 4:25 a.m. for Resident #1 written by LVN H revealed Resident observed crying and stated her stomach hurts and that she has not eaten in days. Lips noted to be dry. Pain medication offered and education provided on purpose and benefits; resident refused at this time.Review of Administration Note dated [DATE] at 4:13 a.m. written by LVN H for Resident #1 revealed PRN Administration was: Effective. Follow-up Pain Scale was: 0Review of Administration Note dated [DATE] at 11:11 p.m. written by LVN H for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of Administration Note dated [DATE] at 8:59 a.m. written by LVN C for Resident #1 revealed PRN Administration was: Effective. Follow-up Pain Scale was: 3Review of Administration Note dated [DATE] at 8:10 a.m. written by LVN C for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of Administration Note dated [DATE] at 4:13 a.m. written by LVN C for Resident #1 revealed PRN Administration was: Effective. Follow-up Pain Scale was: 0Review of Administration Note dated [DATE] at 3:13 a.m. written by LVN H for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of Medication Administration Record dated February 2025 for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain was administered on:-[DATE] at 5:09 a.m. for Pain Level 7 by LVN H-[DATE] at 3:13 am for Pain Level 10 by LVN H-[DATE] at 8:10 am for Pain Level 8 by LVN C-[DATE] at 11:11 p.m. for Pain Level 7 by LVN HReview of Witness Statement dated [DATE] written by LVN F revealed, On February 20, 2026, I LVN F answered the phone at nurse's station for a critical lab result for Resident #1 for WBC at 30.9 and immediately reported it to nurse LVN D in hall 200 with lab information in a piece of paper which I gave to her in her hand and emphasized the critical lab result. I also encouraged her to double check on the portal as the lab guy had an accent. She acknowledged my statement and said okay. Who later failed to report results to MD. This event was witnessed by Med Aide J.Review of Witness Statement dated [DATE] written by LVN D revealed, on [DATE] I LVN D was LVN attending 200 Hall. I was attending Resident #1. As of this date, I do not recall receiving any critical lab results on [DATE].Record review of facility's camera video dated [DATE] provided by Administrator revealed LVN F answered the telephone at the nurse's stations, walked down the 200 Hall with a piece of paper in his right hand, and was seen talking to LVN D who was assigned to Resident #1 and handed her a piece of paper after the laboratory called the facility at 6:06 p.m. to report WBC Critical Lab values.Review of Witness Statement dated [DATE] written by DON revealed I was notified by the weekend supervisor on the date of [DATE] of a residents Blood Sugar of 470. I had the weekend supervisor on the phone and called the physician, on the call, the doctor was notified of how resident was presenting and the blood sugar being above 470, orders obtained by the physician to place resident on medium dose insulin sliding scale and to give 10 units of Lantus. Order place in PCC by weekend supervisor. I then received a call about an hour later the RN supervisor spoke to physician and orders received to give additional insulin, informed by supervisor that Blood Glucose is trending up and They (CN/supervisor) were unable to get ahold of physician. That's when I said to send resident via EMS to ER. At 4;36 physician contacted me stating during the week we would need to analyze the case as there were a couple of missed opportunities that we needed to address, was informed by physician labs were not reported to him on the 20th. Informed the physician that I would look into why it wasn't reported. Physician then stated if he would have known, based on the labs he would have sent her out.Review of Witness Statement dated [DATE] written by LVN B revealed, Upon arrival to patient's room, family had brought glucometer from home and checked pt. blood sugar on own with reading of 495 mg/dl. Pt was responsive and stated pain to abdomen area. Nurse notified RN Supervisor of results, then notified attending physician of results. Received phone order, and order was to start pt on Moderate Sliding Scale and give 10 units of Lispro STAT and to give Lantus 10 units every night and to recheck in about an hour and to report results. Nurse gave the units of Lispro and pt tolerated well. Rechecked at 2:30 p.m. and BS elevated to 517 mg/dl. Notified Attending physician by phone and ordered D/C Moderate Sliding Scale and to increase to High Sliding Scale and to give 14 units of Lispro STAT along Lantus 10 units STAT as well. Nurse found labs that had not reported which were in system and had a critical value 30.9 RN supervisor and Physician by sending photo text to physician with no new orders and did not respond. Rechecked BS at 3:35 PM with results of 563 mg/dl. Notified physician by phone and text with no response back. Pt. started to become excessively clammy and became unresponsive. Notified physician and FNP Q by phone and text with no response back through phone or by text. Due to pt symptoms activated EMS via 911, and family was in agreement to call 911. Upon arriving of EMS, Family left with EMS and was taken to hospital.During a telephone interview on [DATE] at 2:07 p.m. with a family member revealed Resident #1 had not been feeling well for approximately two weeks. The Family member said that a week prior to sending the resident to the hospital on [DATE] the resident was complaining of stomach pain, was throwing up, not eating and had diarrhea. The Family member said she had reported this to LVN D during the week and LVN D had said, The resident has dementia and is making it up and she did not go to assess the resident. The Family member said they had visited the resident on Friday [DATE] and took her out to eat and she ate very little. The Family member said they visited the resident on Saturday [DATE] and she was very sleepy and was not eating. The Family member said on Sunday [DATE] when several family members went to visit the resident at the nursing home at approximately 9:00 -9:30 a.m., the resident was still complaining of abdominal pain, nausea and she looked very weak. The Family member said that on Sunday [DATE] when they went to visit the resident, one of the family members took the resident's glucometer from home to the nursing home, because they were concerned about the resident's condition and suspected the nurses were not checking the resident's blood sugar. The Family member said the family took care of the resident at home and checked her blood sugar once a day in the morning. The Family member said they wanted to take the resident home on [DATE] because the resident's blood sugar checks had not been done since she was admitted to the nursing home on [DATE] and the nursing home staff were not providing the resident with the necessary care to treat her symptoms. The Family member said RN A weekend supervisor, had provided her with the AMA form and had signed the AMA form. The Family member said she had started to prepare to take the resident home in her private vehicle when she was informed by the DON that if they took the resident AMA, Medicare/Medicaid would not pay for the resident's care at the nursing home and the family would be responsible for paying for all the care and services provided to the resident at the facility. The Family member said the DON told them that it would take 2-3 days for them to get medical clearance from the physician for them to take the resident home. The Family member said the DON told her that there was no need to send resident to the hospital, because they were able to treat the resident at the nursing home. The Family member said At 1:00 p.m., on that day the resident looked very sick, so I checked her blood sugar, and it was at 451. The Family member told the surveyor she had a picture of the glucometer to show that family member had checked resident's blood glucose two times on [DATE] because the resident's condition appeared to be worsening. The Family member said they could not remember who had informed them on [DATE] that the nurses had not reported to physician the resident's lab results done on [DATE]. The Family member said LVN B had notified the physician [DATE] of the resident's blood sugar level of 451 and had given an order to administer insulin. The Family member said LVN B and RN A had used a vial of insulin that had pharmacy label for another resident when they administered the insulin to Resident #1 on [DATE]. The Family member said the family member had rechecked the resident's blood glucose 45 minutes after the insulin was administered and the blood sugar was at 517. The Family member said they were concerned because the blood sugar was higher after the insulin had been administered. She said LVN B rechecked the resident's blood sugar for the second time and it was higher after the insulin had been administered. The Family member said resident was still conscious and kept saying that she felt like she was dying. The Family member said EMS was finally called by the nurses and when EMS arrived at the facility Resident #1 was already unresponsive. The Family member said Resident #1 had coded twice in the emergency room at the hospital and died due to ketoacidosis (a life threating emergency complication of diabetes, occurring when the body lacks enough insulin to use glucose for energy). During an interview on [DATE] at 2:25 p.m. with the DON revealed Resident #1 was sent to the hospital via EMS on [DATE] due to high blood glucose and was unresponsive and had expired in the hospital on that day. He said RN A Weekend supervisor had reported to him on [DATE] that LVN B had reported to her Resident #1's blood sugar was at 473, MD was notified and gave a new order for Moderate Dose Sliding Scale coverage, and blood glucose checks ac meals and HS. He said the physician had also given a new order to start the resident on Lantus. The DON said the residents' blood continued to increase above 500 on that day and they had made multiple attempts to contact the physician and NP on [DATE] and they did not answer their group text messages and/or telephone calls. The DON said the attending physician who was also the facility's Medical Director was out of town on vacation on [DATE], So, I instructed the nurse to call EMS and send the resident to the hospital. He said LVN B had called EMS right away and the resident was transported to hospital. He said the resident's family was at the facility with the resident on that day, until the resident was sent to the hospital. The DON said the resident had started to complain of abdominal pain, diarrhea on [DATE] and the physician had ordered a KUB, ultrasound of the abdomen and labs. He said KUB and Ultrasound of the abdomen did not show abnormal results. The DON said the family wanted to take her home on [DATE] in their private vehicle and RN A had given the family the AMA form to sign. He said the family was upset because the resident's condition continued to decline and then they decided to leave her at the facility. He said he was not aware labs were drawn on [DATE] until [DATE] when LVN B notified him after the resident had been sent to the hospital that Critical Lab results were showing in the resident's electronic under Lab Results Critical Lab results received on [DATE] were showing as pending review. He said, That meant Critical Lab results had not been reported to the physician and/or NP on [DATE]. He said Critical Lab values must be immediately reported to the physician and/or NP and notification show be documented in the resident's electronic record.During an interview on [DATE] at 2:42 p.m., with the Administrator, DON and ADON C revealed Resident #1 had been sick for several days complaining of abdominal pain, nausea, and vomiting. The DON said the physician had been called on [DATE] and gave orders for a KUB, ultrasound of the abdomen and labs. The surveyor asked DON and ADON if they were aware that Critical Lab values for WBC had not been reported to the physician and/or NP on [DATE]. The DON said, Yes, LVN B called me on Sunday [DATE] to report that he was reviewing the resident's clinical record after Resident #1 had been sent to the hospital on that day and had noted that the Critical Lab results received on [DATE] were pending review in the resident's electronic record. That meant that the lab results had not been reported to the attending physician and/or NP. The DON said he had called their Corporate RN on [DATE] to inform her that Critical Lab values for Resident #1 had not been reported to the attending physician on [DATE]. The DON said the Corporate Nurse had instructed him to audit labs on all residents to ensure they were drawn, and results had been reported to the physician and/or NP. The DON said the corporate nurse also requested in-service training for the licensed staff on notification of changes in condition to physician and responsible party, documentation of AMS, labs and decline in condition. The DON said they had discussed the missed labs with the Administrator, ADONs, Medical Director, who was Resident #1 attending physician FNP, ADONs and MDS Nurses on [DATE]. The DON said they had in-serviced the staff on reporting changes in condition, reporting lab results and documentation in the resident's clinical record on [DATE]. The surveyor requested copies of the lab audits initiated on [DATE] and copies of in-service records. ADON E said, We started the lab audits on [DATE] and have not completed the lab audit as of today [DATE]. The state surveyor requested a copy of the audits started on [DATE]. The ADON E said We will complete the lab audits today [DATE] as soon and give you a copy. ADON C said Licensed Staff had been trained to call 911 and send the resident to the emergency room for critical change of condition if they could not get a whole of the physician and/or NP and then notify the physician and/or NP after the resident had been sent to the hospital. She said she did not know if LVN B had notified the physician and/or the nurse practitioner the resident was sent to the ER via EMS. She said the DON had informed Resident #1's attending that the nurses had called and sent a group text to him and his NP and that neither had answered their group text messages and/or telephone calls, so the DON had instructed LVN B to call 911 and send resident to the ER via ambulance. She said she did not know if LVN B had documented the notification in the resident's electronic record.During a Telephone interview on [DATE] at 11:18 a.m. with LVN B revealed Resident #1 complained of abdominal pain on [DATE] and had administered PRN Hydrocodone. He said blood glucose check had been done by resident's family on [DATE] at 2:55 p.m. and the physician was notified and ordered blood glucose checks ac meals and HS and had started the resident on Moderate Sliding Scale coverage. He said he had administered 10 units of the Lispro stat and could not remember the time the insulin was administered. He said he had rechecked the resident's blood glucose again 45 minutes later after the insulin was administered and it when up to 517 and the resident complained of being sleepy. He said he had notified the physician a second time, and the physician gave orders to discontinue the Moderate Sliding Scale coverage and to start the resident on High Sliding Scale coverage and to administer 14 units of Lispro and to also administer10 units of Lantus. He said he had not documented the actual times the blood glucose checks were done or when the insulin was administered in the resident's electronic record. He said they had been trained to document the date and times when blood glucose checks were done and administered insulin according to physician's orders. He said they did not have Lantus in the Insulin Ekit and RN A weekend supervisor had borrowed a vial from another resident. He said that at approximately 4:03 p.m., the resident became clammy, unresponsive Heart Rate was 194, family was in the room with the resident. He said he had called the physician and NP, and they had not answered his call. He said he sent the physician/NP a group text message and had not responded so he called the DON to report the situation and he instructed him to call 911 and send the resident to the Emergency Room. The state surveyor requested a screen shot of the text message.During an interview on [DATE] at 11:18 a.m. with RN A Weekend Supervisor revealed LVN C worked on [DATE] during the morning shift. She said, LVNtold me the family member had checked the resident's blood glucose, and I told him to notify the physician and DON to see what they wanted to do. The family member told LVN B they wanted to take the resident to the hospital. She said, I notified the DON and LVN B that I had notified the physician. That is when the doctor ordered blood glucose checks ac and HS and new orders for insulin. She said the DON talked to the family and he informed the physician that the family wanted to take the resident to the hospital. The DON told her the physician wanted to start the resident on insulin and to keep her at the facility. She said LVN B had rechecked the blood glucose after the first dose of insulin was administered and notified the physician that the blood glucose was higher and physician gave a new order for insulin.During a telephone interview on [DATE] at 11:34 a.m. with LVN B revealed he could not remember which family member had told him that they wanted to take the resident to the hospital. He said he had checked the resident's blood glucose after the resident's family member informed him that they had checked the resident's blood glucose. They said the first blood glucose was 473 and he had notified the physician and got new orders for blood glucose checks and HS and to start the resident on Moderate Sliding Scale coverage. He said he had rechecked the resident's blood glucose at 2:20 p.m. and blood glucose had i

Based on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 13 residents (Residents #1 and #2) reviewed for clinical records with transfer assistance.-The facility failed to ensure LVN C documented in Resident #1's clinical record on 2/18/26 that the attending physician gave new orders for labs, Abd US and KUB when resident had a change in condition.-The facility failed to ensure RN A Weekend supervisor documented in Resident # 1's clinical record on 2/18/26 when Abd US and KUB results were sent to the attending physician. - The facility failed to ensure LVN C and LVN D documented in Resident #1's clinical record on 2/19/26 of the follow-up on lab orders that were ordered 2/18/26.- The facility failed to ensure LVN H documented in Resident #1's clinical record on 2/20/26 of the follow-up on lab orders that were ordered 2/18/26.- The facility failed to ensure LVN C documented in Resident #1's clinical record on 2/20/26 that labs were drawn and pending results.- The facility failed to ensure LVN B documented in Resident #1's clinical record on 2/22/26 he had received a telephone call from the lab to report critical lab results from the for Resident #1 on 2/20/26 had not been this in the resident's clinical record.-The facility failed to ensure LVN B documented in a telephone order physician had given a STAT order to administer Lantus 10 units Stat on 2/22/26 when Resident #1's blood glucose was at 517.-The facility failed to ensure LVN B documented in Resident #1's Medication Administration Record on 2/22/26 STAT doses of Lantus were administered according to physician's orders.-The facility failed to ensure DON and Dietary Manager V documented concerns voiced by Resident #1's family member regarding concerns related of not following the resident's prescribed diet in the resident's electronic record.These failures place residents at risk of having incomplete and accurate clinical records.Findings included:Resident #1Closed record review of the Face Sheet dated 02/25/26 for Resident #1 revealed an original admission date 1/14/26.Review of the admission MDS for Resident #1 dated 1/18/26 revealed: Date of admission [DATE] from acute hospital. BIMS Summary Score: 15 Cognitively Intact. Active Diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, Post Procedural Pain, Aftercare following surgical amputation, left below knee amputation, PRN pain medication, Recent surgery requiring active SNF Care, High-Risk Drug Classes: Opioid. Speech/Occupational/Physical Therapy. Discharge Plan already occurring for the resident to return to the community.Review of Medical Visit dated 1/22/26 written by attending physician for Resident #1 revealed Reason for Visit: admission Record Review. History of Present Illness: The patient has a history of DM, HTN, PVD, CAD and recent left foot osteomyelitis and gangrene, status post left below-knee amputation. She agreed to transfer to inpatient rehabilitation/skilled nursing facility for continued recovery, wound care, and functional rehabilitation.Review of a Medical Visit dated 2/18/26 written by attending physician for Resident #1 revealed Reason for Visit: New c/o pain and diarrhea. Patient reporting new Abd pain and diarrhea with low appetite today, ordered us Abd, basic labs and amylase and lipase. Ordered Lomotil. No other medical concerns.Review of Physician Order Summary dated 2/25/26 for Resident #1 revealed: Order Date: 02/22/26 Insulin Glargine Subcutaneous Solution 100 unit/ml Inject 10 units subcutaneously at bedtime for DM. The Physician Order Summary did not list the Stat Order for Lantus 10 units ordered by the physician on 2/22/26.Review of the Medication Administration Record dated February 2026 for Resident #1 revealed LVN B had not documented he had administered Lantus 10 units stat as ordered by the physician on 2/22/26. Review of a Nurse Note dated 2/22/26 for Resident #1 at 2:55 p.m. written by LVN B revealed Upon doing rounds, pt was crying and stating pain to abdomen area, PRN Hydrocodone administered, pt stated pain decreased but 30 minutes later increased to 8/10. Family arrived, pt showed to be agitated and irritable. BS checked with reading of 473 mg/dl Family stated wanted to have pt leave AMA, notified DON and spoke to pt family and informed that if leaves AMA not able to come back. Family agreed to have pt. stay in facility. Notified attending physician by phone and ordered BS checks ac and Hs, with moderate sliding scale and to give Lispro 10 units STAT. Administered 10 units to back of left arm. Pt tolerated well. Rechecked BS 45 minutes later and BS increased to 515 mg/dl Pt clammy and stated feels sleepy. Notified attending physician and ordered to D/C moderate sliding scale and start patient on high sliding scale and to give 14 units of Lispro STAT, and to give the Lantus 10 units as well. Administered both to back of right arm. Pt tolerated well. Educated family on purpose of each insulin. Will continue to monitor.Review of the Physician Order Summary dated 2/25/26 for Resident #1 revealed: Order Date: 02/18/26 CBC w/Diff, Comprehensive Panel, Lipase, Amylase Blood. Order Date: 02/22/26 Insulin Glargine Subcutaneous Solution 100 unit/ml Inject 10 units subcutaneously at bedtime for DM.During an interview and Record 2/24/26 at 10:30 a.m., with DON and ADON C of the 24-Hour Report Sheet dated 2/18/26 - 2/22/26 and Residents electronic Nurses Notes revealed:-LVN C had not documented on 2/18/26 in the Resident #1's clinical record the physician had given new orders for labs and were pending to be drawn.- RN A Weekend supervisor had not documented in 24-Hour Report Sheet and/or Resident # 1's clinical record on 2/18/26 when Abd US and KUB results were sent to the attending physician.- LVN C on the 6-2 shift and LVN D on the 2-10 shift had not documented in Resident #1's clinical record on 2/19/26 the nurses had followed-up on lab orders that were ordered 2/18/26 and were still pending to be drawn.- LVN H had not documented in Resident #1's clinical record on 2/20/26 follow-up on lab orders ordered 2/18/26 and were still pending to be drawn.- LVN C on the morning shift had not documented in Resident #1's clinical record labs were drawn 2/20/26 at 8:19 a.m. and results were pending.- LVN D on the evening shift had not documented in Resident #1's clinical record if LVN C had reported to her at the change of shift lab were drawn on 2/20/26 during the morning shift and results were pending.- LVN B had not documented in Resident #1's clinical record on 2/22/26 when he had notified the physician of critical lab results that were received on 2/20/26 had not been reported to physician.-Resident #2Review of the Face Sheet dated 3/06/26 for Resident #2 revealed original admission date was 3/31/25 and re-admission date was 08/12/2025. Resident #2's diagnoses included: Dementia, Diabetes Mellitus, Hypertension, End Stage Renal Disease, and Adult Failure to Thrive.Review of the Quarterly MDS dated [DATE] for Resident #2 documented Date of Entry 08/13/2025. Clear speech sometimes makes self-understood, sometimes understands others; BIMS Score 2 (severely cognitively impaired); dependent with personal hygiene. Active Diagnoses: End Stage Renal Disease, Diabetes Mellitus, Non-Alzheimer's Dementia, Malnutrition. No weight loss. Therapeutic Diet. High-Risk Drug Classes: HypoglycemicReview of the Care Plan revealed: Review of Care Plan initiated 4/01/25 for Resident #2 documented ADL self-care performance deficit Approaches: The resident requires assistance with personal hygiene.- Review of the Care Plan initiated 4/02/25 for Resident #2 revealed Impaired Cognitive Function: Approaches: Ask yes/no questions. Communicate with resident/family regarding Residents, capabilities and needs.-Review of the Care Plan initiated 4/01/25 for Resident #2 documented: Resident has nutritional problems or potential nutritional problem r/t adult failure to thrive and protein calorie malnutrition. Approaches: Provide, serve diet as ordered. Monitor intake and record every meal. RD To evaluate and make diet change recommendations as needed.-Review of the Care Plan initiated 4/01/25 for Resident #2 documented Resident Receiving a therapeutic diet. Reduce concentrated sweets and Regular texture. Approaches: Administer snacks/Supplements as ordered/Desired within the restrictions. RD To review. Nutritional and hydration status, quarterly and as needed.-Resident #2 had renal failure r/t end stage renal disease. Approaches: Assist with ADLS as needed.Review of the Care Plan Conference dated 3/10/26 for Resident #2 revealed Meeting Time: 03/10/26 at 1:00 p.m. Attendance at Meeting: RN, Dietary, Social Worker, Family, and MDS Nurse. Quarterly Care Plan meeting. Nutrition: Renal regular diet thin liquids. Weight 106.7 labs; Eating 75-100%, mighty shake once a day. Summary of Care Plan: Resident's care plan reviewed with family member. Family requesting cookie protein supplement that is provided at dialysis to be given at facility. Agreed to have resident receive both extra protein and health shake for meals. Facility to continue looking for orange blanket. Family member requesting monthly care plan meetings moving forward. All questions answered. Family attended via phone and agreed with plan of care. Dietitian participated in care plan meeting.Review of the Diet Slip for Resident #2 revealed RCS/Regular House Shake, Regular Texture. Fortified meal plan.Review of the Menu dated 2025 Diet: Regular Thursday Loaded Baked Potato, Toss Salad, Dressing of Choice, Saltine Crackers, Frosted Cake, Milk and Beverages.Review of the Physician Order dated 3/06/26 for Resident #2 revealed: Liberal Renal Diet Regular Texture, Health Shake once a day, HS snack, Needs potassium rich foods for breakfast. Dialysis Monday-Wednesday-Friday.Review of the Nurses Note dated 1/30/26 at 5:46 p.m. written by LVN M for Resident #2 revealed family member had called regarding how CNAs are preparing resident hair before she goes to appointments or dialysis, she verbalized I don't want them to be doing ponytails and putting flower clips, she's not a child and it looks like they are making fun of her, she's old and maybe she's not going to complain but at the other facility she would not agree to have ponytails and flower clips this nurse explained she will pass on report to CNAs and nurses.Review of Nurses Note dated 1/30/26 at 6:06 p.m. written by LVN M for Resident #2 revealed Dietary Manager was notified family had concerns regarding food that was served to the Resident #1 for the dinner meal. During an interview on 2/24/26 at 10:47 a.m. with LVN R revealed that she was not aware of any concerns related to how staff combed the Resident #2's hair or any concerns about the food. She said the resident was alert, oriented to person, place, situation, recognized familiar faces and recognized family members. She said the resident went to dialysis three times a week from 7:30 a.m. - 2:00 p.m. and they packed her a lunch for the resident to eat while at the dialysis center. She said, The never eats her lunch at the dialysis center. She said she checked the lunch box in the morning and always brings her lunch back untouched. She said the resident wants to eat when she returns to the facility from dialysis.During an interview on 2/24/26 at 10:50 a.m. with CNA U said the facility packed a lunch for those residents that went to dialysis in a blue lunch bag. She said Resident #2 never ate her lunch at the dialysis center and the nurses were aware that the resident did not eat while at dialysis because she got nauseated. She said LVN R Charge Nurse on the 400 Hall during the day shift had informed them approximately two weeks ago that the resident's family member did not want them to comb the resident's hair with ponytails, and not want us to put on ribbons, colored rubber bands and barrettes. She said the resident liked the way that they combed her hair because she got a lot of compliments from the staff at the dialysis center. She said the resident was very sad because her family member no longer allowed the staff to comb her hair like they used to.During an observation and interview on 2/24/26 at 10:52 a.m. with Resident #2 revealed, the resident was sitting in a wheelchair by the side of her bed, clean and well groomed. The resident's hair was combed and did not have any ponytails, colored rubber bands, ribbons, or hair barrettes. She said her family member worked and would occasionally come to visit her on the weekends. She said the family member did not like the way the girls combed her hair with ponytails, colored rubber bands, ribbons and little girl barrettes. She said she liked the way the girls combed her hair, but family member did not like it, so now they only brush her hair. The resident appeared to be sad and said she preferred to have her hair done the way they used to before the family member asked that the girls not to put anything on her hair and/or with ponytails. She said, I will do whatever my family member wants. The resident said the facility packed her lunch when she went to the dialysis center on Monday-Wednesday-Friday and did not eat at the dialysis center because she got nauseated while getting her dialysis treatment. She said she would not be able to eat lying down because she was afraid of choking. She said that upon return to the facility, the staff facility checked the blue bag to check if she ate and she reminded the staff that she did not like to eat while getting her dialysis treatment. She said she preferred not to eat upon return from dialysis and would wait for her dinner meal to be served.During a telephone interview on 2/20/26 at 10:56 a.m. with the family member for Resident #2 revealed a visit was made during dinner time on January 29, 2026, and noted the resident had been served a very small baked potato, small salad and ice cream. She said the resident was confused at times and could voice her needs. The family member said she had asked LVN M about the dinner that had been served to Resident #2 on that day. LVN M said they had already notified the Dietary manager that the menu was not followed on that day. The family member said she had reported her concerns about the food that was served to the Resident #2 for dinner on 1/29/26 to the Dietary manager and the DON on that day, and she said that she was not aware of what had been served to Resident #2 for dinner on that day. The family member said she had voiced concern to the evening nurse who was assigned to Resident #2 about how the staff combed the resident's hair like a little girl with bright color ties in her hair and Butterfly clips when she went to appointments and/or dialysis and she felt The staff was not treating the resident with dignity and respect. The family member said the facility sent the Resident #2 with a sack lunch when the resident went to dialysis on Monday-Wednesday and Friday, and the resident did not eat her sack lunch at the dialysis center. She said the sack lunch consisted of a sandwich and yogurt. She said the sack lunch was packed in a plastic bag and was placed in the blue bag that the resident took with her to the dialysis center. She said that when Resident #2 returned to the facility from the dialysis center, no one checked the reusable blue bag to see Resident #1 she ate her sack while she was at the dialysis center. She said she had also reported to the nursing staff that the facility staff had lost a blanket that the Resident #2 had had for almost a year. She said the facility staff just gave Resident #2 another blanket. The family member said she had talked to the weekend staff about the missing blanket and all they did was asked if the blanket was labeled with the resident's name. The family member said the staff had not reported this to Administration or the Social Worker. The family member said the MDS nurse were not inviting her to attend Care Plan meeting again when they had changed staff. The family member said the care plan conference scheduled for January 2026 had been cancelled because the Social Worker had an emergency and they did not reschedule the care plan meeting.During an interview on 2/24/26 at 10:59 a.m. with the DON revealed he was not informed by the staff that the Resident #2's family memberad voiced concern about the way that the staff combed the resident's hair. He said he was not familiar with the facility's staff on Grievances/Concerns. He said he started working on the weekends and had taken over the DON position a month ago. He said the resident's family had reported to him a concern about the food that was served to the resident during the dinner meal and did not recall the date. He said the family was concerned that the resident was not getting enough protein. He said the resident was already eating her dinner meal on that day. He said, I told family to let us know if the resident did not like the food that was served for dinner so the kitchen could give the resident an alternative. He said that the family member for Resident #2 had attended a care plan conference and they had discussed the concerns related to residents' diet, about the food that was served to the residents for the dinner meal. He said, I don't keep notes. I apologize. The DON said he had not documented the family members in the resident's electronic record.During an interview on 2/24/26 at 11:06 a.m. with Dietary Manager V revealed Resident #2's family member spoke to LVN M on the evening shift assigned to Resident #2 and said, I do not remember the date, about the food that was served for dinner. She said she needed to look at the menus to see what day it was that the concern was reported to the facility staff. She said, I was not at the facility when the family came to the facility and voiced the concerns. She said, I called the family two times and left a message, and she never returned the calls. I can go and get my cell phone to give you the dates. She said that on the date in question, they had served Resident #2 a loaded baked potato, with sour cream and cheese, green salad with ranch dressing and dessert. She said she needed to check what type of diet was ordered for the resident. She said she had not documented in the resident's clinical record when she had called the family member to follow up on her concerns related to the food that was served to the resident.During a second interview on 2/24/26 at 11:21 a.m. with Dietary Manager V revealed she had not completed a Grievance/Concern Form to give to the facility's Social Worker when the family member for Resident #2 had voiced a concern about the food that was served to the resident. She said she could not recall when the training on Grievance/Concern policy & procedure was completed. She said she had not documented in the Resident #2's electronic record that she had followed up on the concerns related to the type of foods that were served to the Resident #2 for the dinner meal.Review of facility's policy and procedure on Charting and Documentation Revised in July 2017 revealed: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations; Changes in the resident's condition.

Based on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of (Resident #1) 13 residents reviewed for changes in condition.The facility failed to notify Resident #1's physician Resident #1 was complaining of abdominal pain on 2/20/26 and 2/22/26.This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included:Closed record review of the Face Sheet dated 02/25/26 for Resident #1 revealed an original admission date of 1/14/26.Review of a Medical Visit dated 1/22/26 for Resident #1 revealed, History of Present Illness: The patient has a history of DM, HTN, PVD, CAD and recent left foot osteomyelitis and gangrene, status post left below-knee amputation.Review of the admission MDS for Resident #1 dated 1/18/26 revealed: Date of admission [DATE] from acute hospital. BIMS Summary Score: 15 Cognitively Intact. Active Diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, Post Procedural Pain, Aftercare following surgical amputation, left below knee amputation High-Risk Drug Classes: Opioid. Discharge Plan already occurring for the resident to return to the community.Review of the Care Plan for Resident #1 dated 1/15/26 revealed:-The resident has Diabetes Mellitus. Approaches: Diabetes Medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate resident/family as to the correct protocol for glucose monitoring. Monitor/document/report PRN any signs/symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor for signs and symptoms of infection to any open areas: redness, pain, heat, swelling, or pus formation.-The resident is on pain medication therapy. Administer Analgesic medications as ordered by the physician. Monitor/Document side effects and effectiveness Q Shift. Monitor/Document/Report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention. Review. For pain medication efficacy. Therapeutic regiment followed, but pain control not adequate, changes required.-The resident has potential for pain r/t Amputation Left leg below knee. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify previous responses to analgesia, including pain relief, side effects, and impact on function. Monitor/Document for side effects of pain medications. Observe for constipation, new onset of increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Monitor/Record/Report to nurse loss of appetite, refusal to eat and weight loss. Monitor/record/report to Nurse resident complaints of pain or request for pain treatment. Notify physician if interventions are unsuccessful or a recurrent complaint is a significant change from residents past experience of pain.Review of the New Prescription Summary dated 1/15/26 for Resident #1 written by attending physician revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for severe Pain. Diagnosis Z89512 - (ICD-10) Phantom Pain.Review of a Medical Visit dated 2/18/26 written by attending physician revealed Reason for Visit: New c/o Abd pain and diarrhea. History: reporting new Abd pain and diarrhea with low appetite today. Plan: us Abd, basic labs including amylase and lipase ordered Lomotil.Review of the Radiology Report dated 02/18/26 for Resident #1 revealed, Date of Exam: 02/18/26. History: Unspecified abdominal pain. KUB X-Ray Kidney, Ureter, Bladder: Findings: There is no evidence to suggest bowel obstruction. Impression: No bowel obstruction or ileus. Reported to MD & NP 2/18/25 at 6:45 p.m.Review of the Radiology Report dated 02/18/26 for Resident #1 revealed, Date of Exam: 02/18/26. History: abdominal discomfort. US Abdomen Impression: No acute process. Reported to MD & NP 2/18/25 at 6:45 p.m.Review of the 24-Hour report Sheet dated 2/20/26 revealed:-2:03 a.m. written by LVN H documented Resident #1 Hydro 2/20 at 3 a.m. The DON said LVN H had not notified the attending physician and/or NP resident continued to complain of abdominal pain.Review of the 24-Hour report Sheet dated 2/22/26 revealed:-4:05 a.m. written by LVN H documented Tylenol, not working resident, is still in pain, refusing to eat. The DON said LVN H had not notified the attending physician and/or NP resident continued to complain of abdominal pain.Review of the Administration Noteated 2/22/26 at 5:56 a.m. for Resident #1 written by LVN H revealed PRN Administration was: Effective. Follow-up Pain Scale was: 0Review of the Administration Note dated 2/22/26 at 5:09 a.m. for Resident #1 written by LVN H revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of the Nurses Notesated 2/22/26 at 4:25 a.m. for Resident #1 written by LVN H revealed Resident observed crying and stated her stomach hurts and that she has not eaten in days. Lips noted to be dry. Pain medication offered and education provided on purpose and benefits; resident refused at this time.Review of the Administration Note dated 2/22/26 at 11:11 p.m. written by LVN H for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of the Administration Note dated 2/20/26 at 8:59 a.m. written by LVN C for Resident #1 revealed PRN Administration was: Effective. Follow-up Pain Scale was: 3Review of the Administration Note dated 2/20/26 at 8:10 a.m. written by LVN C for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of the Administration Note dated 2/20/26 at 3:13 a.m. written by LVN H for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain.Review of the Medication Administration Record dated February 2026 for Resident #1 revealed Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for Pain was administered on:-2/22/26 at 5:09 a.m. for Pain Level 7 by LVN H-2/20/26 at 3:13 am for Pain Level 10 by LVN H-2/20/26 at 8:10 am for Pain Level 8 by LVN C-2/20/26 at 11:11 p.m. for Pain Level 7 by LVN HReview of the 24-Hour report Sheet dated 2/21/26 revealed: 6:28 p.m. written by LVN B documented Resident #1 stable. Tylenol, not working resident, is still in pain. DON said LVN B had not notified the attending physician and/or NP that resident continued to complain of abdominal pain.During an interview and Record on 2/24/26 at 10:30 a.m., 24-Hour Report Sheet with DON and ADON LVN C revealed:Review of the Physician Order Summary dated 2/25/26 for Resident #1 revealed: Order Date: 02/18/26 CBC w/Diff, Comprehensive Panel, Lipase, Amylase. Order Date: 02/18/26 Abdominal Ultrasound; Order Date: 02/18/26 KUB; Order Date: 02/20/26 Stool Culture. Pain assessment to be completed every shift. Pharmacy: Order Date: 02/20/26 Dicyclomine HCL 20 mg Give one tablet by mouth two times a day for GI. Order Date: 01/15/26 Hydrocodone-Acetaminophen 7.5-325 mg Give one tablet by mouth every six hours as needed for pain. Ondansetron HCl 4 mg give 1 tablet by mouth every 6 hours as needed for nausea. Order Date: 02/19/26 Pepto Bismol Oral Suspension give 30 ml by mouth every 6 hours as needed for upset stomach and loose stools.Interview and record review on 3/04/26 at 12:44 p.m. with the attending Medical Director/attending physician for Resident #1 revealed he had written on the prescription Hydrocodone 7.5 mg-acetaminophen 325 mg take 1 tablet by oral route every 6 hours as needed for pain PRN severe pain for Diagnosis of Phantom pain. He said, The nurses should have called me to report the resident was having abdominal pain and I would have given them a new order. I would not have approved for the nurses to administer the Hydrocodone for abdominal pain because the resident was already complaining of abdominal pain and the Hydrocodone would have made it worse because it causes constipation. The nurses should have only administered the Hydrocodone for the phantom pain related to recent amputation of lower extremity. The problem is that whoever entered the medication order to the resident's electronic record, did not specify the Hydrocodone was ordered for Phantom Pain related to recent amputation of lower extremity.Review of facility policy and procedure on Change in a Resident's Condition or Status Revised April 2025 revealed: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview, and record review the facility failed to ensure another physician supervises the medical care of residents when their attending physician is unavailable for 1 (Resident #1) of 13 residents reviewed for physician services.The facility failed to ensure another physician was available to supervise the medical care for Resident #1's when her condition continued to worsen, continued abdominal pain, elevated blood glucose at 563 and became unresponsive. Resident #1 was transferred to the hospital emergency room and expired on [DATE].This failure could place residents at risk of delayed treatment/intervention, decline in health and/or death.Findings included:Closed record review of the Face Sheet dated [DATE] for Resident #1 revealed, original admission date [DATE].Review of admission MDS for Resident #1 dated [DATE] revealed: Date of admission [DATE] from acute hospital. BIMS Summary Score: 15 Cognitively Intact. Active Diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, Post Procedural Pain, Aftercare following surgical amputation, left below knee amputation High-Risk Drug Classes: Opioid. Discharge Plan already occurring for the resident to return to the community.Review of Care Plan for Resident #1 dated [DATE] revealed:-The resident has Diabetes Mellitus. Approaches: Diabetes Medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate resident/family as to the correct protocol for glucose monitoring. Monitor/document/report PRN any signs/symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor for signs and symptoms of infection to any open areas: redness, pain, heat, swelling, or pus formation.-Resident has infection diagnosis of Gangrene. Pain medication therapy. Monitor/Document/Report to MD signs and symptoms of delirium, changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, agitation. altered sleep cycle.-The resident is on pain medication therapy. Administer Analgesic medications as ordered by the physician. Monitor/Document side effects and effectiveness Q Shift. Monitor/Document/Report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention. Review. For pain medication efficacy. Therapeutic regiment followed, but pain control not adequate, changes required.-The resident has potential for pain r/t Amputation Left leg below knee. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify previous responses to analgesia, including pain relief, side effects, and impact on function. Monitor/Document for side effects of pain medications. Observe for constipation, new onset of increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Monitor/Record/Report to nurse loss of appetite, refusal to eat and weight loss. Monitor/record/report to Nurse resident complaints of pain or request for pain treatment. Notify physician if interventions are unsuccessful or a recurrent complaint is a significant change from residents past experience of pain.Review of Medical Visit dated [DATE] written by attending physician revealed Reason for Visit: New c/o Abd pain and diarrhea. History: reporting new Abd pain and diarrhea with low appetite today. Plan: us Abd, basic labs including amylase and lipase ordered Lomotil.Review of Radiology Report dated [DATE] for Resident #1 revealed, Date of Exam: [DATE]. History: Unspecified abdominal pain. KUB X-Ray Kidney, Ureter, Bladder: Findings: There is no evidence to suggest bowel obstruction. Impression: No bowel obstruction or ileus. Reported to MD & NP [DATE] at 6:45 p.m.Review of Radiology Report dated [DATE] for Resident #1 revealed, Date of Exam: [DATE]. History: abdominal discomfort. US Abdomen Impression: No acute process. Reported to MD & NP [DATE] at 6:45 p.m.Review of Medical Visit dated [DATE] at 10:29 a.m. written by attending physician revealed Reason for Visit follow up: c/o Abd pain and diarrhea. History: new Abd pain and diarrhea with low appetite ordered amylase and lipase and Pepto started. No other medical concerns reported DOS [DATE]. Summary of Findings: Abdominal pain diarrhea. Plan: Start Bentyl & Zofran PRN.Review of the Hospital ED Triage Note dated [DATE] at 4:28 p.m. for Resident #1 revealed Chief Complaint: Unresponsive. Diagnoses: Altered Mental Status. Vitals: Pulse Rate 91, blood pressure 87/60. At 4:13 p.m. EMS Blood Glucose Check 561, SPO2 less than 90%, pt arrived being bagged by EMS, chest compressions were performed; 4:50 p.m. family member revoked hospital DNR/DNI over the phone. Emergent intubation at this time. While preparing for intubation pt pulse is no longer palpable, CPR started; 4:43 p.m. Patient intubated due to respiratory failure. At 5:00 p.m.; 4:59 p.m. EKG Post ROSC has hyperkalemia, severe acidosis, and hypoxia; 5:45 p.m. patient noted to have agonal respirations, and a faint pulse is placed back on ventilator. At 5:28 p.m. patient is becoming bradycardic, no pulse felt at this time, witnessed arrest. Family members wished to discontinue CPR and resuscitation efforts at this time. Time of death 5:45 p.m.Review of Nurse Note dated [DATE] for Resident #1 at 4:03 p.m. written by LVN B revealed Upon further assessment pt became unresponsive, clammy, HR elevated to 194, family at bedside, notified attending physician by phone, with no answer, sent group message to attending physician and FNP, no response, EMS activated via 911, decision to be sent to hospital based on symptoms above. Family concurred with decision to be sent to hospital.Review of eINTERACT SBAR Summary dated [DATE] for Resident #1 at 4:00 p.m. written by LVN B revealed Situation: Abdominal pain/Altered mental status. Pulse: 194, Respirations 12, Blood Glucose 563, Relevant Medical History: Diabetes. Primary Care Clinician Notified: Yes [DATE] at 4:00 p.m.Review of Nurse Note dated [DATE] for Resident #1 at 3:45 p.m. written by DON revealed LATE ENTRY: DON received a call from weekend supervisor, stating the resident's condition is starting to deteriorate aeb fixed pupils and resident is increasingly lethargic with little improvement, as per weekend supervisor attempts made to notify physician and NP, with no answer. DON notified supervisor to send resident out to the ER due to change in condition.Review of Physician Order Summary dated [DATE] Resident #1 revealed: Order Date: [DATE] CBC w/Diff, Comprehensive Panel, Lipase, Amylase Order Date: [DATE] Abdominal Ultrasound; Order Date: [DATE] KUB; Order Date: [DATE] Stool Culture. Pain assessment to be completed every shift. Pharmacy: Order Date: [DATE] Dicyclomine HCL 20 mg Give one tablet by mouth two times a day for GI. Order Date: [DATE] Hydrocodone-Acetaminophen 7.5-325 mg Give one tablet by mouth every six hours as needed for pain. Order Date: [DATE] Insulin Glargine Subcutaneous Solution 100 unit/ml Inject 10 units subcutaneously at bedtime for DM. Order Date: [DATE] Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 10 units; 351 - 399 = 12 units. If >400 administer 14 units and notify MD, subcutaneously before meals and at bedtime for DM. Order Date: [DATE] Metformin HCl 500 mg give 1 tablet by mouth two times a day for DM. Order Date: Ondansetron HCl 4 mg give 1 tablet by mouth every 6 hours as needed for nausea. Order Date: [DATE] Pepto Bismol Oral Suspension give 30 ml by mouth every 6 hours as needed for upset stomach and loose stools. Order Date: [DATE] Pioglitazone HCl 30 mg give 1 tablet by mouth one time a day for DM. Order Date: [DATE] Sitagliptin 25 mg give 1 tablet by mouth one time a day for DM.Review of Witness Statement dated [DATE] written by DON revealed I was notified by the weekend supervisor on the date of [DATE] of a residents Blood Sugar of 470. I had the weekend supervisor on the phone and called the physician, on the call, the doctor was notified of how resident was presenting and the blood sugar being above 470, orders obtained by the physician to place resident on medium dose insulin sliding scale and to give 10 units of Lantus. Order place in PCC by weekend supervisor. I then received a call about an hour later the RN supervisor spoke to physician and orders received to give additional insulin, informed by supervisor that Blood Glucose is trending up and They (CN/supervisor) were unable to get ahold of physician. That's when I said to send resident via EMS to ER. At 4;36 physician contacted me stating during the week we would need to analyze the case as there were a couple of missed opportunities that we needed to address, was informed by physician labs were not reported to him on the 20th. Informed the physician that I would look into why it wasn't reported. Physician then stated if he would have known, based on the labs he would have sent her out.Review of Witness Statement dated [DATE] written by LVN B revealed, Upon arrival to patient's room, family had brought glucometer from home and checked pt. blood sugar on own with reading of 495 mg/dl. Pt was responsive and stated pain to abdomen area. Nurse notified RN Supervisor of results, then notified attending physician of results. Received phone order, and order was to start pt on Moderate Sliding Scale and give 10 units of Lispro STAT and to give Lantus 10 units every night and to recheck in about an hour and to report results. Nurse gave the units of Lispro and pt tolerated well. Rechecked at 2:30 p.m. and BS elevated to 517 mg/dl. Notified Attending physician by phone and ordered D/C Moderate Sliding Scale and to increase to High Sliding Scale and to give 14 units of Lispro STAT along Lantus 10 units STAT as well. Nurse found labs that had not reported which were in system and had a critical value 30.9 RN supervisor and Physician by sending photo text to physician with no new orders and did not respond. Rechecked BS at 3:35 PM with results of 563 mg/dl. Notified physician by phone and text with no response back. Pt. started to become excessively clammy and became unresponsive. Notified physician and FNP Q by phone and text with no response back through phone or by text. Due to pt symptoms activated EMS via 911, and family was in agreement to call 911. Upon arriving of EMS, Family left with EMS and was taken to hospital. During an interview on [DATE] at 2:25 p.m. with DON revealed Resident #1 was sent to the hospital via EMS on [DATE] due to high blood glucose and was unresponsive and had expired in the hospital on that day. He said RN A Weekend supervisor had reported to him on [DATE] that LVN B had reported to her Resident #1's blood sugar was at 473, MD was notified and gave a new order for Moderate Dose Sliding Scale coverage, and blood glucose checks ac meals and HS. He said the physician had also given a new order to start the resident on Lantus. The DON said the residents' blood continued to increase above 500 on that day and they had made multiple attempts to contact the physician and NP on [DATE] and they did not answer their group text messages and/or telephone calls. The DON said the attending physician who was also the facility's Medical Director was out of town on vacation on [DATE] and the physician's NP assigned to the facility did not answer the telephone call and/or text messages So, I instructed the nurse to call EMS and send the resident to the hospital. He said LVN B had called EMS right away and the resident was transported to hospital.During an interview on [DATE] at 2:42 p.m., with Administrator, DON and ADON C revealed Resident #1 had been sick for several days complaining of abdominal pain, nausea, and vomiting. The DON said the physician had been called on [DATE] and gave orders for a KUB, ultrasound of the abdomen and labs. The surveyor asked DON and ADON if they were aware that Critical Lab values for WBC had not been reported to the physician and/or NP on [DATE]. The DON said, Yes, LVN B called me on Sunday [DATE] to report that he was reviewing the resident's clinical record after Resident #1 had been sent to the hospital on that day and had noted that the Critical Lab results received on [DATE] were pending review in the resident's electronic record. That meant that the lab results had not been reported to the attending physician and/or NP. ADON C said Licensed Staff had been trained to call 911 and send the resident to the emergency room for critical change of condition if they could not get a whole of the physician and/or NP and then notify the physician and/or NP after the resident had been sent to the hospital. She said she did not know if LVN B had notified the physician and/or the nurse practitioner the resident was sent to the ER via EMS. She said the DON had informed Resident #1's attending physician that the nurses had called and sent a group text to him and his NP and that neither had answered their group text messages and/or telephone calls, so the DON had instructed LVB B to immediately call called 911 and send resident to the ER via ambulance. She said she did not know if LVN B had documented the notification in the resident's electronic record.During a Telephone interview on [DATE] at 11:18 a.m. with LVN B revealed Resident #1 complained of abdominal pain on [DATE] and had administered PRN Hydrocodone. He said blood glucose check had been done by resident's family on [DATE] at 2:55 p.m. and the physician was notified and ordered blood glucose checks ac meals and HS and had started the resident on Moderate Sliding Scale coverage. He said he had administered 10 units of the Lispro stat and could not remember the time the insulin was administered. He said he had rechecked the resident's blood glucose again 45 minutes later after the insulin was administered and it when up to 517 and the resident complained of being sleepy. He said he had notified the physician a second time, and the physician gave orders to discontinue the Moderate Sliding Scale coverage and to start the resident on High Sliding Scale coverage and to administer 14 units of Lispro and to also administer10 units of Lantus. He said he had not documented the actual times the blood glucose checks were done or when the insulin was administered in the resident's electronic record. He said they had been trained to document the date and times when blood glucose checks were done and administered insulin according to physician's orders. He said they did not have Lantus in the Insulin Ekit and RN A weekend supervisor had borrowed a vial from another resident. He said that at approximately 4:03 p.m., the resident became clammy, unresponsive Heart Rate was 194, family was in the room with the resident. He said he had called the physician and NP, and they had not answered his call. He said he sent the physician/NP a group text message and had not responded so he called the DON to report the situation and he instructed him to call 911 and send the resident to the Emergency Room. The state surveyor requested a screen shot of the text message.Review of a copy of a screen shot sent to surveyor on [DATE] at 11:16 a.m. by LVN B revealed call placed to NP for Resident #1 Sunday at 1:23 PM 12 seconds to physician/NP. Call placed to attending physician Sunday [DATE] at 1:25 PM by LVN B to physician cancelled call. Outgoing Call [DATE] at 2:45 PM to physician 1 minute by LVN B. Incoming Call Sunday [DATE] at 3:38 PM by DON to LVN B 2 minutes. Outgoing Call [DATE] at 3:43 PM to NP/Attending Physician 5 seconds. Outgoing Call Sunday 3:44 PM 911 3 minutes.Review of a copy of text message screen shot sent to surveyor on [DATE] at 11:16 a.m. by LVN B revealed: Sunday at 4:00 PM to physician by LVN B Resident sent to hospital, HR 194, BS elevated to 563, pt became unresponsive. Sunday 3:37 PM sent by LVN B Just rechecked BS gave her the Lispro 14 units and Lantus 10 units at 2:40 p.m. and just rechecked BS with reading of 563 mg/dl, was looking at labs to see if we could do labs and saw these on [DATE], not sure if these were sent to you. LVN B attached a copy of the lab report dated [DATE] to text message.Telephone call was placed [DATE] at 11:24 a.m., to Resident #1's attending physician. There was no answer, left message to call state surveyor.During a telephone interview on [DATE] at 12:08 p.m. with the attending physician for Resident #1 revealed he was also the facility's Medical Director. He said the nurses had not called him on [DATE] to report Resident #1's blood glucose continued to rise after sliding scale coverage had been administered or that the resident became unresponsive. The Physician was informed by state surveyor that the evening nurse had reported he had placed a group telephone call and had sent a group text message to him and his NP on [DATE] when Resident #1 became unresponsive and the nurse had not received a call back and/or text message from him and/or NP. The physician said, That is not true. That is monstrously false. I have several NPs and designate an NP assigned to the facility. We are always available by telephone and/or group text so there is no need for me to have an alternate physician when I go out of town. He said he expected the nurses to immediately report Critical Lab values to him and/or the NP. He said the critical lab values for the WBC is an indication the resident is going into sepsis and the increased blood glucose levels is the body's stress response that showed the resident was acutely ill and going into full sepsis. He said the facility needed to work on better communication between physicians and NP to prevent this from happening. He said the Lab should call the physicians directly for Critical Lab values. He said the nurses should have notified me and/or NP that the resident continued to complain of abdominal pain [DATE] - [DATE] if prescribed medications are ineffective so that a medical decision could be made regarding treatment options.Telephone call placed to FNP Q on [DATE] at 4:43 p.m., there was no answer, left message to call state surveyor back. Return call pending. NP did not return telephone call prior to exit.The state surveyor requested a copy of the facility's policy and procedure on physician services from the DON on [DATE] and was not provided prior to exit.

Based on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #2) of 13 resident reviewed for grievance resolution. The facility failed to follow their facility policy and procedure on Grievance/Complaints when Resident #2's family member voiced a concern on 01/30/26 to LVN M regarding the way that the staff combed the resident hair and concerns regarding food. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included:Review of the Face Sheet dated 3/06/26 for Resident #2 revealed original admission date was 3/31/25 and re-admission date was 08/12/2025. Resident #2's diagnoses included: Dementia, Diabetes Mellitus, Hypertension, End Stage Renal Disease, and Adult Failure to Thrive.Review of the Quarterly MDS dated [DATE] for Resident #2 documented Date of Entry 08/13/2025. Clear speech sometimes makes self-understood, sometimes understands others; BIMS Score 2 (severely cognitively impaired); dependent with personal hygiene. Active Diagnoses: End Stage Renal Disease, Diabetes Mellitus, Non-Alzheimer's Dementia, Malnutrition. No weight loss. Therapeutic Diet. High-Risk Drug Classes: HypoglycemicReview of the Care Plan revealed: Review of Care Plan initiated 4/01/25 for Resident #2 documented ADL self-care performance deficit Approaches: The resident requires assistance with personal hygiene.- Review of the Care Plan initiated 4/02/25 Impaired Cognitive Function: Approaches: Ask yes/no questions. Communicate with resident/family regarding Residents, capabilities and needs.-Review of the Care Plan initiated 4/01/25 for Resident #2 documented: Resident has nutritional problems or potential nutritional problem r/t adult failure to thrive and protein calorie malnutrition. Approaches: Provide, serve diet as ordered. Monitor intake and record every meal. RD To evaluate and make diet change recommendations as needed.-Review of the Care Plan initiated 4/01/25 for Resident #2 documented Resident Receiving a therapeutic diet. Reduce concentrated sweets and Regular texture. Approaches: Administer snacks/Supplements as ordered/Desired within the restrictions. RD To review. Nutritional and hydration status, quarterly and as needed.-Resident has renal failure r/t end stage renal disease. Approaches: Assist wit ADLS as needed.Review of the Care Plan Conference dated 3/10/26 for Resident #2 revealed Meeting Time: 03/10/26 at 1:00 p.m. Attendance at Meeting: RN, Dietary, Social Worker, Family, and MDS Nurse. Quarterly Care Plan meeting. Nutrition: Renal regular diet thin liquids. Weight 106.7 labs; Eating 75-100%, mighty shake once at day. Summary of Care Plan: Resident's care plan reviewed with family member. Family requesting cookie protein supplement that is provided at dialysis to be given at facility. Agreed to have resident receive both extra protein and health shake for meals. Facility to continue looking for orange blanket. Family member requesting monthly care plan meetings moving forward. All questions answered. Family attended via phone and agree with plan of care. Dietitian participated in care plan meeting.Review of the Diet Slip for Resident #2 revealed RCS Regular House Shake, Regular Texture. Fortified meal plan.Review of the Menu dated 2025 Diet: Regular Thursday Loaded Baked Potato, Toss Salad, Dressing of Choice, Saltine Crackers, Frosted Cake, Milk and Beverages.Review of the Nutritional assessment dated [DATE] for Resident #2 revealed: RCS, Reg Text, Thin, eats 75% of meals and needs supervision with eating.Review of the Physician Order dated 3/06/26 for Resident #2 revealed: Liberal Renal Diet Regular Texture, Health Shake once a day, HS snack, Needs potassium rich foods for breakfast. Dialysis Monday-Wednesday-Friday.Review of Nurses Note dated 1/30/26 at 5:46 p.m. written by LVN M for Resident #2 revealed family member had called regarding how CNAs are preparing resident hair before she goes to appointments or dialysis, she verbalized I don't want them to be doing ponytails and putting flower clips, she's not a child and it looks like they are making fun of her, she's old and maybe she's not going to complain but at the other facility she would not agree to have ponytails and flower clips this nurse explained she will pass on report to CNAs and nurses.Review of Nurses Note dated 1/30/26 at 6:06 p.m. written by LVN M for Resident #2 revealed Dietary Manager was notified family had concerns regarding food.Review of the Grievance Binder revealed there was no Grievance report written for January 2026 to present regarding family members' concerns regarding the way CNAs combed the Resident #2's hair and/or concerns related to food that were reported to LVN M on the evening shift on 1/30/26.During an interview on 2/24/26 at 10:47 a.m. with LVN R revealed that she was not aware of any concerns related to how staff combed the Resident #2's hair or any concerns about the food. She said the resident was alert, oriented to person, place, situation, recognized familiar faces and recognized family members. She said the resident went to dialysis three times a week from 7:30 a.m. - 2:00 p.m. and they packed her a lunch for the resident to eat while at the dialysis center. She said, The never eats her lunch at the dialysis center. She said she checked the lunch box in the morning and always brings her lunch back untouched. She said the resident wants to eat when she returns to the facility from dialysis.During an interview on 2/24/26 at 10:50 a.m. with CNA U said the facility packed a lunch for those residents that went to dialysis in a blue lunch bag. She said Resident #2 never ate her lunch at the dialysis center and the nurses were aware that the resident did not eat while at dialysis because she got nauseated. She said LVN R Charge Nurse on the 400 Hall during the day shift had informed them approximately two weeks ago that the resident's family member did not want them to comb the resident's hair with ponytails, and not want us to put on ribbons, colored rubber bands and barrettes. She said the resident liked the way that they combed her hair because she got a lot of compliments from the staff at the dialysis center. She said the resident was very sad because her family member no longer allowed the staff to comb her hair like they used to.During an observation and interview on 2/24/26 at 10:52 a.m. with Resident #2 revealed, the resident was sitting in a wheelchair by the side of her bed, clean and well groomed. The resident's hair was combed and did not have any ponytails, colored rubber bands, ribbons, or hair barrettes. She said her family member worked and would occasionally come to visit her on the weekends. She said the family member did not like the way the girls combed my hair with ponytails, colored rubber bands, ribbons and little girl barrettes. She said she liked the way the girls combed her hair, but family member did not like it, so now they only brush her hair. The resident appeared to be sad and said she preferred to have her hair done the way they used to before the family member asked that the girls not to put anything on her hair and/or with ponytails. She said, I will do whatever my family member wants. The resident said the facility packed her lunch when she went to the dialysis center on Monday-Wednesday-Friday and did not eat at the dialysis center because she got nauseated while getting her dialysis treatment. She said she would not be able to eat lying down because she was afraid of choking. She said that upon return to the facility, the staff facility checked the blue bag to check if she ate and she reminded the staff that she did not like to eat while getting her dialysis treatment. She said she preferred not to eat upon return from dialysis and would wait for her dinner meal to be served.During a telephone interview on 2/20/26 at 10:56 a.m. with the family member for Resident #2 revealed a visit was made during dinner time on January 29, 2026, and noted the resident had been served a very small baked potato, small salad and ice cream. She said the resident was confused at times and could voice her needs. The family member said she had asked LVN M about the dinner that had been served to Resident #2 on that day. LVN M said they had already notified the Dietary manager that the menu was not followed on that day. The family member said she had reported her concerns about the food that was served to the Resident #2 for dinner on 1/29/26 to the Dietary manager and the DON on that day, and she said that she was not aware of what had been served to Resident #2 for dinner on that day. The family member said she had voiced concern to the evening nurse who was assigned to Resident #2 about how the staff combed the resident's hair like a little girl with bright color ties in her hair and Butterfly clips when she went to appointments and/or dialysis and she felt The staff was not treating the resident with dignity and respect. The family member said the facility sent the Resident #2 with a sack lunch when the resident went to dialysis on Monday-Wednesday and Friday, and the resident did not eat her sack lunch at the dialysis center. She said the sack lunch consisted of a sandwich and yogurt. She said the sack lunch was packed in a plastic bag and was placed in the blue bag that the resident took with her to the dialysis center. She said that when Resident #2 returned to the facility from the dialysis center, no one checked the reusable blue bag to see Resident #1 she ate her sack while she was at the dialysis center. She said she had also reported to the nursing staff that the facility staff had lost a blanket that the Resident #2 had had for almost a year. She said the facility staff just gave Resident #2 another blanket. The family member said she had talked to the weekend staff about the missing blanket and all they did was asked if the blanket was labeled with the resident's name. The family member said the staff had not reported this to Administration or the Social Worker. The family member said the MDS nurses were not inviting her to attend Care Plan meeting again when they had changed staff. The family member said the care plan conference scheduled for January 2026 had been cancelled because the Social Worker had an emergency and they did not reschedule the care plan meeting.During an interview on 2/24/26 at 10:59 a.m. with the DON revealed he was not informed by the staff that the Resident #2's family member had voiced concern about the way that the staff combed the resident's hair. He said he was not familiar with the facility's staff on Grievances/Concerns. He said he started working on the weekends and had taken over the DON position a month ago. He said the resident's family had reported to him a concern about the food that was served to the resident during the dinner meal and did not recall the date. He said the family was concerned that the resident was not getting enough protein. He said the resident was already eating her dinner meal on that day. He said, I told family to let us know if the resident did not like the food that was served for dinner so the kitchen could give the resident an alternative. He said that the family member for Resident #2 had attended a care plan conference and they had discussed the concerns related to residents' diet, about the food that was served to the residents for the dinner meal. He said, I don't keep notes. I apologize. The DON said he had not documented the family members in the resident's electronic record. During an interview on 2/24/26 at 11:06 a.m. with Dietary Manager V revealed Resident #2's family member spoke to LVN M on the evening shift assigned to Resident #2 and said, I do not remember the date, about the food that was served for dinner. She said she needed to look at the menus to see what day it was that the concern was reported to the facility staff. She said, I was not at the facility when the family came to the facility and voiced the concerns. She said, I called the family two times and left a message, and she never returned the calls. I can go and get my cell phone to give you the dates. She said that on the date in question, they had served Resident #2 a loaded baked potato, with sour cream and cheese, green salad with ranch dressing and dessert. She said she needed to check what type of diet was ordered for the resident. She said she had not documented in the resident's clinical record when she had called the family member to follow up on her concerns related to the food that was served to the resident. During a second interview on 2/24/26 at 11:21 a.m. with Dietary Manager V revealed she had not completed a Grievance/Concern Form to give to the facility's Social Worker when the family member for Resident #2 had voiced a concern about the food that was served to the Resident #2. She said she could not recall when the training on Grievance/Concern policy & procedure was completed. She said she had not documented in the Resident #2's electronic record that she had followed up on the concerns related to the type of foods that were served to the Resident #2 for the dinner meal.During an interview on 3/10/26 at 10:16 a.m. with Social Worker W said no one had reported to her the concerns that the family had reported about how the Resident #2's hairas combed and concerns about the food. She said the staff had been trained on reporting any Grievances/Concerns reported to them so she could complete a Grievance/Concern Form to address the Grievances/Concerns and ensure that the issues had been resolved.Review of facility's policy and procedure on Grievance/Complaints, Filing revised April 2017 revealed: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Policy Interpretation and Implementation: Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievance also may be voiced or filed regarding care that has not been furnished. All grievance, complaints or recommendations stemming from residents or family groups concerning issues will be responded to in writing, including a rationale for the response. The administrator has delegated the responsibility of grievance and/or complaints to the grievance officer who is (was left blank). Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident. Will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator, or his or her designee, will make such reports orally within (was left blank) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the residents, and a copy will be filed in the business office.

Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 13 Residents (Resident #1) reviewed for medication administration.:The facility failed to ensure facility's emergency insulin kit contained Lantus to use in an emergency when Resident #1's blood glucose reading was at 517 on [DATE]. The physician gave a STAT order for Lantus and was not available in the facility's emergency insulin kit. The nurse borrowed a Lantus insulin vial that belonged to another resident.This failure could place residents at risk of not receiving prescribed medications that could result in delayed medical treatment and decline in medical condition.Findings included:Closed record review of the Face Sheet dated [DATE] for Resident #1 revealed, original admission date [DATE].Review of admission MDS for Resident #1 dated [DATE] revealed: Date of admission [DATE] from acute hospital. BIMS Summary Score: 15 Cognitively Intact. Active Diagnoses: Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, Post Procedural Pain, Aftercare following surgical amputation, left below knee amputation High-Risk Drug Classes: Opioid. Discharge Plan already occurring for the resident to return to the community.Review of Care Plan for Resident #1 dated [DATE] revealed:-The resident has Diabetes Mellitus. Approaches: Diabetes Medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate resident/family as to the correct protocol for glucose monitoring. Monitor/document/report PRN any signs/symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor for signs and symptoms of infection to any open areas: redness, pain, heat, swelling, or pus formation.Review of Hospital ED Triage Note dated [DATE] at 4:28 p.m. for Resident #1 revealed Chief Complaint: Unresponsive. Diagnoses: Altered Mental Status. Vitals: Pulse Rate 91, blood pressure 87/60. At 4:13 p.m. EMS Blood Glucose Check 561, SPO2 less than 90%, pt arrived being bagged by EMS, chest compressions were performed; 4:50 p.m. family member revoked hospital DNR/DNI over the phone. Emergent intubation at this time. While preparing for intubation pt pulse is no longer palpable, CPR started; 4:43 p.m. Patient intubated due to respiratory failure. At 5:00 p.m.; 4:59 p.m. EKG Post ROSC has hyperkalemia, severe acidosis, and hypoxia; 5:45 p.m. patient noted to have agonal respirations, and a faint pulse is placed back on ventilator. At 5:28 p.m. patient is becoming bradycardic, no pulse felt at this time, witnessed arrest. Family members wished to discontinue CPR and resuscitation efforts at this time. Time of death 5:45 p.m.Review of Medical Visit dated [DATE] at 10:29 a.m. written by attending physician revealed Reason for Visit follow up: c/o Abd pain and diarrhea. History: new Abd pain and diarrhea with low appetite ordered amylase and lipase and Pepto started. No other medical concerns reported DOS [DATE]. Summary of Findings: Abdominal pain diarrhea. Plan: Start Bentyl & Zofran PRN.Review of Physician Order Summary dated[DATE] Resident #1 revealed: Order Date: [DATE] Insulin Glargine Subcutaneous Solution 100 unit/ml Inject 10 units subcutaneously at bedtime for DM. Order Date: [DATE] Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 10 units; 351 - 399 = 12 units. If >400 administer 14 units and notify MD, subcutaneously before meals and at bedtime for DM. The physician order summary did not document the STAT order received on [DATE] by LVN B to administer 10 units of Lantus subcutaneously.Review of the Medication Administration Record dated February 2025 for Resident #1 revealed:[DATE] Insulin Glargine Subcutaneous Solution 100 units/ml inject 10 units subcutaneously at bedtime for DM. The Medication Administration Record did not document on [DATE] by LVN B to administer 10 units of Lantus subcutaneously STAT according to physician's order.Review of the Nurse Note dated [DATE] for Resident #1 at 4:03 p.m. written by LVN B revealed Upon further assessment pt became unresponsive, clammy, HR elevated to 194, family at bedside, notified attending physician by phone, with no answer, sent group message to attending physician and FNP, no response, EMS activated via 911, decision to be sent to hospital based on symptoms above. Family concurred with decision to be sent to hospital.Review of eINTERACT SBAR Summary dated [DATE] for Resident #1 at 4:00 p.m. written by LVN B revealed Situation: Abdominal pain/Altered mental status. Pulse: 194, Respirations 12, Blood Glucose 563, Relevant Medical History: Diabetes. Review and Notify: Primary Care Clinician Notified: Yes [DATE] at 4:00 p.m.Review of Nurse Note dated [DATE] for Resident #1 at 3:35 p.m. written by DON revealed LATE ENTRY: Informed by weekend supervisor labs pending review from Friday have not been reported to physician, DON informed RN to inform MD for further evaluation and review. CN reported lab values to physician and is awaiting orders. Resident's Glucose continues to trend up and is now 567, informed to encourage oral fluids, as per weekend supervisor resident has received 14 units of lispro and 10 units of Lantus, as per MD order. Resident to be encouraged to increase oral fluid intake.Review of Nurse Note dated [DATE] for Resident #1 at 2:55 p.m. written by LVN B revealed Upon doing rounds, pt was crying and stating pain to abdomen area, PRN Hydrocodone administered, pt stated pain decreased but 30 minutes later increased to 8/10. Family arrived, pt showed to be agitated and irritable. BS checked with reading of 473 mg/dl Family stated wanted to have pt leave AMA, notified DON and spoke to pt family and informed that if leaves AMA not able to come back. Family agreed to have pt. stay in facility. Notified attending physician by phone and ordered BS checks ac and Hs, with moderate sliding scale and to give Lispro 10 units STAT. Administered 10 units to back of left arm. Pt tolerated well. Rechecked BS 45 minutes later and BS increased to 515 mg/dl Pt clammy and stated feels sleepy. Notified attending physician and ordered D/C moderate sliding scale and start patient on high sliding scale and to give 14 units of Lispro STAT, and to give the Lantus 10 units as well. Administered both to back of right arm. Pt tolerated well. Educated family on purpose of each insulin. Will continue to monitor.During a Telephone interview on [DATE] at 11:18 a.m. with LVN B revealed Resident #1 complained of abdominal pain on [DATE] and had administered PRN Hydrocodone. He said blood glucose check had been done by resident's family on [DATE] at 2:55 p.m. and the physician was notified and ordered blood glucose checks ac meals and HS and had started the resident on Moderate Sliding Scale coverage. He said he had administered 10 units of the Lispro stat and could not remember the time the insulin was administered. He said he had rechecked the resident's blood glucose again 45 minutes later after the insulin was administered and it when up to 517 and the resident complained of being sleepy. He said he had notified the physician a second time, and the physician gave orders to discontinue the Moderate Sliding Scale coverage and to start the resident on High Sliding Scale coverage and to administer 14 units of Lispro and to also administer10 units of Lantus. He said he had not documented the actual times the blood glucose checks were done or when the insulin was administered in the resident's electronic record. He said they had been trained to document the date and times when blood glucose checks were done and administered insulin according to physician's orders. He said they did not have Lantus in the Insulin Ekit and RN A weekend supervisor had borrowed a vial from another resident. He said that at approximately 4:03 p.m., the resident became clammy, unresponsive Heart Rate was 194, family was in the room with the resident. He said he had called the physician and NP, and they had not answered his call. He said he sent the physician/NP a group text message and had not responded so he called the DON to report the situation and he instructed him to call 911 and send the resident to the Emergency Room. The state surveyor requested a screen shot of the text message.During an interview on [DATE] at 11:18 a.m. with RN A Weekend Supervisor revealed LVN C worked on [DATE] during the morning shift. She said, LVNtold me the family member had checked the resident's blood glucose, and I told him to notify the physician and DON to see what they wanted to do. The family member told LVN B they wanted to take the resident to the hospital. She said, I notified the DON and LVN B that I had notified the physician. That is when the doctor ordered blood glucose checks ac and HS and new orders for insulin. She said the DON talked to the family and he informed the physician that the family wanted to take the resident to the hospital. The DON told her the physician wanted to start the resident on insulin and to keep her at the facility. She said LVN B had rechecked the blood glucose after the first dose of insulin was administered and notified the physician that the blood glucose was higher and physician gave a new order for insulin. She said the physician had ordered Lantus and they did not have Lantus in the insulin Ekit so she had borrowed a new vial of Lantus from another resident to administer the Lantus as ordered by the physician. She said after the Lantus was administered she threw the insulin vial in the biohazard container. She said they had been trained not to borrow medications from other residents.Review of the facility's policy and procedure on Administering Medications revised 2019 revealed: Policy Heading Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation: Medications are administered in accordance with prescriber's orders, including any required time frames. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage, the route of administration; injection site (if applicable); any results achieved and when those results were observed; and signature of the person administering the drug.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 1 (Residents #3) of 13 residents reviewed for abuse. The failed to ensure allegations of abuse were immediately reported by the facility staff to the Administrator when Receptionist X witnessed when Resident #4 calling Resident #3 a cow.This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.Findings include: -Resident #3Review of Face Sheet dated 3/09/26 for Resident #3 revealed an admission date of 10/24/22.Review of History & Physical dated 2/27/26 for Resident #3 documented [AGE] year-old female with progressive multiple sclerosis, obese, the resident is chairbound and receives assistance her with ADLs. Oriented to person, place, and time.Review of Quarterly MDS dated [DATE] for Resident #3 documented clear speech, makes self-understood and understands others. BIMS Score 15 (cognitively intact). Active Diagnoses: multiple sclerosis, morbid (severe) obesity due to excess calories. Weight 268 pounds.Review of the Care Plan dated 3/02/26 for Resident #3 revealed:-Resident has episodes of adverse behaviors: Fabricates facts/unreliable historian/manipulates staff/accusatory behavior towards staff. Approaches: Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. 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. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved, and situation. Document behavior and potential causes.-Resident has a potential mood problem r/t incident with another resident calling her cow Approaches: Behavioral health consult as needed. Monitor/record to MD prn mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Recommendation for a room offered.During an observation and interview on 2/20/26 at 12:00 p.m. revealed Resident #3 was sitting in a wheelchair in her room watching television. Resident was alert, oriented to person, place, and time. She said Resident #4 yelled at others and called her a cow. She said her Spanish was limited and could not understand everything that he said to her. She said Resident #3 does not enter her room. She said, He just yells at me indirectly when he passes by my room. They said this made her feel very anxious and frustrated because the facility staff were not doing anything to stop him from calling her names and yelling at her.Resident #4Review of Face Sheet dated 2/20/26 for Resident #4 revealed admission date 10/27/22.Review of History & Physical dated 2/09/26 for Resident #4 revealed [AGE] year-old male with diabetes, physical debility, and hypertension. Alert and oriented to person and place, forgetful. Cooperative and appropriate mood.Review of the Quarterly MDS dated [DATE] for Resident #4 Entry Date: 10/27/22. Clear speech, makes self-understood, understands others. BIMS Score: 14 (Cognitively intact); Verbal aggression (e.g. threating others, screaming at others, cursing at others). Wheelchair. Active Diagnoses: Hypertension, Diabetes Mellitus. Antidepressant.Review of the Care Plan revealed:-Date initiated: Resident #4 impaired thought processes/Dementia.-Date initiated: 11/10/25 Resident #4 had potential to be verbally aggressive r/t called another resident the cow. Approaches: Trauma assessment completed. Contracted health provider evaluation.3/01/25 Female Resident stated, this resident called her inappropriate names.Review of IDT noted dated 11/23/25 at 8:58 p.m., written by LVN O, revealed nurse was informed by 300 Hall nurse that Resident #4 was asked to leave female resident's room in 300. He used foul language towards CNA, verbally aggressive, raising tone of voice and exhibiting hostile behavior.Review IDT Note dated 11/20/25 written by the contracted health provider 11/20/25 for Resident #4 revealed Encounter: New Evaluation - Psychiatric Evaluation: Reason for Follow-Up: Staff requested- evaluate due to prior physical altercation with another patient. Evaluate for aggressive behavior. Treatment Plan: At this time patient is not an acute danger to self or others. Do not engage in arguing with resident regarding unreasonable requests made by the resident. Behavioral interventions: Redirect as needed.-Review of Telehealth Psych dated 11/06/25 at 3:30 p.m., written by NP - revealed When Resident #4 asked about incident of him calling other residents names, he shook his head, began pushing his wheelchair back and did not answer questions. Said bye to NP on screen. Note written by the previous RN DON AA.-Review of IDT Note dated 11/03/25 for Resident #4 revealed resident altercation was reported to HHSC via Tulip Intake #1047552.- Review of IDT Note dated 1/15/26 for Resident #4 written by LVN N complaining of roommate having TV too loud.-Review of IDT note dated 1/05/26 written by LVN N revealed Resident #4 was arguing with roommate, calling him names due to TV being too loud and does not let him sleep. Roommate's TV volume was lowered. Resident calm down.-Review of contracted psychological care provider for Resident #4 revealed Diagnostic assessment dated [DATE] Reason for referral: Verbal Aggression. Patient has been observed insulting male peers. Pt. has been observed yelling at his roommate and another male peer, insulting them. Pt denied instigating conflict. Pt's mood disturbance may be related to interpersonal stress. Diagnoses: Anxiety Disorder, Depressive Disorder. Treatment Plan: Address anxiety, interpersonal problems, irritability. Completed by: Ph. D, Licensed Psychologist.-Review of contracted psychological care provider note for Resident #4 revealed Subsequent assessment dated [DATE] Reason for referral: Verbal Aggression. Mental Status Examination Oriented To: Person, Place, Day, Month, Year, Situation, Speech: Fluent, Mood: Neutral, Affect: Mood Congruent, Thought Process: Logical Linear, Associations: Intact Association, Thought Content: WNL, Suicidal Ideation: None; Homicidal Ideation: None Risk ofAggression: Verbal; Insight: Fair; Judgement: Fair; Attention: WNL; Short Term Memory: Intact; Long Term Memory:Psychiatric Assessment for Resident #4-Review of Psychological Services Progress for Resident #4 revealed: Date of Service: 3/4/2026Visit Type: Psychotherapy Note. Mental Status Examination. Appearance/Behaviors: Polite, well groomed, Sensorium: Alert. Orientation: Person, Place, TimeDuring an observation on 2/20/26 at 11:55 a.m. revealed Resident #4 was sitting in a wheelchair in the dining room area with other residents waiting for lunch to be served.During a telephone interview on 2/20/26 at 11:14 a.m. with a friend of Resident #3 revealed Resident #4 yells and calls Resident #3 a cow and this has been going on for a year and a half. She said Resident #4 had been moved to another hall and still goes to call Resident #3 a cow. She said these behaviors happen more on the weekends. She said the weekend Receptionist X had witnessed this on the weekends. She said Resident #4 yelled at his roommate, called people names and was nasty to everyone. The friend said she had reported this to the Administrator last year and nothing was done. She said that the administrator was aware that Resident #4 threatens to hit Resident #3 who has MS and she does not have a lot of strength in her arms to defend herself. She said Resident #3 had snapped at Resident #4 because she tries to stop this man from harassing her. She said Resident #4 was in a wheelchair and wheeled himself everywhere in the facility. She said the administrator was not handling the problem.During an interview on 2/24/26 at 10:44 a.m. with CNA Y revealed Resident #4 was alert and oriented to person, place, and time, required minimal assistance with ADLS, chairbound and propels his wheelchair with his hands all over thefacility. She said she had never seen him go into other resident rooms. She said she had never seen him yell, swear, or call names to other residents. She said he spends a lot of time playing dominoes with a female Resident.During an interview and record review on 2/24/26 at 9:25 a.m. with LVN T assigned to Resident #4 on the 6 a.m. -2 p.m. shift revealed resident was alert, oriented to person, place, and time. He was independent with ADLs and only required minimal assistance with bathing. She said that he never entered other resident rooms. She said that approximately 3 months ago, there was an incident that was reported by Resident#3 about Resident #4 calling her names. She said she did not know where the incident had occurred. She said Resident #4 had no previous incidents related to this incident. LVN T said there was a Progress Note in Resident #4's electronic record dated 1/05/26 regarding name calling with roommate. She said Resident #4 was receiving psychological services from contracted health provider and came to see him on a weekly basis. She said his family rarely visited Resident #4. She said he spends most of his time playing dominoes with a female resident all over the facility.During an observation and interview on 02/24/26 at 9:40 a.m. withe Resident #4 was sitting in a wheelchair in his room. He was talking to himself in a loud tone of voice and was making loud noises. He was oriented to person, place, time and situation. He said he had never insulted any of the residents. He said that he got very bothered by the noise that the oxygen machine made, that was used by his roommate and had requested a new roommate. Resident was pleasant and cooperative.During an observation on 2/24/26 at 10:07 a.m. revealed Resident #4 as sitting in a wheelchair in the dining room speaking loudly to himself.During an interview on 2/24/26 at 10:09 a.m. CNA Z revealed Resident #4 was alert, oriented to person, place, and time. She said Resident #4 wheeled his wheelchair independently and never wandered into other resident rooms. She said he speaks in a very loud tone of voice. She said that Resident #4 made other residents very uncomfortable with his loud tone of voice. She said he played dominos with a female resident everywhere in the facility. She said she had not witnessed Resident #4 insulting or name calling any of the residents.During an observation on 2/24/26evealed Resident #4 was wheeling his wheelchair by the nurse's station towards his room talking to himself and making loud noises.During an interview on 3/11/26 at 1:05 p.m. with Receptionist X revealed Resident #3 was alert and oriented to person, place, and time. She said that approximately a month ago Resident #4 was in the Living Room playing dominoes with another resident and Resident #3 was in the reception area talking to her. She said he heard Resident # 4 call Resident # 3 the cow. She said Resident #4 had done this before and she had moved Resident # 3. She said, I went to ask Resident #4 why he had called Resident # 3 a cow. She said she had not reported this to anyone at the facility and had told Resident # 4 that if he did it again, she was going to report to the Administrator. She said she had been trained to immediately report verbal abuse to the administrator. She said, I asked Resident #3 if she wanted me to report it and she said no. I told her that if it happened again, I'm going to have to report it. She said she had received a training by Email on ANE 7/01/25 and they had been trained to immediately report any abuse to the administrator. She said that Resident #3 had told her Resident #4 makes a loud noises when he passed by Resident #3's room such as Whoa that was very annoying behavior and that he just did that to Resident #3.During an interview on 3/01/26 at 1:14 p.m. the Administrator said the facility had reported an allegation of Resident Abuse to state office December 2025 involving Resident # 3 and Resident #4. Resident #4 had called Resident #3 a cow. Resident #3 scratched Resident #4 on the chest. He said he had talked to Receptionist X and told her that she was expected to Immediately report to him any resident abuse. He said, I was not aware of this being an on-going problem of Resident #4 calling Resident #3 a cow. He said facility staff had witnessed Resident #4 calling out the cow when he wheeled down the 300 Hall to go to therapy. He said he had told Resident #4 that he needed to be respectful to other residents and told him not to be making remarks that made other residents feel bad. He said the facility staff had been trained to immediately report to him any allegation of abuse, neglect, and mistreatment. He said failure to immediately report any allegation of abuse placed the residents at risk of further abuse.Review of facility's policy and procedure on Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 2021 revealed: Policy Statement - Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms. Policy Interpretation and Implementation: The Resident Abuse, Neglect and Exploitation Prevention Program consist of a facility wide commitment and resource allocations to support the following objectives. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, including facility staff, other residents, staff form other agencies, family members, friends, visitors and/or any other individual. Develop and implement policies to prevent and identify them: Abuse or mistreatment of residence; Neglect of residents; and/or Theft, exploitation, or misappropriation of resident property. Ensure adequate staffing and oversight/Support. To prevent burnout, stressful working situations and high turnover rates. Provide staff orientation and training/orientation Programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive behavior. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigation.

Based on observation, interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for physician notification of changes. The facility failed to immediately consult with the physician and/or Nurse Practitioner when resident's family member requested to transfer Resident #1 to the emergency room for evaluation of ecchymosis and blood blister in the middle of the chest.This failure could place residents at risk of delayed medical treatment. Findings Included:Review of the admission Record dated 10/24/25 revealed Resident #1 was originally admitted to the nursing facility on 03/31/25 and re-admitted on [DATE]. Review of Hospital History & Physical dated 08/11/25 revealed, Resident #1 had ESRD on Hemodialysis (the final stage of kidney disease, where the kidneys can no longer function and need hemodialysis. Hemodialysis is a treatment that uses a machine to filter and clean the blood like a healthy kidney would), Diabetes Mellitus, type II (a condition where the body either does not produce enough insulin or cannot use the insulin it makes effectively, leading to high blood sugar levels), Anemia (a condition in which the body does not have enough red blood cells or hemoglobin, the protein in red blood cells that carries oxygen), GI Bleed (bleeding that occurs in the digestive tract, from the esophagus to the anus) and Dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement , and orientation). Review of Quarterly MDS dated [DATE] for Resident #1 revealed, Clear speech. Sometimes makes Self-Understood; Sometimes understand others. BIMS Summary Score 01 - Severely Cognitively Impaired. Functional Limitation in Range of Motion - impairment on both sides to lower extremity. Mobility - dependent chair/bed-to-chair transfer. Incontinent of bowel & bladder. Active Diagnoses: Anemia, ESRD, Diabetes Mellitus, Non-Alzheimer's Dementia, PVD (is a circulation problem where blood vessels outside of your heart and brain become narrowed, blocked, or damaged, often due to a buildup of plaque. This makes it harder for blood to flow to your arms and legs) Special Treatments - Hemodialysis. Review of Care Plan dated initiated: 10/24/25 for Resident #1 revealed, Resident had a fluid blister to mid-chest. Interventions: Administer antibiotic therapy as prescribed. Monitor for signs of progression or desclination (deterioration) blister. Provide wound care per treatment order. Review of Skin assessment dated [DATE] for Resident #1 written by LVN I revealed, Resident noted with blood filled blister to middle of chest area. Review of Event Report dated 10/20/25 at 9:15 PM, written by LVN I for Resident #1 revealed, Incident Date: 10/20/25. Type of Incident: Skin Tear/Discoloration. Location: Resident's Room. Nursing Description: Resident arrived from Dialysis, assessed resident noted blood filled blister to middle of chest next to dialysis port. Resident denies pain to area. Notified NP. New order to clean area with NS and cover with protective dressing, start Cephalexin 250 mg po BID x 10 days prophylactically, and she well be here Thursday to see resident. The family arrived at the facility and were notified of findings and new orders from NP. DON, ADON notified. Resident Description: Resident states, it just happened, she denies a fall, denies someone or something hitting that area of her chest., AAOx3, able to make needs known. The administrator was notified 10/21/25 at 10:02 AM. Review of Hospital emergency room Notes from dated 10/23/25 for Resident #1 revealed, Service Date/Time: 10/23/25 at 9:14 AM. emergency room Discharge Instructions revealed Diagnosis from Today's Visit: S/P hemodialysis catheter insertion, Superficial bruising of chest wall. During an interview on 10/24/25 at 9:14 AM, with LVN A Charge Nurse assigned to Resident #1 in the 300-Hall, said, I know why you are here. [Resident #1's] [family member] told me she was going to call the state, because the dialysis had requested for the nursing home to send the resident to the emergency room for evaluation of the ecchymosis (bruise) and large blister in the middle of the resident's chest, that was close to the dialysis access site. I asked her why the dialysis center could not send the resident to the hospital if she was still at the dialysis center. He said Resident #1 did not have the ecchymosis or the blister in the middle of the chest on Monday 10/20/25 when she was sent to dialysis during the morning shift. He said, I had already left when the resident returned from dialysis on that day during the evening shift. He said the evening nurse called the Nurse Practitioner on 10/20/25, and an order was given to start the resident on an antibiotic and would come to see the resident on Thursday. He said, I returned to work on Wednesday 10/22/25 when the nurse from the dialysis center called me and said the nephrologist (kidney doctor) had recommended the resident be sent to the ER for evaluation of the ecchymosis to make sure it was nothing serious due to the proximity to the dialysis access site. I asked the dialysis nurse why they had not sent the resident to ER from the dialysis center instead of sending the resident back to the nursing home. In about ten minutes, I got a call from the resident's [family member] on Wednesday at approximately 12 noon, and she was very upset, yelling and she said the nephrologist had requested for the nursing home to send the resident to the ER for evaluation of the ecchymosis and blood blister on the middle of the chest because of the proximity to the dialysis access site as soon as possible. I asked her why the dialysis center could not send her to the ER from the dialysis unit instead of sending the resident back to the nursing home. The [family member] was very upset and said, so you don't want to send her to be checked at the hospital and hang up on me. I reported this to the DON right away. The resident was sent to the emergency room on Wednesday 10/23/25 by ambulance, and they did an x-ray and labs. She returned from the hospital with instructions to leave the affected area on chest to room air.During an observation and interview on 10/24/25 at 9:27 AM, with LVN A Charge Nurse on the 300-Hall revealed, Resident #1 had maroon ecchymosis of irregular configuration and had a blood-filled blister on the middle of the upper chest close to the dialysis access site. The ecchymosis area was approximately 12 cm x 3 cm, and the blood blister was approximately 4 cm x 1 1/2 cm.During a telephone interview with family member on 10/24/25 at 9:43 AM said, LVN A on the morning shift was very rude to me when I called him on Wednesday 10/22/25 at approximately 1:15 PM to follow up on why he did not want to follow the nephrologist's recommendation to send [the resident] to the hospital for evaluation of the bruise and blood blister on the middle of her upper chest as suggested by the nephrologist at the dialysis center. I was very concerned because of the location of the bruise on [Resident #1's] chest. LVN A said, Oh really, if they felt it was an emergency why did they not send her to the emergency room from the dialysis center if she is still there. I hung up on him because he made me very upset because he did not want to follow the nephrologist recommendation to send [the resident] to the emergency room for evaluation. I also followed up with the evening nurse LVN I on that day at approximately 7:00 PM, and she asked me exactly what LVN A had said, she asked why the dialysis center had not sent [the resident] to the emergency room if she was still at the dialysis center instead of sending her back to the nursing home. I asked the LVN I why they were refusing to send [Resident #1] to the emergency room for evaluation as suggested by the nephrologist. LVN I, asked me why the dialysis had not sent [Resident #1] to the ER for evaluation if the resident was still at the dialysis center. I do not understand why I must fight a battle with the nurses to get them to get the necessary medical care for [Resident #1]. During an interview on 10/24/25 at 3:37 PM with LVN ADON J said, LVN A told me this morning that the resident's [family member] had called on 10/22/25, was very upset and wanted to know why they did not want to send Resident #1 to the emergency room for evaluation as requested by the dialysis nephrologist. LVN A said he had told the family member that if they thought it was an emergency, why would the dialysis not send her to the emergency room instead of waiting for the resident to return to the nursing facility. She said the Nurse Practitioner had given the order to send the resident to the ER for evaluation and the ambulance had come to pick up the resident after midnight on that day. During an interview on 10/24/25 at 4:02 PM with the DON, in the presence of the Administrator revealed, She said, On Wednesday 10/22/25 LVN A reported to me that he had received a telephone call from the resident's [family member] on that day asking to send [the resident] to the emergency room for evaluation of the ecchymosis and blood blister in the middle of the chest at the request of the nephrologist at the dialysis center. She said the resident was sent to the emergency room on [DATE] during the evening shift because the ambulance had picked up the resident after midnight on that day. During a telephone interview on 10/27/25 at 10:37 AM, with the Facility Manager at Dialysis Center revealed, the resident's family member was upset because the nursing home staff kept asking her why the dialysis center had not sent the Resident #1 to the ER for evaluation of the ecchymosis and blood blister in the middle of the chest on 10/22/25 as suggested by the dialysis nephrologist. He said the dialysis center cannot send residents to the ER for non-emergency situations, and that is why they had called the nursing home staff to inform them of the nephrologist request. He said the resident's vital signs were stable on that day and the resident did have a superficial bruise in the middle of the chest. He said he had suggested to the family member to speak to the social worker at the nursing home to see if she could help her to send the resident to the ER for evaluation as suggested by the nephrologist at the dialysis center. During an interview on 10/27/25 at 11:25 AM with FNP revealed, the nurse had reported to her on Monday 10/20/25 that Resident #1 had a superficial hematoma (bruise) and blood blister in the middle of the chest and she gave orders to keep the area clean and to administer Keflex (an antibiotic) as ordered. She said LVN I had not mentioned anything on that day about sending the resident to the ER for evaluation. She said she had received a call from the nursing home on [DATE] regarding a high potassium level of 6.2 and nothing was mentioned about the hematoma in the middle of the chest. She said later that night, she got another call from LVN I, asking to send the resident to the ER per the family member's request. She said the staff knows that if a family member requests to send a resident to the hospital all they must do is to call her and she will give the nurses an order. She said, It is the family's right to make a request to send their loved one to the hospital for evaluation.During a telephone interview on 10/27/25 at 4:35 PM with facility's Medical Director revealed he had examined Resident #1, and his instinct was that the ecchymosis and blood blister are related to an autoimmune disorder called Bullous Pemphigoid (is a rare autoimmune disease where the body's immune system mistakenly attacks the skin, causing large, itchy blisters on the arms, legs, and torso), that some patients with ESRD could develop. He said the resident was not having pain in the affected area on the chest. He said that the nurses at the facility should have attempted to call the resident's attending physician on Wednesday 10/22/25, when the family member had asked to send the resident to the hospital as requested by the nephrologist at the dialysis center. All the nurses need to do is call and request an order to send the resident to the ER for evaluation per family's request. He said that it was the family's right to request to send the resident promptly to the hospital for evaluation. During a telephone interview with the RN at the Dialysis Center on 10/28/25 at 10:09 AM, revealed she had called the nursing facility to inform LVN A on the day shift on Wednesday 10/22/25 that the nephrologist at the dialysis center had given an order to send Resident #1 to the ER for evaluation of ecchymosis and a blood blister in the middle of the chest due to the close proximity to the dialysis access site. The RN said the nephrologist had determined the ecchymosis and blood blister was not an emergent situation, the resident was stable and did not know what had caused the ecchymosis and blister in the middle of the chest and the nursing home could send the resident to the ER for evaluation upon return to the nursing facility. She said LVN A had not allowed her to finish telling him what the nephrologist's orders were. She said LVN A had said, Send Resident #1 to the ER for what. Resident #1 was already been started on antibiotics and the Nurse Practitioner will be coming to see the resident on Thursday 10/23/25. The RN said she had received a call from the resident's family member on 10/23/25 and she said she wanted her family member to be sent to the ER for evaluation as ordered by the nephrologist. The RN said the dialysis center will only transport patients to the emergency room for life threating situations, altered mental status or unstable vital signs. During a telephone interview on 10/28/25 at 3:51 PM with attending physician for Resident #1 revealed, he did not think the ecchymosis and blood blister in the middle of the chest were not caused by trauma, because the resident did not complain of pain and there were no signs of suspicion of trauma and x-ray done at the ER was negative for trauma. He said it could be an autoimmune skin condition that affects some patients with ESRD. He said he had given orders for a dermatology consultation to determine what type of skin condition the resident had. He said, The nurse at the nursing facility should have called me to get an order to send the resident to the ER for evaluation as requested by the family. Review of facility's Policy and Procedure on Change in a Resident's Condition revised April 2025, provided by DON on 10/27/25 revealed, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident' medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: The nurse will notify the resident's physician or physician on call when there has been a (an): accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/treatment center; specific instruction to notify the physician of changes in the resident's condition; ultimately is based on the judgement of the clinical staff. Regardless of the resident's current medical or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interviews and record review, the facility failed to ensure the resident had the right to prompt efforts by the facility to resolve resident grievances, for one (Resident #2) of three residents reviewed for grievance resolution. The facility failed to ensure prompt efforts to resolve grievances voiced by Resident #2's family who filed a grievance on 08/22/25 and 10/17/25. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.Findings included:Review of the admission Record dated 10/27/25 for Resident #2 revealed, original admission date 06/05/25; re-admission [DATE]. Review of Medical Visit dated 10/27/25 for Resident #2 revealed [AGE] year-old female with recurring UTIs (an infection of the urinary tract), now on hospice. History of cystitis (an inflammation of the bladder, the organ that stores urine), chronic UTI (infections of the urinary tract that are either persistent or keep coming back). Resident alert, oriented to person.Review of Quarterly MDS dated [DATE] for Resident #2 revealed, clear speech, makes self-understood; understands others; BIMS Summary Score: 12 (cognitively moderately impaired); Self-Care-substantial/maximal assistance with eating; Dependent with oral hygiene, toileting, shower, dressing, and personal hygiene. Mobility - Dependent with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, toilet transfer, shower transfer. Incontinent of bowel & bladder. Active Diagnoses: Renal Failure (is when the kidneys stop working properly, are unable to filter waste, remove excessive fluid, and balance chemicals in the blood), Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively).Review of Care Plan for Resident #2 revealed, Date initiated: 10/16/25 Infection diagnosis of Sepsis (a life-threatening condition that occurs when the body's immune system overacts to an infection). Approaches: Administer medications per order. Monitor/document/report to MD signs and symptoms of delirium, changes in behavior, altered mental status. Date initiated: 10/16/25 The resident has alteration in neurological status r/t encephalopathy (a general dysfunction of the brain). Approaches: Assess for effects of psychotropic meds, dystonia (a movement disorder characterized by involuntary, sustained, or repetitive muscle contractions that cause abnormal postures or twisting movements), akinesia (the inability to initiate or perform voluntary muscle movements, often experienced as being frozen or having difficulty starting to move), rigidity, and tremors. Cueing, reorientation as needed. Date initiated: ADL self-care deficit. Approaches: Bed Mobility requires assistance to maximize independence with turning & repositioning in bed. Requires assistance with personal hygiene, toileting, and transfers.Review of Concern/Grievance Form dated 08/22/25 revealed, Concern From: Was left blank. Resident Name: Resident #2. Name of the person giving the complaint. [family member]. Telephone: Was left blank. Employee filling in this form: Social Worker. Related to: Nursing Care. Description: Resident [family member] c/o of call bell not being placed where resident can see it. Family reports resident has vision problems and needs call light bell attached to center of her chest. Family complains that staff is inconsistent with placement. Persons/Departments contacted on 08/22/25: Social Worker, ADON J, and Administrator. Summary/Findings: Interventions discussed/clinical team. Recommendations/Action Taken: Sign-In Log will be implemented to ensure call bell placement. Resolution of Grievance/Complaint was left blank. Did not document resolution. Identify the methods used to notify the resident and/or resident representative of the resolution: Was left blank. Date of Notification: Was left blank. This form was completed by the Social Worker and Administrator on 08/27/25.Review of Concern/Grievance Form dated 10/17/25 revealed, Communicated by: Family. Name: Resident #2's family member. Relationship: family member/POA. Communicated to: DON, and SW. Name/Dept: DON, Social Worker Communicated via: Verbal. Concerned about: None were checked. Describe concern in detail: Family verbalized concerns: Documented in part - Night nurse LVN P lacks empathy. She focused on facility rules instead of patient care. Nurse asked the family to leave the facility at 9:59 PM, after requesting to stay with the resident. Staff did not check on resident throughout the night. Resident unable to operate call bell. Staff members assigned responsibility for the investigation: DON. Assigned by: Was left blank. Date: Was left blank. Due Date: Was left blank. Findings of investigation: Was left blank. Plan to resolve concern/grievance: Documented in part - DON provided personal cell number to be reached for concerns. Education provided to nurse LVN P. Family will be allowed to remain in the facility after visiting hours to accommodate. Touch call light will be provided. Log will be left at bedside to ensure pt. care and room rounding. Signature of Person completing above report: Was left blank. Signature of Administrator: Was left blank.During an observation and interview on 10/27/25 at 2:53 PM, with Resident #2's family member revealed he visited Resident #2 daily and stayed all day until another family member relieved in the afternoons after she got out of work. The resident was lying asleep in bed with Pad Call Light clipped on her gown on top of her chest. The family member said, Yesterday 10/26/25 I took a picture because [Resident #2's] call light was not within reach, it was clipped on the head of the bed on her left side. He said Resident #2 was able to use the call light if it was kept within reach. He said, We had a meeting with the nursing administration about the 10 PM - 6 AM not answering [Resident #2's] call light and was finally answered two hours later. On Sunday 10/26/25 [Resident #2] was not checked all night by the nursing staff. We could see in the camera; the staff entered the room and just peeked through the side of the divider curtain and left the room without checking if she needed to be changed because she was incontinent. [Another family member] is [Resident #2's] POA. We placed a camera in her room to check that they keep her call light within reach, and she is provided with the needed care.During an interview on 10/27/25 at 3:12 PM with the Social Worker revealed, Resident #2's family had voiced concerns about resident's call light not being within reach. She said, There should be a sign-in log posted on the door to the entrance of the room for staff to initial when they check for call light placement. She said, I know that the sign-in logs were posted on the door prior to the most recent hospitalization. To my knowledge, the sign-in log should still be in place. She said she did not know if the staff had been trained on the use of the sign-in log to check for call light placement. She said the family also made a grievance about the lack of empathy when they were asked by the night nurse LVN P to leave, when they had asked if they could stay with Resident #2 after visiting hours. She said they had talked to the staff and the family and were informed that arrangements could be made to accommodate their request to stay after visiting hours and if the resident's roommate agreed to their request. She said the family had placed a camera in the resident's room. She said the resident's family member visited daily during the day and another family member in the evenings. She said, I met with the [family member] today and he did not voice any concerns. She said that she was not aware that the resident's call light was not within reach on Sunday 10/26/25 when the resident's family member came to the facility in the morning. She said the resident should be checked at least every two hours. She said she was responsible for handling Grievances and complaints according to facility policy and procedure. She said they had not been documenting a resolution of Grievances and/or notification on the Grievance Forms according to facility policy and procedures.During an observation and interview on 10/27/25 at 3:44 with Resident #2's family member revealed, the sign-in log to check for call light placement was not posted on the door to the entrance of the room. The resident's family member was in the room. When the state surveyor asked the family member about the sign-in log to check for call light placement, he said it had not been posted on the door for a while. He said, We were told by the social worker that the facility was going to post a sign-in log for the staff to sign when they entered the room to check that [Resident #2's] call light was always kept within reach so she could call for assistance as needed. The sign-in log has not been posted on the entrance door for a while as we were told was going to be done by the Social Worker. He said he and another family member had to make sure the call light was placed on Resident #2's chest where she could reach it, and that the staff checked Resident #2 every two hours and kept the call light within reach.During an interview on 10/27/25 at 3:47 PM with CNA H assigned to the 300-Hall on the evening shift, revealed Resident #2 used to have a sign-in sheet on the entrance door to initial when they entered the room to check for call light placement and care provided to the resident. He said, I don't remember seeing the sign-in log today on the entrance door to [Resident #2's] room.During an observation and interview on 10/27/25 at 3:52 PM, with LVN ADON J assigned to the 300-Hall revealed, she had just posted the sign-in sheet on the entrance door to Resident #2's room. She said that she did not know why the sign-in Log to check for call light placement was not posted on the door. She said she was responsible for checking that the sign-in log was posted on Resident #2's door. She said they had not provided any training for the nursing staff on the use of the sign-in logs that should be used to sign when they entered the resident's rooms to check for call light placement and care provided.During an interview on 10/27/25 at 3:55 PM, with CNA G assigned to the 300-Hall on the evening shift revealed Resident #2, used to have a sign-in sheet on the entrance door to initial any time they entered the resident's room. She said the sign-in log had not been posted on the door for a while.During a confidential interview on an undisclosed date at an undisclosed time revealed, the staff just posted the sign-in on the entrance door to resident's room. It was not posted today when the state surveyor came to see the resident. The staff has not posted the sign-in sheet for a while. The CNAs are supposed to sign the sign-in log when they entered the Resident #2's room to check for call light placement, but they had not been doing it.During an interview and record review Sign- In Log on 10/27/25 at 4:02 PM with LVN ADON J in the presence of the DON said the CNAs needed to sign the sign-in log every time they entered the resident's room to check for light placement. She said that the last day the nursing staff documented on the Sign-In Log for October 2025 was 10/05/25.During an interview on 10/28/25 at 10:35 AM with LVN ADON O revealed, she said the CNAs made rounds every two hours and checked that the pad call light for Resident #2 was kept within reach. She said there should be a sign-in log posted on the entrance to the resident's room for the staff to sign when they enter the room to check for the call light placement. She said she was not aware of the resident's family voicing any concerns about the night staff not checking the resident all night on 10/26/25. During an observation and interview on 10/28/25 at 11:17 AM revealed, Resident #2 was lying in bed awake, and her family member was at the bedside. The resident was oriented to person, month, year, and recognized her family member. The Resident was able to answer simple questions. It was observed that the pad call light was clipped to her gown. The Resident's family member asked the resident to push the pad call light to demonstrate to the surveyor that she could use the call light. It was observed that the resident was only able to call for help using the pad call light with the family member's guidance.During an interview on 10/28/25 at 4:52 PM with the DON in the presence of the Administrator revealed, they had a family conference with Resident #2's family regarding a concern related to the night staff not checking the resident all night on Sunday 10/26/25. She said the CNAs had been instructed to sign the sign-in log when they entered the room to check on the call light placement as agreed when they had addressed a previous concern voiced by the resident's family regarding the call light not being within reach. She said a Grievance Form had not been completed to address the family's concern.During an interview and record review of Grievance Forms on 10/28/25 at 4:53 PM with the Administrator revealed, the Grievance forms should be completed according to facility policy. He said they were not allowed to revise any forms without the approval from their corporate office. He said, each Grievance form should be filled out and each grievance form should have documentation of the resolution and notification of resolution. He said the Grievance forms kept in the Grievance Binder for 2025 did not document a resolution method used to notify the resident and/or resident representative of the resolution and date of notification.Review of In-Service Training Report dated 09/19/25 presented by the Social Worker revealed, Subject: Grievance/Complaint Filing. Summary of In-service: New Grievance Form, New Grievance Process, and New Grievance Location.Review of facility's policy and procedure on Grievance/Complaints, Filing revised April 2017 revealed: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Policy Interpretation and Implementation: Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievance also may be voiced or filed regarding care that has not been furnished. All grievance, complaints or recommendations stemming from residents or family groups concerning issues will be responded to in writing, including a rationale for the response. The administrator has delegated the responsibility of grievance and/or complaints to the grievance officer who is (was left blank). Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident. Will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator, or his or her designee, will make such reports orally within (was left blank) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the residents, and a copy will be filed in the business office.

Based on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure LVN I accurately documented in Resident #1's Event Report on 10/20/25 when the resident returned from the dialysis center with ecchymosis and a blood blister in the middle of the chest.The facility failed to ensure the DON documented skin assessment for Resident #1 according to facility policy on documentation.The facility failed to ensure LVN I wrote a physician's telephone order on 10/22/25 to send Resident #1 to the emergency room for evaluation of ecchymosis and a blood blister in the middle of the chest.This failure could place residents at risk of having incomplete and inaccurate clinical records. Findings included:Review of the admission Record dated 10/24/25 revealed Resident #1 was originally admitted to the nursing facility on 03/31/25 and re-admitted on [DATE]. Review of Hospital History & Physical dated 08/11/25 revealed, Resident #1 had ESRD on Hemodialysis (the final stage of kidney disease, where the kidneys can no longer function and need hemodialysis. Hemodialysis is a treatment that uses a machine to filter and clean the blood like a healthy kidney would), Diabetes Mellitus, type II (a condition where the body either does not produce enough insulin or cannot use the insulin it makes effectively, leading to high blood sugar levels), Anemia (a condition in which the body does not have enough red blood cells or hemoglobin, the protein in red blood cells that carries oxygen), GI Bleed (bleeding that occurs in the digestive tract, from the esophagus to the anus) and Dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement , and orientation). Review of Quarterly MDS dated [DATE] for Resident #1 revealed, Clear speech. Sometimes makes Self-Understood; Sometimes understand others. BIMS Summary Score 01 - Severely Cognitively Impaired. Functional Limitation in Range of Motion - impairment on both sides to lower extremity. Mobility - dependent chair/bed-to-chair transfer. Incontinent of bowel & bladder. Active Diagnoses: Anemia, ESRD, Diabetes Mellitus, Non-Alzheimer's Dementia, PVD (a condition where blood vessels outside your heart and brain narrowed, blocked, or damaged, preventing enough blood from flowing to your limbs and organs) Special Treatments - Hemodialysis. Review of Care Plan dated initiated: 10/24/25 for Resident #1 revealed, Resident had a fluid blister to mid-chest. Interventions: Administer antibiotic therapy as prescribed. Monitor for signs of progression or desclination (deterioration) blister. Provide wound care per treatment order. Review of Skin assessment dated [DATE] for Resident #1 written by LVN I revealed, Resident noted with blood filled blister to middle of chest area. Review of Event Report dated 10/20/25 at 9:15 PM, written by LVN I for Resident #1 revealed, Incident Date: 10/20/25. Type of Incident: Skin Tear/Discoloration. Location: Resident's Room. Nursing Description: Resident arrived from Dialysis, assessed resident noted blood filled blister to middle of chest next to dialysis port. The Event Report did not document the ecchymosis (bruise) around the blood blister. Resident denies pain to area. Notified NP. New order to clean area with NS and cover with protective dressing, start Cephalexin 250 mg po BID x 10 days prophylactically, and she will be here Thursday to see resident. The family arrived at the facility and were notified of findings and new orders from NP. DON, ADON notified. Resident Description: Resident states, it just happened, she denies a fall, denies someone or something hitting that area of her chest., AAOx3, able to make needs known. The administrator was notified 10/21/25 at 10:02 AM. Review of Hospital emergency room Notes dated 10/23/25 for Resident #1 revealed, Service Date/Time: 10/23/25 at 9:14 AM. emergency room Discharge Instructions revealed Diagnosis from Today's Visit: S/P hemodialysis catheter insertion, Superficial bruising of chest wall. Review of Physician Order Summary dated 10/27/25 for Resident #1 revealed, the physician order summary did not document an order to send the Resident #1 to the ER for evaluation of the ecchymosis (bruise) and blister in mid chest. During an observation and interview on 10/24/25 at 9:09 AM with Resident #1 revealed, she was lying in bed awake, was oriented to person and place. Resident said, Look at the bruise on my chest, it does not hurt. I do not know how I got the bruise and the bump in the middle of my chest. It developed suddenly, they sent me to the emergency room, and I was told it was nothing serious. It was observed resident had ecchymosis and a blood blister in the middle of the chest. During an interview on 10/24/25 at 2:45 PM, with LVN I revealed she was assigned to Resident #1 on the 2 PM-10 PM shift on Monday 10/20/25. She said the resident was alert, oriented to person, place, and time and was able to answer questions. She said she had assessed Resident #1 on 10/20/25 upon return from the dialysis center and she had noticed the resident had a blood blister in the middle of the chest and bruising around the area surrounding the blister. She said she had immediately reported the bruise and blister on the middle of the resident's chest to the DON, ADON and Nurse Practitioner. She said the Nurse Practitioner had given orders to start the resident on an antibiotic, cover the area with a protective dressing and said she would come and see the resident on Thursday 10/23/25. During an interview on 10/24/25 at 4:02 PM with the DON revealed, ADON O had reported to her on Monday 10/20/25 via text message that Resident #1 had bruising and a blood blister in the middle of the chest. She said, I assessed the resident on Tuesday on 10/21/25 and did not document my assessment in the resident's clinical record. She said they had been trained to document assessments in the resident's electronic clinical record. During second interview on 10/27/25 at 4:13 PM with LVN I revealed, she had completed the Event Report for Resident #1 on Monday 10/20/25 and said she was more focused on the blood blister than the ecchymosis around the blood blister in the middle of the chest. She said, That is why I did not document the ecchymosis on the Event Report. She said she had not written a physician telephone order on 10/22/25 for the order given by the nurse practitioner to send Resident #1 to the ER for evaluation of the ecchymosis and blood blister in the middle of the chest as requested by the resident's family member. She said she had been trained to write telephone orders given by the physicians and/or Nurse Practitioners in the resident's electronic clinical record. During an interview and record review of Event Report on 10/27/25 at 5:18 PM with the DON, revealed LVN I had not documented the ecchymosis in the middle of Resident #2's chest on 10/20/25 when she had completed the Event Report. She said, The nurse only documented the resident had the blood blister in the middle of the chest. During an interview and record review of Nursing Progress Notes on 10/29/25 at 9:19 AM with the DON in the presence of Administrator and LVN ADON O revealed, she had assessed Resident #2 on Tuesday 10/21/25 after the morning meeting and had noted the ecchymosis and blood blister in the middle of the chest. She said she had not documented her assessment in the resident's clinical record. She said the staff had been trained to document all resident assessments in the resident's electronic clinical record. The DON said LVN I had not written a Physician Telephone Order to send the Resident #2 to the ER for evaluation of ecchymosis and blood blister in mid chest on 10/22/25. She said the staff have been trained to write Physician Telephone Orders for all orders given by NP and/or physicians. Review of facility's Policy and Procedure on Charting and Documentation Revised July 2017 revealed, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations; Changes in the resident's condition; Events, incidents or accidents involving the resident; Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LVN, physician, therapist, etc.) in accordance with state law and facility policy. Documentation of procedures and treatments will include care-specific details, including: the assessment data and/or any unusual findings obtained during the procedure/treatment; notification of family, physician or other staff, if indicated; the signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #39) of 6 residents reviewed for incontinent care. The facility failed to ensure adequate bladder incontinence absorbent products were provided to address urine leakage and dignity for Resident #39. This deficient practice could place residents at-risk for infection; skin break down and decrease in self-worth due to improper care practices. Findings included: Record review of Resident #39's admission record dated 08/29/2025 revealed a 69 y/o male admitted on [DATE]. Record review of Resident # 39's diagnosis report dated 08/29/2025 revealed diagnosis of cognitive communication deficit and Benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident # 39's quarterly MDS dated [DATE]th, 2025, revealed a BIMS of 15 indicating the person was cognitively intact. Section GG functional abilities revealed Resident # 39 needed substantial/ maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement). Record review of Resident #39's care plan revealed resident was at risk for infections/pressure/venous/ statis ulcers, and skin desensitized to pain or pressure, slow healing process related to diabetes mellitus. He also had a potential for pressure ulcer development related to immobility. Nursing intervention was to follow the facility policy/ procedure/ protocols for the prevention/treatment of skin breakdown. He also had ADL self-care performance deficit related to dementia. Nursing intervention included extensive assistance x1 staff with all his toileting and incontinent care. In an interview on 08/26/2025 at 10:30 a.m., Resident # 39 revealed that he had trouble with the briefs that was being provided to him, he stated they did not fit, and he would have a lot of accidents. He stated that he had gotten urine on the bed sheets and his clothes, he stated that wetting himself made him uncomfortable. He stated that the briefs was small and uncomfortable around the inner thigh area and groin area. He stated that he did not recall telling staff about briefs being too small for him. In an interview on 08/29/2025 at 11:15 a.m., CNA G revealed that late July early August she had mentioned to the central supply coordinator and to ADON that Resident #39 had been found in bed with urinated sheets and clothes due to the brief not fitting properly as he had a long torso and current size brief fit him small. She had mentioned that he would benefit from a larger size. She stated after that, Resident #39 was still provided the same size brief, therefore resident was still being found urinated. In an interview on 08/29/2025 at 11:30 a.m., the central supply coordinator revealed that every morning she rounded and provided residents with their size of brief based off a list that she had listing each resident's size of brief. She stated that each resident was measured by a CNA and their size of brief was documented. She stated that if CNAs voiced to her that resident need a bigger size brief, then resident would be given the bigger size brief. Regarding Resident #39, she stated that she recalled a CNA mentioning to her about two weeks ago, that Resident #39 needed a bigger size brief due to him having a long torso and the brief being too short and it bunching up in inner thigh area. She stated that he was resized to a 2xl, however she stated that she sometimes provided the correct size and sometimes she does not and did not give a reason as to why. She stated that by not providing the right sized briefs the resident was at risk for cuts, rashes and skin breakdown. She stated that she was responsible for providing the rightsized briefs to each resident. In an interview on 08/29/2025 at 1:30 p.m., the ADON revealed that it was reported to her that Resident #39 needed a larger sized brief. She stated that she and the CNA that did weights and sizing, resized Resident #39 on 08/05/2025. She stated that he now uses a 2 extra Large. She stated that residents had the right to request the size they want even after being fitted. She stated that providing residents with the wrong sized brief could cause them to have skin break down, and she stated that it was a dignity issue as well. She stated that CNA staff and nurses were responsible to communicating any changes to brief sizes to central supply coordinator and she was responsible for providing the correct sized briefs to the residents. In an interview on 08/29/2025 at 2:00 p.m., the Administrator revealed that central supply coordinator was responsible for ordering and distributing briefs to each resident. He stated that she has a list of resident sizes that she follows and that was how she knew which size to provide for the resident. He stated that he did not know about Resident #39 having an issue with the briefs. He stated that he did not see an issue with providing the wrong sized briefs to residents, especially if it was a larger size. He stated that residents needed to be changed in a timely manner to prevent any skin breakdown from happening. He stated that there were a lot of residents requesting an extra-large brief and therefore sizing was done as an intervention to help each resident know their correct size of brief and make ordering briefs easier for central supply coordinator. Per facility administrator, there was no policy on each resident receiving supplies for ADLs.

Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Resident #45, #46 and #47) reviewed for call lights. The facility failed to ensure resident call lights were within reach for 3 Resident #45, #46 and #47). This failure placed residents at risk of having their needs unmet when they are unable to contact staff.Findings included:Resident #45 Record review of Resident #45's admission record dated 08/29/2025 revealed a [AGE] year-old male with an original admission date of 12/07/2023 and a readmission date of 04/27/2025. Record review of Resident #45's history and physical dated 04/27/2025 revealed he had diagnosis of unspecified convulsions (a seizure event where the specific cause is not documented in patients' medical record) and high blood pressure. Record review of Resident #45's Quarterly MDS dated [DATE] revealed in section GG Functional Abilities Resident #45 needed supervision or touching assistance meaning Helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. For showering, upper body dressing and lower body dressing. There was no BIMS score available. Record review of Resident #45's care plan reviewed on 04/27/2025 revealed Resident #45 was at risk for blurred vision, dizziness, headaches and nosebleeds related to high blood pressure and received medication for high blood pressure. Resident #45 was at risk of falls, and intervention included ensuring residents call light was within reach. In an observation on 08/26/2025 at 11:11 a.m., in Resident #45's room revealed residents call light was on the floor, not within reach of the resident. Resident # 46 Record review of Resident #46's admission record dated 04/25/2025 revealed a [AGE] year-old female with the original and initial admission date of 04/25/2025.Record review of Resident #46's history and physical dated 04/18/2025 revealed diagnoses of intractable epilepsy (seizures resistant to treatment), febrile illness (elevated body temperature), traumatic brain injury, and breakthrough seizures (seizure activity after a period of 12 months of not having one). Record review of Resident #46's quarterly MDS dated [DATE] revealed Resident # 46 had a BIMS score of 09, indicated moderate cognitive impairment. Section I-Active Diagnoses revealed Resident #46 was diagnosed with Anemia, Other neurological conditions, Seizure disorder, psychiatric/mood disorders, muscle weakness (generalized), unsteadiness on feet, and cognitive communication deficit. Section J-Health conditions revealed Resident #46 had two or more falls since admission without injury.Record review of Resident #46 care plan reviewed on 04/25/2025 revealed Resident #46 experienced five actual falls and ensure staff made frequent room rounds per shift and place and continue interventions on the at-risk plan.In an observation on 08/26/2025 at 10:50 AM, Resident #46's call light was wrapped around the nightstand and clipped to the drawer handle. During a revisit on 08/26/2025 at 2:46 PM, the call light was still in the same position while Resident #46 was asleep. Resident #47 Record review of Resident #47's admission record dated on 01/17/2025 revealed an [AGE] year-old female with an admission date of 11/08/2023.Record review of Resident #47's history and physical dated 01/17/2025 provided resident's diagnoses of left hip fracture, generalized weakness, Myotonic Dystrophy ( A muscle disease featuring an inability to relax muscles at will), and high blood pressure. Record review of Resident #47's quarterly MDS dated [DATE] revealed a BIMS score of 02, indicated severe cognitive impairment. Section GG-Functional Abilities revealed Resident #47 was coded for having impairment on both sides on her upper extremity and substantial/maximal assistance for completing activities for daily living and mobility.Record review of Resident #47's care plan enacted on 01/17/2025 revealed the resident had an actual fall while attempting to ambulate on 07/07/2024 and intervention implemented was to educate the resident on the importance of utilizing the call light for assistance. Resident #47 was previously identified as a fall risk beginning on 11/29/2023. In an observation made on 08/27/2025 at 09:29 AM, in Resident #47's room, the call light was observed on the visitor chair and wrapped around the front right leg approximately hanging one foot from the ground. Resident #47 was sitting in their wheelchair facing away from the call light. In an interview on 08/28/2025 at 1:53 PM, CNA G reported the purpose of the call light is to provide residents with means of communication to staff in need of assistance, care, and emergencies. She reported that CNA's and Nurses are responsible for ensuring that call lights are within reach for the resident. Photos of call lights observed in the facility was presented to CNA G, who confirmed that the call lights were out of reach. She denied having a recent in service on call lights since beginning employment at facility. CNA G stated the resident could fall, be soiled, thirsty, amongst other outcomes if the call light is not in proximal distance for resident's access. In an interview on 08/28/2025 at 2:14 PM, LVN F said call lights are utilized for residents to communicate needs, concerns, and assistance. She confirmed that CNAs and Nurses are responsible for monitoring call lights and adjusting call light position if out of reach. LVN F stated her last in-service training for call light use and positioning was this year. She reported the effect this could have on a resident could be frustration, being left in pain, and affect resident's dignity.In an interview on 08/29/2025 at 4:30 pm, the DON said call lights was for residents to use to be able to ask for assistance. She stated that it was a form of communication between staff and residents. She stated that call lights not being within reach of residents put the residents at risk of not receiving the assistance they were requesting. She stated that all staff, especially nursing and CNAs, were responsible for ensuring that call lights were within reach of the residents. She stated that the last Inservice done was in July 2025. In an interview on 08/29/2025 at 04:33 PM, the administrator said that call lights are used to assist residents with needs and provide a form of communication for assistance. The administrator said that a resident without a call light would limit that individual's ability to communicate with staff and provided examples of what a resident might need (soiled, be in pain, cause infections and skin irritation). The administrator said that everybody who is employed at the facility is responsible for repositioning call lights, to include non-nursing staff. Additionally, the administrator said MDSS, ADONs, and DON are responsible for ensuring nursing staff and CNAs are completing rounds and positioning call lights within reach. The administrator stated the call light should be within reach for residents and be placed on the bed, rail, wheelchair, shirt, or have it in their care plan for any variance of the previously mentioned. The administrator said the last in-service for call lights was conducted 2-3 months prior. The administrator agreed the photos provided displayed call lights outside of resident's immediate reach. The administrator said this deficiency limits the residents' ability to communicate which could result in the resident feeling frustrated, embarrassed, and infringe on their dignity. Record review on 8/29/2025 at 1:05 PM of Call System, Residents does not address accessibility of call light placement in relation to the resident. The facility's policy states, Each resident is provided with means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview, and record review, the facility failed to provide ADL care for 2 of 16 residents (Resident # 99 and #156) reviewed for ADLs.-The facility failed on 08/26/2025 to ensure Resident #99 and #156's fingernails were trimmed, clean and free from debris.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.The findings include: Resident # 99.Record review of Resident # 99's admission Record dated 8/27/2025 revealed a [AGE] year-old male with an admission date of 12/11/2023.Record review of Resident # 99's health and physical dated 08/11/2025 revealed medical diagnoses of anxiety disorder, panic attacks, depression, and hypertension. Record review of Resident # 99's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. It indicated the resident required supervision or touching assistance with his personal hygiene. MDS indicated the resident required substantial to maximal assistance with toileting hygiene, shower, bathing and lower body dressing. Record review of Resident # 99's care plan dated 08/26/2025 revealed the resident had an ADL self-care performance deficit related to cerebrovascular accident (a medical emergency that occurs when the blood flow to a part of the brain is suddenly interrupted). The care plan interventions stated the resident had been educated on the importance of hand hygiene as needed. The care plan revealed the resident required limited assistance with personal hygiene. Resident # 156. Record review of Resident # 156's admission Record dated 8/27/25 revealed a [AGE] year-old female with an admission date of 09/13/24. Record review of Resident # 156's health and physical dated 09/10/2024 revealed medical diagnoses of anxiety disorder, major depressive disorder, muscle wasting and atrophy, diabetes mellitus (a chronic metabolic disease characterized by elevated levels of blood sugar) and unspecified dementia. Record review of Resident # 156's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. The MDS revealed the resident required substantial to maximal assistance with toileting hygiene, showering and lower body dressing. Record review of Resident # 156's care plan dated 08/26/2025 revealed the resident had an ADL selfcare performance deficit. The care plan revealed interventions from staff to assist the resident with showering and personal hygiene.In an observation and interview with Resident #99 on 08/26/2025 at 10:30 AM, the resident was lying in bed. Resident #99's fingernails were long and dirty. He stated that he did not like to have long fingernails, and that the facility did not allow the residents to have nail clippers in their possession. Resident #99 stated he tried his best to keep his nails clean but without equipment to clean them, it was difficult for him. Resident # 99 stated he had requested the facility to help him trim his fingernails in the past couple of weeks, but they had not gotten back to him. In an observation and interview on 08/26/25 at 10:50 AM Resident #156 was found lying in bed watching TV. Resident #156's fingernails were long and had debris under her nails in both hands. Resident #156 stated she did not wish to have long fingernails and had requested assistance from the staff to trim them when she was assisted to take a shower, but they had not gone back to help her. She stated she needed to wait until she was assisted with toileting or showers to wash her hands and underneath her fingernails. In an interview on 8/28/25 at 1:22 PM with CNA C, she stated it was not acceptable for residents to have long fingernails. CNA C said that if staff found long fingernails on a resident, they were to report it to an RN who would decide whether to trim the fingernails or refer the resident to a podiatrist. CNA C stated that when staff assisted a resident with a shower, they had to report to the RNs of anything abnormal with the resident's skin or physiology, including nail length. CNA C said that the facility did not allow nail clippers to be left with residents as a preventative measure, so they do not harm themselves. CNA C stated that the risk of leaving a resident with their nails long could result in a risk of infections if they ate with their hands and their nails were long and dirty. CNA C explained there was also a risk of residents scratching themselves which could result in skin infections. In an interview on 8/28/25 at 1:29 PM with CNA D, she stated RNs was supposed to trim the residents' fingernails. CNA D explained that RNs was informed after assisting residents with hygiene or showers and they would assist the resident with nail clipping. CNA D stated the risk of them not being assisted with their nails getting clipped could result in them getting anxious or depressed, making them feel the facility did not care about them, and physically there was a risk for them scratching themselves or digging into their skin which could result in an infection.In an interview on 8/28/25 at 1:35 PM with CNA E, she stated that CNAs was responsible for assisting the residents with nail trimming their fingernails if they were not diabetic. CNA E stated it was not acceptable to leave the residents' nails long because there was a risk of them scratching themselves which could lead to infection or bleeding. In an interview on 8/28/25 at 1:41 PM with LVN F, she stated it was the CNAs' and LVNs' responsibility to trim the residents' fingernails. She said if the resident was diabetic, it would be an LVN who trimmed their nails. LVN F stated it was not acceptable for the residents not to be assisted with this ADL because this could make them feel like the facility and staff did not care about them and it could impact their mood and self-esteem. LVN F stated there was also a risk of infection if they scratched themselves with dirty fingernails and if the resident was in blood thinners, there was a risk of excessive bleeding if they scratched themselves or dug their nails into their skin. In an interview on 8/28/25 at 1:50 PM with the DON, she stated it is a correct statement that residents can't have nail clippers in their rooms because not all residents are alert and oriented and can harm themselves or other residents while trying to trim their nails. The DON stated that long fingernails could cause scratches, and they could open their skin. She explained that nails could get caught in sheets and cut or scratch the resident's skin. The DON said that mentally, leaving a resident with long fingernails could make them feel uncomfortable. The DON stated the possible outcome could be that a resident may scratch themselves and open their skin, creating irritation or bleeding. She stated that anybody can cut the resident's fingernails unless they had a diagnosis of diabetes and if it was a complicated case, the facility referred the resident to a podiatrist.In an interview on 8/29/25 at 3:50 PM with the Administrator, he stated that it was not acceptable for residents to have long fingernails if it was not their preference. The Administrator explained that CNAs were responsible for either trimming the resident's fingernails or reporting it to RNs or LVNs if a podiatrist referral was needed for a diabetic resident. The Administrator also noted that the potential outcome of long fingernails could be that residents would scratch themselves, and the resulting wounds could become infected, leading to sickness. Review of facility policy titled Fingernails/Toenails, Care of: revised in 2018, read in part: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. -The facility failed to maintain 1 of 3 washers in operating condition.The failure could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health.Findings include: During an observation on 08/28/25 at 1:30 PM, of the facility's laundry department revealed 1 commercial washer that was not operational. During an interview on 08/28/25 at 1:32 PM with the Housekeeping Supervisor revealed that the washer had been out of service for a year now. She stated that it broke down when the other company had ownership of the facility. She stated that when the new company took over, the parts for the washer were ordered. She stated that she believed that the parts for the washer were already received by the facility. She stated that since they had two working washers, the broken one did not affect residents receiving their laundry back, therefore she did not see the risk of affecting resident. During an interview on 08/28/25 at 2:00pm with Resident #41 revealed that she had not had any delays with getting her laundry back. During an interview on 08/28/25 at 2:10 pm with Resident #42 revealed that she had not had any delays with getting her laundry back. During an interview on 08/29/25 at 1:00 pm with the Maintenance Director, revealed that the washer had been broken for a year. He stated that before the new company took over, he had asked for the washer to be fixed, however it was never granted. When the new company took over, he asked for the washer to be fixed, and he was able to order the new parts for the washer. He stated that the new parts for the washer were received about a month ago, but it hads not been fixed because since there were two other washers, the third washer was not a priority and there was no excuse for that washer to still be out of service. He stated that to his knowledge, that had not delayed residents receiving their laundry back. He stated that he was the one who was responsible for ensuring the washer was in working condition. During an interview on 08/28/25 at 3:00 pm with the Administrator revealed, the washer had not been working since February 2025. He stated that they were waiting for installation. He could not confirm if the facility had received all the parts needed to fix the washer but stated that the facility would need to hire the right person to fix it as this was outside the scope of the Maintenance Director. He stated that the broken washer was mostly used to wash residents' individual clothes and napkins from the kitchen. He stated that he did not see a problem with two of the three washers being in a working condition because this had not caused a delay in residents receiving their clothes back. On 8/29/2025 at 10:30am, the Administrator stated that there was no policy regarding essential equipment.

Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include providing a written summary of investigation to resident or resident representative filing the grievance for 1 (Resident #114) of 6 residents reviewed for resident rights. -The facility failed to provide a written summary of the investigation to resident or resident representative who filed the grievance as per facility policy for Resident #114. - The facility Administrator failed to follow up on grievances related to misappropriation of personal property for Resident # 114.This failure could place residents at risk of not receiving resolutions to their grievances. Findings included: Record review of Resident #114's face sheet dated 08/29/2025 revealed a 77 y/o female admitted on [DATE]. Record review of Resident #114's history and physical dated 07/23/2025 revealed Resident #114 with a diagnosis of dementia. Record review of Resident #114's quarterly MDS assessment dated [DATE] revealed a BIMS score of 02 meaning severe cognitive impairment. In an interview on 08/27/2025 at 11:30 a.m., Resident # 144's responsible party, she stated that she let facility social worker know when Resident #144's phone went missing. She filed a grievance form on 07/25/25 concerning this matter. She stated that she was advised to file a police report by the social worker. She stated that she had also asked the social worker to speak to the facility administrator, and he had yet to follow up with her, from 08/01 to present. She stated that she was frustrated due to the lack of communication on following up with her on filed grievance. She stated that she had not received any type of documentation regarding the investigation done on part of the facility regarding lost phone. Record review of Grievance report on 08/28/2025 dated 07/25/2025 revealed that the grievance form was completed by facility social worker and grievance was reported and reviewed by facility administrator that same day on 07/25/2025 per his signature. Resolution of grievance section was left blank, not noting whether resolution was reached or not. In an interview on 08/29/2025 at 10:15 a.m., the social worker said that she assisted with reviewing grievances and providing recommendations as the facility grievance officer. She stated that when a grievance was filed, she discusseds with the team to include the DON and administrator to reach a solution regarding each grievance. She stated that she then talked to the family or resident to let them know what the conclusion was. She stated that if the person who filed a grievance was not happy with the outcome there was other available solutions such as offering a care plan meeting with the care team to be able to address concerns. She stated that typically resolutions were documented on grievance form along with the investigation that was done by the facility. Social worker stated that the resolution of grievance section of Resident #144's grievance form was left blank because, resident representative did not provide follow up on missing phone location as she was instructed by local Police Department and because resident representative had stopped speaking to facility social worker making it difficult to establish contact. She stated that she did not provide a written summary of findings/ resolutions to resident representative because she did not ask for it. She stated that she was not sure that as per facility policy she had to provide a written summary of findings or interventions taken by the facility to correct issues. She stated that she did not provide a written summary of findings and actions taken to person filing grievance unless they directly asked for it. In an interview on 08/29/2025 at 3:30 p.m., the Administrator said that he was made aware of this grievance on 08/26/2025 although he acknowledged signing the grievance form on 07/25/2025 and stated that he did not pay attention to what the grievance was about when he signed it. He stated that today he saw an email that was sent from Resident #144's representative on 08/26/2025 and replied to that email today 08/29/2025. He stated that typically he communicated with the social worker regarding following up on grievances but overlooked this grievance and stated that facility did not follow policy and procedure regarding grievances. He stated that social worker let him know that she provided guidance to resident representative on steps to take to correct concern. He stated that he was not sure that a written summary of findings/investigation actions was supposed to be provided to the person filing grievance. He stated that by not following up with grievances filed, a resident and any person filing a grievance could be affected by developing lack of trust, and fear of filing a grievance due to it not being followed up promptly and not knowing the outcome of the grievance. Review of grievances/ complaints, filing policy and procedure revised 04/2017 read in part . The resident, or person filling the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #131) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident #131's oxygen concentrator filter free from lint and dust. This deficient practice could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include:Record Review of Resident #131's face sheet dated 08/27/25 revealed a [AGE] year-old female with admission date 08/12/25. Record review of Resident #131's Nursing Home PPS (Prospective Payment System) MDS dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. Record review of Resident #131's history and physical dated 08/21/25 revealed a medical history which included: Hypertension (high blood pressure), Chronic Pain, impaired mobility and cognition. Record review of Resident #131's care plan revealed the resident received oxygen via nasal cannula (a flexible tubing with two prongs that fit into a patient's nostrils and provides continuous oxygen from an oxygen source such as a tank or concentrator). The interventions noted included for staff to keep room cool and free of irritants (smoke, dust, cleaning agents). Observation on 08/26/25 at 2:22 PM of Resident #131 in her room, revealed the resident was lying in her bed with oxygen on via nasal cannula at 4 liters per minute. The oxygen concentrator air filter was observed with dust and lint. During an interview on 08/29/25 at 10:47 AM with CNA G, she stated Sunday night shift nursing staff were responsible for cleaning the oxygen concentrator filters. She stated cleaning the oxygen concentrator filters could be completed as needed if observed dirty, including day shift nursing staff. She stated the nurses were responsible for monitoring the CNAs to ensure they completed tasks such as cleaning the oxygen concentrator filters. CNA G stated the risks of dirty oxygen filters included bacteria and potential illness to residents. In an interview on 08/29/25 at 11:36 AM with LVN F, she stated the Sunday night shift nursing staff were responsible for cleaning oxygen filter concentrators. She stated Central Supply was also responsible for the supplies including clean oxygen filters. She stated the risks of dust on oxygen filters included residents potentially being exposed to infections. In an interview on 08/29/25 at 12:13 PM with Central Supply, she stated night shift CNAs cleaned residents' oxygen concentrator filters. She stated she was not aware who was responsible for monitoring oxygen filters. She stated the risks of dirty oxygen concentrator filters included residents catching an infection. In an interview on 08/29/25 at 03:59 PM with the ADON, she stated all nurses were responsible for monitoring oxygen concentrators and their filters. She stated the ADONs and the DON were responsible for monitoring staff and residents which included residents' oxygen concentrators. She stated the risks of dusty oxygen concentrator filters for residents included infection or illness. In an interview on 08/29/25 at 4:25 PM with the DON, she stated the nurses on Sunday night shifts were responsible for cleaning oxygen concentrator filters. She stated oxygen concentrator filters were to be clean. She stated supervisors from different departments were assigned different residents which they round on daily throughout the week. She stated the residents' needs, and their environment was assessed including the oxygen concentrators. She stated the risks of dirty oxygen concentrators included bacteria and infections for residents who utilize oxygen. Record Review of the Patient Manual provided by the facility titled, Millenium M10: Respironics revealed in part: Maintenance: Cleaning and Changing the Air Inlet Filter- Cleaning the air inlet filter is the most important maintenance activity that you will perform and should be done at least once a week.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 nurse medication carts (400) reviewed for medication storage. The nurse medication cart used for hall 400 was inspected on [DATE] and had an insulin vial that had an open date of [DATE] which meant the insulin had already expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.The findings were: During an observation and interview on [DATE] at 11:46 AM revealed the nurse medication cart for hall 400 was inspected with LVN B present. In the top drawer of the medication cart was a 10ml insulin vial that had been opened and had an open date of 06-30-25. LVN B said she had not noticed the vial had expired and that it was each nurse's responsibility to monitor for that. LVN B said she would remove the vial from the cart as it had expired since they were only good for 30 days after being opened. LVN B said if that insulin was used on a resident, then it could lead to the medication not being as effective. During an interview on [DATE] at 1:22 PM the DON said the expectation was for nursing staff to remove expired insulins from the medication carts. The DON said once the insulin container was opened, they were usually good for 28 to 30 days. The DON said if insulin that had expired was used then it could lead to adverse effects and not be as effective. The DON said it basically was each nurse's responsibility to inspect their medication cart for any expired or undated medications and discard them. During an interview on [DATE] at 1:54 PM the Administrator was made aware of the observation of the expired insulin vial found in the nurse medication cart. The Administrator said it was expected for the nursing staff to remove the expired insulins from the cart. The Administrator said if that insulin was used it could lead to adverse effects and not the desired effect. Record review of the facility document titled Insulin administration and dated 2001 indicated in part: Steps in procedure - Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time om the vial (follow manufacturer recommendations for expiration after opening). Record review of the facility document titled Medication storage and dated 01/25 indicated in part: Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Record review of the insulin manufacturer instructions dated 2022 indicated in part: After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 31 days. Keep away from heat and out of direct light. Throw away all opened vials after 31 days, even if there is still insulin left in the vial.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #44) reviewed for incontinent care in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #44. The failure could place resident's risk for cross contamination and the spread of infection.Finding included: Record review of Resident #44's electronic admission record dated 08/26/2025 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #44's quarterly MDS dated [DATE] indicated in part: BIMS = 15 indicating the resident was cognitively intact. Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Occasionally incontinent. Record review of Resident #44's care plan indicated in part: I am Frequently incontinent of Bowel and Bladder. I will remain free from skin breakdown due to incontinence and brief use through the review date. INCONTINENT: Check me every 2hrs and as required for incontinence. Provide Incontinent care as needed. Change clothing PRN after incontinence episodes. Date Initiated: 07/08/2022. During an observation on 08/26/2025 at 9:28 AM revealed CNA A performed incontinent care for Resident #44. CNA A entered the resident's room, sanitized her hands and put some gloves on. CNA A proceeded to undo the resident's brief and took some wet wipes and wiped the resident's vaginal area while her gloved hands came in touch with the resident's vagina. CNA A then turned the resident on her side and with some wet wipes wiped the resident's rectal area. The CNA's gloved hand was noticed to come in contact with the resident's buttocks and rectal area during the wiping. CNA A then took a bottle of lotion from the resident's dresser while wearing the same gloves. CNA A then took a clean brief and fastened it to the resident while still wearing the same gloves. During an interview on 08/27/2025 at 1:04 PM CNA A said she should have changed her gloves before she took the clean brief and placed it on the resident. The CNA said not changing her gloves could lead to cross contamination and re-contaminating the new brief and other items touched with the contaminated gloves. CNA A said she just forgot to change her gloves and that she had been trained on when to change her gloves but again she just forgot to. During an interview on 08/28/25 at 1:22 PM the DON was made aware of the observation of the incontinent care performed by CNA A. The DON said it was expected for the CNA to change her gloves once they became contaminated to prevent cross contamination. The DON said that she was not sure as to why the CNA had not changed her gloves. The DON said ADON H was the infection preventionist and she would conduct random training and return demonstration for CNAs regarding infection control. The DON said they would be conducting more training. During an interview on 08/28/25 at 1:38 PM ADON H said she was the infection preventionist. The ADON was made aware of the observation of the incontinent care performed by CNA A. ADON H said CNA A should have changed her gloves, sanitized her hands and put on a pair of new gloves after the CNA had cleansed the resident's private areas. The ADON said if the CNA had not done that then she was contaminating the items she touched with those gloves. ADON H said that the CNA not changing her gloves could lead to cross contamination and the spread of infections for example UTI's. The ADON said she would conduct more training and in-services regarding incontinent care. During an interview on 08/28/25 at 1:55 PM the Administrator was made aware of the observation of the incontinent care performed by CNA A. The Administrator said it was expected for the CNA to change their gloves once they became contaminated to prevent cross contamination. Record review of the facility's policy titled Perineal Care dated 2001 indicated in part: Purpose - The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures and wash hands with soap and water. Sanitize hands and put on gloves (PPE as indicated). Record review of the facility's policy titled Handwashing/Hand hygiene dated 2023 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene - Hand hygiene is indicated after contact with blood, body fluids or contaminated surfaces; after touching a resident; Before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Use an alcohol-based hand rub containing 60% alcohol for most clinical situations: Single-use disposable gloves should be used; before aseptic procedures; when anticipating contact with blood or body fluids; The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy titled Monitoring compliance with infection control dated 08/2019 indicated in part: Routine monitoring and surveillance of the workplace are conducted to determine compliance with the infection prevention and control policies and practices. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies and the availability of personal protective equipment and its appropriate use.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Residents #2, and #3) of 3 residents reviewed for accidents and supervision. The facility failed to provide supervision to prevent accidents for Residents #2 and #3 who exited the facility thru the front door on 2/26/25. The noncompliance was identified as PNC . The IJ began on 2/26/25 and ended 2/27/25. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of injuries. Findings included: Record review of Resident #2's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted on [DATE] and readmitted [DATE] with diagnoses of Parkinson's disease with dyskinesia (an age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate with involuntary movements of face, arms, or leg), muscle weakness, unspecified dementia, anxiety, repeated falls, restlessness and agitation, altered mental status, unspecified lack of coordination, attention and concentration deficit, cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 01, indicating his cognition was severely impaired. Record review of Resident #2's quarterly elopement assessment dated [DATE] revealed that the resident ambulated independently or with the use of a device. The resident frequently requested to go home and was severely impaired , as he never or rarely made decisions. He had a history of restless and wandering behavior. He had been residing in the facility for a year or more. The assessment indicated that he did not recognize stop lights or signs and was unaware of necessary precautions when crossing streets. Although he was able to state his name, he did not know the location of his current residence. He was able to recognize his physical needs. Record review of Resident #2's care plan dated 2/8/24 revealed a focus area for elopement risk/wanderer related to resident wanders aimlessly with interventions that included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Record review of Resident #2's progress note written by LVN G dated 2/26/25 revealed at approximately 8:08 pm resident was found outside of the facility with another resident. Resident was brought back to the facility and given a head-to-toe assessment. Resident had no signs of injury and was put to bed. vital signs within normal limit. Respirations even and unlabored. DON notified. Resident #3 Record review of Resident #3's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of speech and language deficits, cognitive communication deficit, dementia, anxiety, and paranoid schizophrenia. Record review of Resident #3's quarterly MDS dated [DATE] revealed his cognition was moderately impaired, there was no BIMS score noted . Record review of Resident #3's last quarterly elopement risk assessment dated [DATE] revealed that he ambulated independently or with the use of a device. His adjustment to the facility was marked by a confused expression when completing tasks. His cognitive skills were severely impaired. His behavior was noted as restlessness and wandering. He had been residing in the facility for one year or more. The assessment indicated that he did not recognize stop lights and did not know the precautions to take when crossing streets. Although he was able to state his name, he did not know the location of his current residence and did not recognize his physical needs. Record review of Resident #3's progress note written by LVN F dated 2/26/25 revealed at around 8:08 pm resident was found wondering [sic] outside with another resident. Resident was brought back in, full head to toe assessment done, no visible injuries noted. vital signs within normal limit and respiration even and unlabored . Notified DON. Observation of facility video revealed a total of 13 minutes from the time Residents #2 and #3 were seen walking out the front door to the time they were taken back inside the facility: 2/26/25 at 7:51 PM- Nurse station footage: Resident #2 and Resident #3 were walking towards the front door. A lab personnel passed by and opened the door for visitors. Both residents were seen crossing the first set of doors. 2/26/25 at 7:52 PM - Nurse station footage: Resident #2 and Resident #3 exit the front door. A lab personnel was noted walking back in. 2/26/25 at 7:53 PM- Camera from outside: captured Resident #2 and Resident #3 walking out the front door with a visitor holding the door open for them. Resident #2 had his walker, and both were wearing appropriate clothes and shoes. They both walked toward the left side of the building. Resident #2's walker appeared to get stuck in a dirt area, and the visitors assisted with Resident #2's walker . 2/26/25 at 7:53 PM - Camera from outside: The visitor walked away from Resident #2 and Resident #3, and they were no longer visible on camera. 2/26/25 at 8:07 PM - 8:08 PM - Both residents were assisted back into the facility. During an interview and observation on 3/4/25 at 7:53 pm, CNA E stated that on 2/26/25 she was the assigned CNA for Resident #3. CNA E stated she had last seen Resident #2 and Resident #3 before her lunch break at around 7:30 pm. They were observed by CNA E walking down the 400 hall together, with no agitation or distress observed. CNA E stated Resident #2 and Resident #3 wandered and walked around the facility and tended to walk together; and Resident #3, who is severely cognitive impaired, followed Resident #2. CNA E stated she did not hear any exit door alarms go off. CNA E stated when her break was over around 8:00 pm she had noticed staff walking towards the front door and observed Resident #2 and Resident #3 being assisted back into the facility through the front door. CNA E traced the steps it appears Resident #2 and Resident #3 took during their elopement, with the Surveyor. CNA E and the Surveyor walked approximately 100 feet from the facility's front door, and no hazardous materials were noted on the concrete floor , there was good light due to light posts noted approximately 20 feet from where Resident #2 and Resident #3 were found. During an observation and interview on 3/4/25 at 8:48 pm, Resident #2 was observed sitting at the edge of his bed, wearing appropriate shoes. He was alert and oriented to person only (AOx1) and appeared pleasantly confused, with no recollection of the elopement. He was unable to answer questions and showed no signs of distress. During an observation and attempted interview on 3/5/25 at 9:05 am, revealed Resident #3 was observed walking down the 400 hall toward the door before turning around and walking back up the hallway. He appeared very confused and did not respond to any questions. Two CNAs were noted by the computer station in the middle of the hallway, observing him. No signs of distress were observed. During an interview on 3/5/25 at 9:54 am, the DON stated that on 2/26/25 she received a text message from the Maintenance Director at 8:22 PM, informing her that two residents (Resident #2 and Resident #3) had been seen outside the facility. The DON stated she made her way to the facility and by the time she arrived, Dietary Aide D had already brought them back inside, and both residents were assessed with no injuries noted. The DON stated she notified the Administrator, and he took over the investigation. The DON stated she was later notified that the residents had exited the facility after a lab technician inadvertently held the front door open for them. The DON stated the next morning (2/27/25), the Maintenance Director reviewed security footage confirming that a lab technician and visitor had let Resident #2 and Resident #3 outside. The DON stated as a corrective action, the facility conducted an in-service training emphasizing that door codes should not be shared with any outside entities, including providers or family members. The DON stated the facility changed the door codes to prevent future unauthorized exits. The DON stated that both residents (Resident #2 and Resident #3) did not have any safety awareness and would have been at risk for falls and increased supervision was implemented. During an interview on 3/5/25 at 10:33 am, the Maintenance Director stated he had been notified of Residents #2 and #3 elopement on 2/26/25 after hours. The Maintenance Director stated the following day on 2/27/25 he reviewed the camera and noticed that a lab technician had opened the door for two visitors around 7:53 PM after exiting the restroom. The Maintenance Director stated she inadvertently held the door open, allowing the visitors and Residents #2 and #3 to leave. The Maintenance Director stated he also reviewed footage from the front camera, which showed one of the visitors assisting Resident #2 with his walker, as it had gotten stuck. After a few minutes, they (visitors) walked away. The Maintenance Director stated he checked the alarm system and doors and confirmed there were no issues identified. The Maintenance Director stated in response to the incident, the facility conducted in-services on elopement response procedures, specifically regarding alarm door activations, and updated the door codes to prevent future unauthorized exits. During an interview on 3/5/25 at 12:45 pm, Dietary Aide D stated that on the day of the incident (2/26/25), she had finished work around 8:05-8:10 PM. Dietary Aide D stated as she was driving off, she noticed Residents #2 and #3 near the flagpole in front of the premises (approximately 100-150 feet away from the front door). Dietary Aide D stated she immediately called Dietary Aide C, who was driving ahead of her, to confirm if she had seen them as well. Dietary Aide D stated Dietary Aide C did confirm seeing them, and she asked her to return to the facility to alert the staff while she stayed with the residents. Dietary Aide D stated it took a while to convince both residents to get into the car. Dietary Aide D stated that both residents appeared confused, with Resident #3 being the most confused of the two. Dietary Aide D stated she had recently attended an in-service about changing the door codes and was instructed not to share them. During an interview with a Visitor on 3/25/25 at 12:36 pm she said she had received a call from the administrator, who inquired about the incident and educated her on the importance of safety for all residents. The administrator advised her not to allow residents to exit the facility, as it could pose a danger to them. During an interview on 3/5/25 at 2:53 pm, the Administrator stated the DON notified him that Residents #2 and #3 had been found outside but had already returned to the facility. The Administrator stated the following morning, video footage revealed that a lab technician had opened the door for visitors, who then held it open, allowing Residents #2 and #3 to exit. The Administrator stated he contacted the lab facility to express concerns, and the lab stated they would address the issue with their staff. The Administrator stated the Maintenance Director was instructed to change all door codes, and in-service training was conducted. During a follow up interview on 3/25/25 at 12:38 pm, the DON stated that because both residents (Residents #2 and #3) were ambulatory and tended to wander near the first set of front doors, they were flagged as an attempted elopement risk in order to increase supervision . There had been no reported attempts by either resident to actually open the door. Record review of undated Elopement/Missing Resident policy revealed in part To provide an organized procedure to search for an eloped or missing resident. Staff will respond in timely and organized manner to search for a resident who has eloped or is missing. A- when a resident is noted missing from the room or unit, the staff shall inform the DON of the charge nurse in his/her absence, that we have an elopement or missing resident, the residents name, and the room number. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering on 3/4/25. Observations: During an observation on 3/4/25 at 12:45 pm, there was a laminated sign on the front door that reflected: please do not open the door for anyone that is not in your party, as it may be a resident noted in red letters and highlighted in yellow for attention. Observation on 3/4/25 at 8:48 pm, revealed CNA I pushed the front door, triggering the alarm. Four staff members at the nurses' station were observed getting up to respond. Interviews from 3/4/25-3/7/25: LVN A, CNA B, Dietary Aide D, CNA E, CNA I, CNA J, the Receptionist and Activities Director confirmed receiving in-services regarding door codes being changed with reinforcement of not providing the code to any outside entity and elopement policy that included increased supervision for high risk elopement residents. Record review: In-service to all staff: elopement policy (that included supervision) dated 2/26/25. In-service to all staff: door codes dated 2/26/25- do not provide door code to anyone this includes lab techs, pharmacy, families, outside providers, etc., please notify Administrator, DON and ADON if code has been jeopardized.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 10 residents reviewed for missing person. The facility failed to provide supervision to prevent accidents for Resident #1 who exited the building on 4/19/24 and was left to sleep outside overnight. This failure placed Resident #1 at risk of insect bites, a fall, and weather exposure, which could result in injuries, hospitalization , or death. The noncompliance was identified as PNC. The IJ began on 4/19/24 and ended 04/22/24. The facility had corrected the noncompliance before the survey began. Findings included: Record review of Resident #1's face sheet dated 07/09/24 revealed a [AGE] year-old male with diagnosis of Parkinson's disease, altered mental status, muscle wasting and atrophy, muscle weakness, unspecified lack of coordination, cognitive communication deficit. He did not have a history of wandering and/or exit seeking. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating he had moderate cognitive impairment and required x1 person assist with transfers. Record review of Resident #1's elopement risk dated 02/07/24 revealed his physical capability was total dependence, he understood and verbalized acceptance of needs for nursing home, no history of attempts to leave own residence/facility, no restless or anxiety, he was a new admission, he recognized stop lights and signs, knows precautions when crossing streets, can state his name, knew location of current residence and recognized his physical needs. He was scored low for elopement risk. Record review of Resident #1's baseline care plan dated 02/08/24 revealed I am a smoker; I have been assessed to be: independent smoker with goals My desire to smoke will be honored daily and will smoke in designated area through next review date and interventions of complete smoking assessment as per facility policy, ensure I am aware of smoking times and assist if needed, ensure staff aware of my smoking desire. There was also a focus area for ADL self-care perform ance deficit with goal will improve current level of function with all ADL's through the review date and interventions of [Resident #1] requires assistance by staff to maximize independence with transferring. Record review of Resident #1's smoking assessment dated [DATE] revealed he was cognitively capable of making the decision to smoke. He was able to understand the facility smoking policy. Resident #1 was able to indicate designated smoking area verbally/physically. Resident #1 did not have any functional limitation to prevent him from smoking without assistance or supervision. Resident #1 was able to independently light his own cigarette and had adequate vision. Resident #1 did not have a history of smoking related problems that would be hazardous to self or others. He was able to verbalize understanding of the facility's smoking policy and issues related to smoking. Resident #1 did not show any physical signs that he may have a problem with smoking safely such as cigarette burn holes in clothing, burns in body, burn on Resident #1 or/in furniture . Resident #1 did not require smoking apron, cigarette holder and supervision while smoking, Record review of Resident #1's MARS dated April 2024 revealed no medications were missed between 9:27 pm to 6:52 am Last scheduled medication was administered at 8pm on 04/19/24. Record review of facility's incident report log for April 2024, revealed no incidents noted the night of 04/19/24. Record review of patio footage revealed: 4/19/24 at 09:21:01 PM door is seen being pushed (in the bistro area). 4/19/24 at 09:27:18 PM Resident #1 was seen pushing door with hands and feet and he is on a wheelchair. 4/19/24 at 09:30:17 PM Resident #1 pushed door wider with feet. The footage did not have audio. 4/19/24 at 09:34:33 PM Resident #1 made his way out from door. 4/19/24 at 09:39:51 PM Resident #1 was seen making his way down the walkway outside. 4/19/24 at 09:43:12 PM Resident #1 was last seen on video. 4/20/24 at 06:28:47 AM empty wheelchair seen by the fence in patio area, Resident #1 was not seen. 4/20/24 at 06:40 AM Resident #1's head was seen as if raising his head. 4/20/24 at 06:52:50 AM LVN E was seen walking out and walked over to wheelchair. 4/20/24 at 06:53:32 AM LVN E approached Resident #1. 4/20/24 at 06:54:50 AM RN D was seen walking out to both LVN E and Resident #1. 4/20/24 at 06:55:52 AM both nurses assisted Resident #1 to wheelchair. 4/20/24 at 06:56:26 AM LVN E, RN D and Resident #1 entered facility. Record review of nurses' station footage revealed: 04/19/24 at 09:28:43 PM CNA A seen walking by bistro looking to the bistro direction and continued walking. Refence timeline above. 4/19/24 at 09:27:18 PM Resident #1 was seen pushing door with hands and feet. He is on a wheelchair. 4/19/24 at 09:30:17 PM Resident #1 pushed door wider with feet and went outside. During an interview on 07/09/24 at 5:36 am, CNA B stated she had worked the night shift (10 pm-6 am) on 04/19/24. CNA B stated when she arrived for report at around 9:50 pm, no unusual reports were provided. CNA B stated when she did her first round around little after 10 pm, she had noticed Resident #1 was not in his room and assumed he had gone out with family. CNA B stated she did her second round around midnight and had noticed Resident #1 was not in his room and reported to LVN C whose response was OK and continued to be on her phone. CNA B stated her 3rd round at approximately 2 am, she noticed Resident #1 was not in his room and reported it again to LVN C whose response was the same. CNA B stated she did not ask any other staff for Resident #1's whereabouts due to LVN C's unbothered response to both reports. CNA B stated 2 days later she had been questioned by the Administrator in which she realized Resident #1 had been left outside the night she had reported him not being in his room. CNA B stated she had received in-services on conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), and change of shift report to be completed room by room at bedside. CNA B stated prior to the incident she had been trained to report a missing person to her supervisor and on 04/19/24 the charge nurse (LVN C) was her supervisor. During interview on 07/09/24 at 9:01 am, Resident #1 stated he remembered the incident but does not remember the date. Resident #1 stated he wanted to go smoke and did not ask anyone. He stated he went to the back patio and pushed on the door hard enough and eventually it opened. Resident #1 stated he stared at the moon and lost track of time. He stated he remembered he fell and was not hurt. Resident #1 stated he stayed on the floor of the patio and woke up on the floor the next day. Resident #1 stated he did not sustain injuries and was not cold. Resident #1 stated he was wearing pajama pants and a tshirt. Resident #1 stated he felt safe and comfortable at the facility. Resident #1 stated he was shocked that he stayed outside all night but has not been affected by it. During an interview on 7/9/24 at 9:25 am, The Administrator stated during his investigation related to Resident #1's incident on Monday 04/23/24 he had asked the Maintenance Director to check the patio and nurse's station footage. The Administrator stated during his review of the nurse's station footage he identified CNA A looking in the direction of Resident #1 when attempting to exit the door and he continued walking as if he did not care. The Administrator stated he also identified LVN C had not been conducting her night rounds. The Administrator stated when he reviewed the footage in pieces as it allows, LVN C was seen either in the nurse's station on her phone or walking in and out of rooms but did not see her checking Resident #1's room. The Administrator stated he did not talk to CNA A due to him not returning call back since he no longer worked at the facility. The Administrator stated he had intended to suspend LVN C, but she had resigned as soon as she was questioned about the incident. The Administrator stated LVN C had stated she was busy attending to residents with tracheostomies because their alarm had gone off at least twice during the night shift and continued with medication administration and restocking supplies. The Administrator stated CNA B had reported and gave written statement she had voiced concern of Resident #1 not being in his room the night of 04/19/24 on 2 occasions and LVN C had dismissed her concerns with OK and continued to be on her phone. The Administrator stated he spoke to Resident #1 who had reported he was ok; he had mentioned wanting to go out to smoke and got distracted by watching the moon. The Administrator stated Resident #1 had alleged he had a fall and eventually dozed off and fell asleep on the floor. The Administrator stated no injuries were identified and Resident #1 had denied any pain/discomfort and denied being cold overnight. The Administrator stated he had referenced the weather and had been a little chilly over the weekend. The Administrator stated he referred LVN C's license to the Texas Board of Nursing due to lack of monitoring that placed Resident #1 at risk and about 60 residents that had been under her care on 04/19/24. The Administrator stated the facility-initiated in-services for conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), and change of shift report to be completed room by room at bedside. The Administrator stated someone had not reactivated the bistro door exit alarm that resulted in the alarm not activating when Resident #1 had pushed on the bistro exit door. The Administrator stated the bistro exit door had a delayed egress bar. The Administrator stated the Maintenance Director completed an in-service to ensure the exit doors are reactivated with pin pad by door that was alarming after silencing the alarm in the alarm panel. The Administrator stated a notice was placed over the alarm pad that instructed and reminded staff on the steps to check what door was alarming, how to silence the alarm, and to reset the door alarm by the keypad where the door was alarming. The Administrator stated this failure could have placed Resident #1 at risk of injury and insect bites. The Administrator stated the DON was responsible for overseeing the CNAs and charge nurses regarding bedside shift change report to ensure all residents were in their assigned room. The Administrator stated no other incidents were identified/reported for the night of 04/19/24. During an interview on 07/09/24 at 10:01 am, the DON stated she had started working at the facility after the incident with Resident #1 occurred. The DON stated she had been notified of the incident by the Administrator and had continued to monitor the at bedside change of shift report by spot checking at random. The DON stated there had not been similar incidents reported. The DON stated per Resident #1 elopement assessment he did not have elopement/ wandering behavior. The DON stated residents who had history of wandering and/or elopement had been moved to be placed in front of the nurse's station for closer monitoring. The DON stated this had been completed prior to her starting her job at the facility. The DON stated she had not received any report on missing person since she had started working at the facility. The all-door exits were delayed egress bar no issues have [NAME] identified with alarms not working. The DON stated maintenance had in-serviced staff on reactivating the alarm when coming back inside. A call was placed on 07/09/24 at 10:31 am to CNA A, but the mailbox was full and was unable to leave a VM with information to return call. During an interview on 07/09/24 at 1:19 pm, RN D stated Resident #1 was her patient on 04/20/24 coming on the 6am-2pm shift. RN D stated when she received report from LVN C she had mentioned there had been a few room changes and she was not going to go look for them. RN D stated LVN C did the narcotic count with her and gave report with minimal information, and she left. RN D stated when she started her initial rounds, she had noticed Resident #1 was not in his room, and she alerted CNAs to assist with room checks as she continued her rounds. RN D stated when she was notified by CNAs that Resident #1 was not in any of the rooms in his assigned hallway, she initiated code purple (missing person) and LVN E had called her to notify her that Resident #1 was found outside in the patio by him and was on the floor. RN D stated she went outside to the patio and saw LVN E with Resident #1 who was on the floor. LVN E stated she had assessed him and did not find any injuries; Resident #1 had denied any pain and denied any discomfort. RN D stated LVN E and she assisted Resident #1 back to his wheelchair and took him inside to get bathed and cleaned up. RN D stated Resident #1 was monitored closely the rest of the day with no changes in condition noted. RN D stated she notified NP who gave orders for continued monitoring. RN D stated the facility-initiated in-services for conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), to ensure the alarm was reactivated and where to find instructions to activated the alarms, and change of shift report to be completed room by room at bedside. During interview on 07/09/24 at 1:32 pm, LVN C stated she had arrived around 10 pm on 4/19/24, received report from one hallway at around 10:10 pm and proceeded to get report from the second hallway she was responsible for. LVN C stated she was the nurse responsible for the hallway where Resident #1 allegedly resided. (reviewed census dated 04/19/24; Resident #1 was on one of the hallways under LVN C's care). LVN C stated after she received report she had intended to start initial rounds but was side tracked by 2 residents with tracheostomies whose alarm started going on. LVN C stated that took some time to take care of. LVN C stated she then attempted to initiate rounds but was pulled by one of the CNAs who had stated a female resident who was on the census was not in the room. LVN C stated they looked around and the female resident was located on a different hallway. LVN C stated after that was settled, she started restocking and getting her things ready for blood sugar checks. LVN C stated she had asked the CNAs if everyone was in their room and they had stated yes. LVN C stated she got busy with medication administration and her residents with tracheostomies required treatments. LVN C stated she was not notified of Resident #1 not being in his room and had not rounded on Resident #1 due to being busy with what was explained. A call was placed on 07/09/24 at 2:53 pm to CNA A, but the mailbox was full and was unable to leave a VM with information to return call. The call was not returned by date and time of exit on 07/10/24. Record review of undated Elopement/Missing Resident policy read in part To provide an organized procedure to search for an eloped or missing resident. Staff will respond in timely and organized manner to search for a resident who has eloped or is missing. A- when a resident is noted missing from the room or unit, the staff shall inform the DON of the charge nurse in his/her absence, that we have an elopement or missing resident, the residents name, and the room number. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering on 07/03/24. In-services conducted and completed on 04/22/24 for: In-service on conducting head count at beginning of shift. In-service on alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved. (i.e., CNAs do 10pm, 12 am, 2 am, 4 am rounds and charge nurses do 11pm, 1am, 3am, 5 am rounds) In-service on code purple (missing person) In-service on change of shift report to be completed room by room at bedside. In-service on reporting to charge nurse, verifying with other staff on all hallways (CNAs and nurses) for resident accountability, and when not found in premises report to DON. In-service on ensure the adjacent door is checked and verified for closure and potential missing residents. In-service on ensure the alarm was reactivated, the alarms are to prevent elopement, checking to ensure no one has left is essential to alarm process. Record review of Resident #1's skin assessment dated [DATE] revealed no injuries noted. Record review of Resident #1's pain assessment dated [DATE] revealed no pain/distress noted and no pain voiced by Resident #1. Record review of Resident #1's SBAR dated 04/20/24 revealed no injuries noted, family member and physician were notified with no new orders provided. LVN C's license was reported to TBON (Texas Board of Nursing) on 05/02/24. LVN C's timesheet for month of April 2024 revealed 04/19/24 night shift was last day worked. CNA A's timesheet for month of April 2024 revealed 04/19/24 night shift was last day worked. Observation and interviews on 7/9/24 from 4:30 am- 6:30 am revealed CNAs B, H, I J and LVNs F, G, L, M received and understood in-services on conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), to ensure the alarm was reactivated and where to find instructions to activated the alarms, and change of shift report to be completed room by room at bedside. CNBs A, H, I J and LVNs F, G, L, M observed going in room by room for change of shift report. LVN E pushed bistro exit door and the alarm activated, CNA H and LVN G responded to the door alarm, and they pointed at the instructions over the alarm panel that read open the alarm panel, silence the alarm, light should be green. Check the surroundings with nurse in the area by that door is alarming making sure nobody gets out, then, reset the door at keypad by door alarming. Go back to panel to arm the alarm, light should be green.

Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as possible and ensure each resident receives adequate supervision to prevent accidents for 3 (Residents #22, Resident #8 & Resident #35) of 24 residents reviewed for accidents. 1. The facility failed to make sure Resident #22 had preventive measures added when Resident #22 got her hand stuck between PVC pipe of the bed that reulted in a fractured right thumb and despite the injury the facility took no steps to prevent future injuries. 2. The plastic arm of Resident #8's wheelchair was torn and exposed. 3. The plastic on the arms of Resident #35's wheelchair was torn and sticking up. This failure could place residents at risk of getting their fingers caught in beds made of PVC pipes, and at risk of equipment not staying in safe operating condition and could cause irritationed, scraped, and torn skin to residents Findings included: Record review of Resident #22's Face Sheet admission on 03/04/2020 to the facility. Record review of Resident #22's History and Physical dated 09/09/2021 revealed an [AGE] year-old female with a diagnosis of Alzheimer's Dementia and mixed anxiety and depressive disorder. Record review of Resident #22's Order Recap 03/07/2023 admitted under 2 Oaks Hospice with dementia with other behavioral disturbance. 04/08/2023 behavior monitoring for withdrawn, lack of interest, feeling helpessness; 04/22/2023 right hand x-ray to rule out fracture use of portable (xray) due to bed bound status. Record review of Resident #22's Care Plan dated 03/10/2023 potential for spontaneous fractures of Osteoporosis, will be kept safe, comfortable, and functional without experiencing any fractures. 03/29/2023, Resident was at risk for falls cognitive impairment with impaired safety awareness. Attempt to identify cause of fall and alleviate problem to extent possible, educate on noncompliance with safety interventions and explain possible risks/outcomes, observe frequently and place in supervised area when out of bed. Observation on 05/22/2023 at 9:02 AM Resident #22 was sitting down on her fall mat leaning against her PVC piped bed that exposed holes in between the mattress and the pipes. Interview on 05/22/2023 at 3:53 PM Weekend Supervisor stated Resident #22 had caught her finger in between the PVC piping of the bed when she was trying to get out of bed. Weekend Supervisor stated Resident #22 tried to transfer herself and got it stuck which led to a right thumb fracture. Weekend Supervisor stated she was not aware of any alterations to the PVC piping bed to ensure that Resident #22 would not get her fingers caught again. Weekend Supervisor stated resident was restless, constantly moving in bed and sitting on the side of the bed or on the floor mat. Weekend Supervisor stated when resident sustained the fall her finger got stuck in a gap that was between the bed frame and mattress. Weekend Supervisor stated resident was able to stand up without assistance and had unsteady gait. Weekend Supervisor stated resident was able to walk with assistance. Weekend Supervisor stated the staff would not ambulate the resident when resident was restless and constantly kept sitting on the side of the bed reaching out for objects in her room. Weekend Supervisor stated resident's daughter visited the resident and did not walk the resident. Weekend Supervisor stated the incident was an unwitnessed fall and had to be categorized as a fall since it was unwitnessed. Interview on 05/22/2023 at 4:26 PM LVN B stated Resident #22 had a fracture to her right thumb when she got it stuck in between the PVC piping of the bed. LVN B stated they have not put any interventions to prevent another incident of Resident #22 getting her fingers stuck again. Observation on 05/22/2023 at 4:26 PM with LVN B, Resident #22 bed was all PVC piping with no padding or interventions to keep Resident #22 from getting her fingers caught within the piping. Interview on 05/23/2023 at 9:54 AM LVN C stated she was told in report that Resident #22 had got her finger stuck with in the piping of the bed. LVN C stated there had been no modifications or interventions put in place for Resident #22 to prevent another injury other than placing pillows in the openings of the piping of the bed. LVN C stated the facility had to come up with a solution to prevent another injury but had not. LVN C stated the risk of Resident #22 getting her fingers caught still existed. Interview attempt on 05/23/2023 at 1:54 PM with CNA W who reported the incident was condcuted but received no answer. Interview on 05/23/2023 at 3:48 PM LVN D stated she was notified of Resident #22 who was holding her finger the day of the incident where she got the finger stuck in between the mattress and PVC piped bed. LVN D stated Resident #22 was holding her right hand where her right thumb was very swollen. LVN D stated it was getting bruised and x-ray was ordered to confirm if the finger was fractured. LVN D stated it was confirmed fractured. LVN D stated the CNA had told her that she found Resident #22 with her hand caught between the PVC piped bed pipes. LVN D stated the facility did not do any interventions to address the piped bed to prevent any future injuries. Observation on 05/24/2023 at 2:26 PM revealed Resident #22's bed PVC piping had been wrapped in a green padding. Interview on 05/24/2023 at 3:57 PM DON stated Resident #22 was trying to get up from bed and got her finger stuck with the bed resulting in a fracture. DON stated she had instructed for the staff to place pillows in the areas where the pipes were exposed so that Resident #22 would not get caught and further injury herself. DON stated that the risk still existed, and Resident #22 could still get injured. Interview on 05/24/2023 at 5:24 PM Administrator stated the incident for resident #22 was not discussed in the morning meeting and nothing had been done to prevent recurrence of injury. DON did not mention if the bed was reevaluated for Resident #22 to make sure it was appropriate for Resident #22's needs. Record review of the facility incident report dated 05/22/2023 indicated Resident #22 had a fall due to to trying to get out of bed, trying to stand up. Resident #22 had fractured her right thumb and was going to be sent out to the hospital. It was reported that the doctor, family, and hospice were notified of the incident. It was stated that the family and hospice had agreed to not send out the resident and care was given by the facility. Incident Report did not indicate any interventions to prevent future injury to Resident #22. Review of Resident #8's face sheet dated 05/24/2023 documented that she was a [AGE] year-old female with an admitted to the facility of 01/17/2020. Review of History and Physical dated 08/10/2022 documented she had a diagnosis of dementia and had decreased mobility. Review of Resident #8's comprehensive care plan dated 02/04/2023 documented Resident #8 required assistance with ADLs: transfer and bed mobility. Goal was that resident would not decline in transferring/ bed mobility. Interventions included to assist resident with 1 staff for transfers and encourage the resident to participate to the fullest extent possible with each interaction. Review of Resident #8's quarterly MDS assessment dated [DATE] documented she had a BIMS score of 2 (severely cognitively impaired). She required extensive assistance with one person assistance to transfer and to move around the facility. She used a wheelchair. Record review of Resident #35's face sheet dated 05/22/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #35's History and Physical dated 03/03/2023 documented in part that she had diagnoses including multiple sclerosis, repeated falls, and morbid obesity. Record review of Resident #35's quarterly MDS dated [DATE] documented in part that her BIMS was 14 (cognitively intact). She did not walk during the lookback period. She required extensive assistance from two people to transfer between surfaces and extensive assistance from one person to move around the facility. She used a wheelchair. Record review of Resident #35's care plan dated 02/06/2023 documented that she had an ADL self-care performance deficit. The care plan did not address the level of assistance she needed to move around the facility. In interview and observation on 05/21/23 beginning at 09:31 AM in Resident #35's room a wheelchair was observed next to her bed. It was observed with the cracked plastic cover on the arms of a wheelchair, and that the cracked plastic was curled up and felt stiff to the touch. Resident #35 said that it was her wheelchair and that she got bruising on her arms from rubbing against the wheelchair arms. Observation on 05/21/23 at 12:43 PM revealed Resident # 8's wheelchair arm rest on right side was torn and part of the exposed cushion was missing. In an interview on 05/23/23 at 8:55 AM with CNA V, she revealed Resident # 8's wheelchair had been torn for a while. She said maintenance could probably fix it. CNA V did not know why Resident # 8 had not had her wheelchair fixed. She said the risk to the resident could be a skin tear or a scrape. In an interview on 05/23/23 at 8:59 AM, LVN C revealed she did not know how long Resident # 8's wheelchair had been torn. She said the maintenance worker was the one responsible for addressing issues with wheelchairs. She said the risk of the wheelchair not being fixed could be that Resident # 8's skin could develop a skin tear. In an interview on 05/24/23 at 8:51 AM, CNA A revealed she was aware Resident # 8's wheelchair had been exposed but did not know how long. She said she would be responsible for telling the nurse but had not done so and could not state why. She said the risk of wheelchair being torn could be resident's skin breaking. In an interview on 05/24/23 at 2:13 PM with Maintenance, he revealed he had changed Resident #8's armrest after ADON had informed him it was torn. He said before then, he had not known about the wheelchair. He said the correct process was for staff to write the work order in the Maintenance binder. He said the risk of not informing him of issues with medical equipment could be that residents could get hurt. In an interview on 05/24/23 at 04:36 PM the DON said that Resident #35's broken wheelchair arm covers could cause skin tears and trauma to the patient. It was the responsibility of Central Supply to monitor equipment condition. The DON said that reports of equipment that needed repair should be put in the maintenance log, but staff may not have been aware of the log until concerns were raised recently. Record review of Maintenance book revealed no work order for Resident # 8 's or Resident #35's wheelchair had been completed. Record review of facility policy titled Preventative Measures for Wheelchairs dated 2023 read in part .All staff have a responsibility to ensure that wheelchairs in need of repairs are not used and are reported for repairs. Preventative maintenance should be performed weekly or as indicated .check arm rests .for tears . Record review of the facility Accidents and Supervision policy dated 2022 revealed the resident environment will remain free of accidents hazards as was possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards and risk, evaluating and analyzing hazards and risk, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary.

Based on observations, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for 1 (Resident #1) of 9 residents reviewed for quality of care in that: -The facility staff did not supervise Resident #1 who had a diagnosis of dysphagia (difficulty swallowing) and an altered diet. On [DATE] he had a choking incident and on [DATE] had another choking incident which resulted in his death. This failure resulted in the identification of Immediate Jeopardy (IJ) on [DATE] at 3:25PM. While the immediacy was removed on [DATE], the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents who were on an altered diet and had a diagnosis of dysphagia at risk for choking. Findings included: Review of Resident #1's Face sheet dated [DATE] showed a [AGE] year-old male with an admitted to the facility on [DATE]. He had diagnoses of dysphagia and Alzheimer's disease. Review of Care Plan dated [DATE] showed Resident #1 had a swallowing problem and was at risk for aspiration. The goal was for Resident #1 to be free from symptoms of aspiration through interventions of maintaining HOB to ,d+[DATE] degrees during feedings, crushing medications, provide thickened liquids, and monitor for respiratory status. ADLs for eating: Supervision. Interventions included to monitor food and fluid intake, provide assistance with ADL to extent necessary, and report any episodes of choking/coughing. Review of quarterly MDS assessment dated [DATE] showed Resident #1 had a BIMS score of 11 showing he was moderately cognitive impaired. This meant he had memory impairment and mental delays. Quarterly MDS showed Resident #1 had a therapeutic diet. Review of physician orders dated [DATE], showed Resident #1 had a mechanical soft texture with honey thick consistency fluids. Orders also included ST initial evaluation dated [DATE]. Review of nursing note dated [DATE] showed Resident observed to be struggling to eat due to texture of food. Resident assisted to spit out the food. Resident provided with PRN breathing treatment for bilateral anterior and posterior congestion. Resident is calm and relaxed oxygen upon inhalation treat at 1200 was 94 oxygen. Resident will continue to monitor. Review of progress note dated [DATE] showed Around 1245 this nurse was called to Resident #1's room, upon nurse arrival to room this nurse noted wheezing sound on pt.pt was sitting up on bed. pt was awake but unable to speak. Food plate was on the table tray, food on the plate was shredded beef, mashed potatoes, and broccoli in little pieces about 1cm, tick honey liquids. No obstruction noted on pt throat. This nurse immediately started Heimlich maneuver and ask CNA to get the other nurses and call 911. Nurses took turns performing Heimlich maneuver until EMS arrived around 1255. Pt was placed on supplemental 02 by face mask. Report given. Last VS BP ,d+[DATE], HR 54, T 97.4, RR 18, O2 room air 94%. weekend supervisor and NP aware. Review of progress note dated [DATE] showed This nurse called upon CNA from 100 hall. Code initiated. all nurses reported to Resident #1's room. Resident was noted to be in sitting position on side of the bed. Upon assessment resident noted with asphyxiation, related to possible obstructed airway upon oral intake. Inspection of room noted tray at bedside, resident with correct diet order of Mechanical Soft diet, and honey thick liquids. On plate resident eating mashed potatoes, smushed broccoli and shredded beef. Nurse performing Heimlich maneuver, resident non-responsive to maneuver, at this time nurses continued to attempt to dislodge obstructed airway. nurses taking turns to alleviate burn out. Paramedics previously called by charge nurse, awaiting arrival. At this time, resident was placed on a non-rebreather to alleviate breathing patterns. Resident vital signs are as follows: Last VS BP ,d+[DATE], HR 54, T 97.4, RR 18. Paramedics left facility with resident on stretcher with continuous oxygen. Resident alive and left via front door on stretcher. POA was attempted to be found in chart. Resident own POA, DON notified, ADMIN notified. Review of Hospital records dated [DATE] showed that Resident #1 had been transferred to the hospital on [DATE] due to choking incident. It showed that upon arrival to the ER, he was found to be expired. He was cold to touch and had no pulse, his oxygen level was 60 and his temperature was 97 degrees. He was pronounced dead at 13:22. Review of EMS report showed Resident #1 was a [AGE] year-old c/o choking as per nursing staff. Staff stated that Pt was eating. When staff came back to check on him Pt. was choking. Nursing staff stated that they checked Pt. airway and did not see anything in his mouth. (EMS) made Pt contact and found Pt in agonal respirations and not responding. As (EMS) was repositioning Pt to assess his airway Pt became pulseless and apneic. Pt. airway was assessed, and a big, long piece of meat was removed from his trachea. Pt improved with O2 saturations via PPV. CPR was initiated and Pt was packaged and loaded. Pt was transported . In an interview on [DATE] at 10:28 AM with CNA A, she said Resident #1 had a choking incident on [DATE] during his lunch mealtime. She said he later had another choking incident on [DATE] where he died . In an interview on [DATE] at 11:53 with CNA B, she said on [DATE], Resident #1 was struggling to breathe during his lunch meal. When she found that he was chocking, she ran out to get help. LVN C stayed with him while she ran out to get help. When she returned with the DON, she said LVN C showed them the piece of food that he was choking with by his bedside. After removal of food, the resident began to breathe better. In an interview on [DATE] at 12:00 PM with the Speech Therapist, she said she was at the facility on [DATE], but was not notified of the choking incident. She said prior to the incident, she had been working with Resident #1 because he had a history of dysphagia. She stated that on [DATE], he was upgraded from puree diet to mechanical soft with honey thick liquids after he had completed his speech therapy sessions. She stated she had not been notified of a diet downgrade for [DATE] and that for any choking incidents such as the one that occurred on [DATE], she should have been notified of the situation. She stated with the notification, it would prompt Resident #1's diet to be changed. In an interview on [DATE] at 12:01 PM with the Weekend Supervisor she said on [DATE] CNA F had called her and told her that she needed help with Resident #1 because he was choking. She called a code, and all the nurses went with her and went into Residents #1's room. Upon arrival, she saw LVN E doing the Heimlich maneuver, and switched out with her to continue the maneuver. After 2 minutes, she said a brown substance came out of his mouth. At that point, he started to wheeze breathe. 911 arrived 7 minutes after code started. She said that when Resident #1 was sent to the hospital, he was still wheeze breathing .She said she was told by LVN E that Resident #1 had later passed away. In an interview on [DATE] at 12:48 PM with LVN C, she said on [DATE] after 12:30 PM, she was charting in the nurse's station near Resident #1's room when she heard some coughing. When she walked in, he was coughing and chewing at the same time. She said she called for help from the CNAs, and she began to help him. She said she patted his back and pushed his chin down and he was able to cough up a small piece of bread from his mouth. She said CNA B, DON, and ADON were in the room. She assessed Resident #1's lungs and found them to be congested. She administered PRN breathing treatments and continued to monitor him. She said he seemed perfectly fine , and she did not call the physician because she figured he already had orders. She said she figured she had everything in place and everything she needed for Resident #1; therefore, she did not notify him. In an interview on [DATE] at 1:07 PM with the ADON, he said on [DATE], he had been called by the DON to Resident #1's room. When he walked in, he saw Resident #1 on the bed and a dime size piece of bread on the bedside table. He said the resident received breathing treatments and appeared fine the rest of the evening. He said he did not struggle with his dinner meal. He stated he did not notify the physician. In an interview on [DATE] at 10:54 AM with CNA D, she said that on [DATE], she walked in to remove Resident #1's meal tray and noticed that he looked light, pale. She said she could not hear any noises from his mouth, but she could tell he was choking. She said he was sitting up on his bed with his eyes wide open. She called for help, and LVN E began the Heimlich maneuver. The Weekend Supervisor also walked in and took over the Heimlich maneuver. In an interview on [DATE] at 11:06 AM with LVN E, she said it was about 12:30 PM on [DATE] when CNA F told her that Resident #1 was choking. When she walked in, he was sitting up on the bed and she saw him wheezing. She stated she started doing the Heimlich maneuver and the CNAs called the weekend supervisor. She said she had checked his throat but there had been nothing there. She said EMS arrived and they connected him to pulse oximeter to check his vitals. She said when he left, he was alive, was breathing and had a pulse. In an interview on [DATE] at 12:18 PM with the DON, she said on [DATE] CNA B came to her office and told her they needed help with Resident #1. She told the ADON, and they both went into Resident #1's room. She said when she walked into the room, she saw that Resident #1 was good and LVN C was showing her the piece of bread that he had been choking on. She said it was dime size. She said he looked fine, and that he was not in state of emergency. She said no changes had been made to his treatment, and the staff continued to monitor him. She stated that her nurses and herself would usually notify the physician in situations like that. She said, I did not notify him; I don't know if the nurse notified him. She stated she was not concerned with him having any more issues after the incident of [DATE]. She said she was not aware of resident having history of dysphagia. She stated that on [DATE], he had another chocking incident. The charge nurse had notified EMS, the physician, DON and Administrator. She said Resident #1 was transferred to the ER and later died at the hospital. In an interview on [DATE] at 2:29 PM with NP, she said the facility had notified her on [DATE] that Resident #1 had been choking on his meal and was sent out to the hospital. She stated she could not recall if the facility had notified her about a previous choking incident. She stated with the notification, there would have been interventions in place for Resident #1. Review of facility's policy titled Changes of Condition dated ,d+[DATE] read An accident or incident involving the resident, which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in the life-threatening conditions or clinical complications; a need to alter treatment significantly. 1. When non-licensed staff note a change in a resident, they should immediately notify the charge nurse. 2. When a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR form 3. Complete an incident/accident report if indicated 4. The nurse should document on the 24-hour report that an SBAR was completed 5. The licensed nurses and nursing assistant will communicate to the oncoming shift orally and thorough the 24-hour report the change in conditions and interventions . On [DATE] at 3:25PM the IJ was identified and the Administrator, DON and ADON were informed. The IJ template was provided at this time . The POR was requested at this time. The facility's Plan of Removal was accepted on [DATE] at 3:20 PM and reflected the following: Problem: Failure to notify on Changes of Condition Goal: Every Nurse will understand the process for following up on changes of conditions. All staff will recognize the signs & symptoms of choking. Approaches: All staff will be in-service on identified and reporting changes of conditions. Licensed staff will be in-serviced on completing SBAR (Change of Condition). A change of condition would be a fall, skin tear, fever, congestion, etc. Licensed staff are to notify MD, RP, and DON/ADON/ADMIN. Licensed staff to notify appropriate departments, such as Therapy, Dietary, Social Services. Licensed staff to communicate with IDT via 24hrs report for 72 hours and in clinical morning meeting. Q-shift charting Education to be completed by [DATE] documentation (SBAR, Progress note, Incident/Accident Report) will be completed/reviewed by nursing management Clinical meeting form to be signed after review in clinical meeting that is done Monday thru Friday. All resident who are altered diets have the potential to be affected. All residents that are on mechanically altered diets will be assessed by a nurse to ensure residents are not showing signs or symptoms of aspiration. All residents who are on altered diets have the potential to be affected. Pull report from PCC on Mechanical Diet will be posted on 24hrs for follow up. All nursing staff will be educated on where to locate a resident's diet in PCC. Staff will be in-serviced on visually looking at the while they are eating in their rooms throughout meals to ensure the resident is safe. Nursing staff will visual residents at least twice during their meal. Visual checks will be documented in PCC. Licensed staff will follow the facility policy for what is considered a change of condition. The facility will place educational material at the nurse's station for review prior to starting their first shift. Charge nurses will give verbal report in morning meeting Monday thru Friday to report any changes of condition. During the weekend the weekend supervisor will review all 24-hour sheets to ensure any changes of conditions have been documented & proper notification was done. Nurse management will review the 24-hour shift reports at least twice daily to identify any changes of conditions. Admin Team will pull 24-hour report from PCC daily to ensure all changes of conditions are identified. Speech-Language Pathologist will educate staff on safeguards for residents with swallowing disorders such as watery eyes, coughing, clearing of the throat, spitting out food & drooling. Licensed staff will educate to complete an SBAR for any change in swallowing patterns for all residents. Weekend Supervisor will review 24hrs report on Saturday and Sundays. Report to DON/ADON for further follow-ups Education Material provided to the staff will include in-service on Changes of Conditions, that will be continue with monthly education. Documents will be saved in designated area In-service all staff how to recognize signs and symptoms of choking. Staff will also be educated on the signs of choking: grasping their throat, turning blue, watery eyes, unable to speak. Staff will be provided handouts on identifying swallowing problems and what choking looks like. Staff will also be educated where the choking poster is located in the dining room. Managers were educated on change of condition & will ask random staff daily during guardian angels if they know what a change of condition is & what to do if you suspect a resident has had a change. Monthly education will be done with all staff on what to do if you think a resident has had a change of condition. On [DATE] observations, interviews and record review were conducted to confirm the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy: Observations on [DATE] at 3:30 PM revealed a staff meeting took place led by the Administrator, ADON and Speech Therapist to discuss their plan of removal and begin in-service trainings. Observations on [DATE] at 5:00 PM revealed LVN C checked meal trays on 300 hall to ensure meal correlated with diet order. Observations on [DATE] at 8:45 AM revealed CNA I was educating 3 CNAs on different meal types to include: mechanical soft, puree, and regular. She also showed them the choking hazard poster. Observations on [DATE] at 11:55 AM revealed LVN K checked meal trays in 400 hall to ensure meal correlated with diet order. CNA O was seen rounding on residents during mealtime. Observations on [DATE] at 12:03 PM revealed LVN J checked every meal tray in 300 hall to ensure meal correlated with diet order. CNA I was seen rounding on residents during mealtime. Review of Clinical meeting sign-in sheets showed there was a meeting on ,d+[DATE] and ,d+[DATE]. At this meeting, the facility discussed changes for residents that occurred day before. Review of in-services for ,d+[DATE] and ,d+[DATE] showed topics reviewed were: Identified Change of Condition documented on 24 and 72-hour reports, Reporting change of condition, assessing residents on mechanically altered diets, choking and identifying swallowing problems, visually observing residents eating at least 2 times per meal, altered food diets, daily guardian angel rounds, and identifying changes in condition. There were 58 signatures from staff on the in-service record. Review of choking hazards and signs and symptoms of choking handouts dated [DATE]. All staff were able to give examples of choking signs and what the process would be to treat it. Interviews conducted on ,d+[DATE] at 8:00 AM-1:46 PM included 6 Licensed staff and 5 CNAs of ,d+[DATE], ,d+[DATE] and ,d+[DATE] shifts. It also included dietary staff, therapy staff, activities staff, and department heads. They all confirmed receiving training regarding Change of condition policy and reporting changes to managers. All staff interviewed reported they had been trained to look out for signs of choking, monitor for changes of condition, report changes and document those changes. They verbalized they understood how to monitor for changes and report them to clinicians. On [DATE] at 2:05 PM, the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility continued to monitor its plan for effectiveness.

Based on interview, observation and record reviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for neglect. On 12/12/2019 Certified Nursing Assistant (CNA) C left Resident #1 who was confused and had unsteady gait, sitting on the toilet unattended. resident sustained [REDACTED]. This failure could place residents at increased risk of injury due to inadequate supervision. Findings include: Resident #1- Closed Record Review Review of Admission Record dated 12/18/2019 documented resident #1 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Physician's Progress Note dated 09/09/2019 for resident #1 documented, Admission Medical History: [AGE] year old female admitted from hospital status [REDACTED]. Musculoskeletal: Lower Extremities weakness. Neurological: Decreased cognition. Psychiatric: Judgment and insight poor. Safety awareness compromised. Short term memory compromised. Plan: Diagnosis: [REDACTED]. Plan: Full weight bearing as tolerated, abductor pillow to protect leg crossing. Cognitive decline. Review of Physician's Progress Note dated 09/12/2019 for resident #1 documented additional [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented: hearing adequate; clear speech; makes self understood; understands others; vision adequate; Brief Interview for Mental Status (BIMS) score 6 (Severe Cognitive Impairment); Acute onset mental status change-inattention. Activities of Daily Living (ADLs) extensive assistance from two people with bed mobility, transfers; extensive assistance of one person with locomotion on/off unit, dressing, toilet use and personal hygiene; Balance during transition and walking: not steady, only able to stabilize with staff assistance when moving on and off toilet. Functional Limitation in Range of Motion: impairment to lower extremity. Mobility Device: wheelchair. Frequently incontinent of bowel and bladder. Review of Care Plan dated 09/15/2019 for resident #1 documented: Cognitive Impairment AEB (as evidenced by) Dementia/Alzheimer's; Impaired ability to make decisions; Impaired Safety Awareness. Approaches: Involve in care to maintain or increase level of independence. Potential for injury related to History of fall and is at risk for further falls, cognitive impairment, short term memory deficit, impaired safety awareness and incontinence. Approaches: Encourage me to assume a standing position slowly and not to ambulate/transfer without assistance. Observe frequently and place in supervised area when out of bed if warranted. Ensure staff aware of safety needs of the resident. Instruct resident to call for help before getting out of bed or chair, demonstrate the use of call lights. Requires assistance with Activities of Daily Living (transfers and toilet use) related to Cognitive Deficits and immobility. Approaches: Instruct me to call for help before getting out of bed or chair. Demonstrate use of call. Answer promptly. Two persons to transfer with Hoyer Lift. Review of Fall Risk assessment dated [DATE] for resident #1 documented: Fall Risk score 27. Score over 10 indicates risk for falls. Review of Fall Risk assessment dated [DATE] for resident #1 documented: Fall Risk score 22. Score over 10 indicates risk for falls. Review of Incident Report dated 12/12/2019 for resident #1 documented: Unwitnessed Fall. Incident Description: During lunch time while trays were being served, noted resident to be absent in dining room as she is usually present for meals. Certified Nurse Aide (CNA) C went to look for resident in her room. CNA C informed nurse resident was found on the floor on left side next to wheelchair. When asked resident what happened, she stated that she got herself off the toilet and attempted to transfer to wheelchair by herself which is when she fell . Resident complained of pain to left rib and left hip. New orders for x-ray to left ribs/left hip and urine analysis to rule out urinary tract infection. Resident's Ortho wedge applied. Predisposing Physiological Factors: Confused, incontinent, gait imbalance and weakness. Review of the facility's Provider Investigation Report dated 12/12/2019 for resident #1 documented: Incident Category: Neglect. Incident Date: 12/12/2019 at 12: 00 PM. Location: Resident's bathroom. Functional Ability: Extensive. Interviewable: No. Description of Incident: Resident CNA C assisted the resident to the restroom and remained in the resident's room. CNA C stepped out of the bathroom and went to dresser to get a brief and wipes. When CNA C returned to the restroom, she found the resident lying on the floor on her back beside the toilet. Description of Injury: Left displacement of the prosthetic femoral head. Interview on 12/30/2019 at 2:13 PM, CNA L stated she had cared for Resident #1 before the incident on 12/12/2019. She indicated that Resident #1 had been in Bed B and that her briefs and wipes were kept in the large drawers of the dresser at the foot of Bed B. Observation on 01/02/2020 at 12:43 PM, with CNA L of Resident #1's bathroom and bedroom areas revealed a door to the left that led into the bathroom area. Entering the bathroom the toilet was about five feet beyond the bathroom door. A sink was situated to the left of the door and three feet beyond the sink was the toilet. Exiting the bathroom two beds were located to the left, with the Resident #1's bed located at the far end of the bedroom under a window. The large dresser for bed B where the briefs and wipes were kept was about 15 steps away from the bathroom door. Review of written statements attached to the Provider Investigation Report documented: - On 12/11/2019 on the 10:00 PM to 6:00 AM shift CNA A stated that Resident #1 was restless and trying to get out of bed very often. She was confused and pulled out (off) her brief two times and voided on her bed. - On 12/12/2019 on the 6:00 AM to 2:00 PM shift CNA B stated that when she went to change Resident A's brief it was pulled down and she seemed very anxious. Resident #1 started yelling she needed to use the bathroom again shortly after being changed and taken to the living room area. - CNA C (6:00 AM - 2:00 PM shift) documented that on 12/12/2019 she went to the get Resident #1 for lunch and the resident asked to go to the bathroom. The CNA put the resident on the toilet, removed her brief, and left the bathroom to get a clean brief and wipes which were in the resident's dresser. When CNA C returned to the bathroom Resident #1 was on the bathroom floor. - Licensed Vocational Nurse (LVN) D (6:00 AM to 2:00 PM shift) documented that on 12/12/2019 Resident #1 followed her normal routine and was calm without any complaints and did not exhibit any changes in routine or behavior prior to her fall on that day. Review of Physician's Progress Note dated 12/12/2019 for resident #1 documented: status [REDACTED]. Chief Complaint: Follow up on complaints of anxiety at night and [MEDICAL CONDITION], recent fall, and blood pressure. Re-admitted [DATE]. Resident was at the nursing home, she continued to complain of more pain to the site of her fracture, moaning and eating less. Radiology noted an acute intertrochanteric and subtrochanteric [MEDICAL CONDITION] hip. The fracture fragments are mildly displaced. A left hip arthroplasty is noted. History of Present Illness: It was brought to my attention by nurse that the patient is having anxiety at nighttime and is unable to sleep. While I was here at the facility the resident apparently fell off her wheelchair and is complaining of pain to left hip and rib area. Resident has resulting left leg internal rotation. Left leg is also shorter than the right. Will follow up with an x-ray. No acute distress. Review of X-Ray report attached to Provider Investigation Report dated 12/12/2019 for resident #1 documented: X-ray left hip; Fall. Findings: There is a subacute comminuted fracture through the stem of prosthesis. Review of a physician's orders [REDACTED]. Review of Resident #1's Census Report accessed on 12/23/2019 at 2:45 PM documented that she was discharged from the facility on 12/12/2019 and readmitted on [DATE]. Review of Hospital physician progress notes [REDACTED].#1 documented: Patient alert and oriented to name, confused. Lower left extremity with limited range of motion, increase pain with movement. [MEDICAL CONDITION] end of the left femur after a ground level fall. One to one sitter to be initiated. Patient is a poor historian likely due to dementia. Findings: Chronic dislocation of the left femoral head and pseudoarticulation with area of heterotopic [DIAGNOSES REDACTED] along the lateral acetabular rim. In an interview on 12/30/2019 at 9:23 AM, CNA A stated that she worked with Resident #1 during the 10:00 PM to 6:00 AM shift the night before Resident #1 fell . CNA A stated that Resident #1 was very agitated and had been agitated all night. CNA A reported resident #1 had removed her brief two times and had wet the bed several times on her shift and had reported these behaviors to the night nurse Registered Nurse (RN) J, two times. In an interview on 12/30/2019 at 11:26 AM, Registered Nurse (RN) J stated that on the night of 12/11/2019 Resident #1 was repeatedly removing her brief and complaining about being wet although her brief was dry. RN J stated that this behavior was unusual for this resident and that she mentioned this to the morning nurse. The morning nurse said that this was normal behavior for Resident #1 and that Resident #1 was always saying something like that. Review of Resident #1's Medication Administration Note by RN J dated 12/12/2019 at 3:17 AM documented that the resident took off her brief multiple times saying she was wet but in fact was dry. In an interview on 12/30/2019 at 2:42 PM, CNA B stated that Resident #1 was the first resident she got up on the morning of 12/12/2019. That morning Resident #1 was restless. Her brief was partially pulled down and it was dry. During and after breakfast the resident kept saying she wanted to go to the bathroom. After breakfast the CNA helped her to the bathroom, but the resident did not void. CNA B stated that Resident #1 did not seem herself and that she mentioned it to LVN D in the dining room. CNA B stated that right before lunch CNA C took Resident #1 to the bathroom again. CNA B stated that Resident #1 had a poor memory and would try to stand up on her own in the bathroom. She was only strong enough to hold on to the rails for a moment or two so CNA B would not leave the resident in the bathroom by herself. In an interview on 12/23/2019 at 12:53 PM, CNA C stated that Resident #1 was at risk for falls and needed extensive assistance from one person for transfers. She stated that on the morning of 12/12/2019 Resident #1 fell in the bathroom after she had put the resident on the toilet, removed her wet brief, and stepped out of the room to get a clean brief and wipes from the resident's dresser. The Resident's bed was the B bed (the bed furthest from the bathroom). CNA C stated that she found the brief and wipes right away and was only out of the bathroom for about 15 seconds, and that when she returned to the bathroom the resident was on the floor. CNA C stated that she always told residents not to get up without help. She stated she had never been trained to get a brief and wipes ready before providing incontinent care to residents in the bathroom. In an interview on 12/23/2019 at 2:57 PM, CNA F stated that Resident #1 was a fall risk as evidenced by having a lowered bed, fall mat and being told by the nurses to keep an eye on her. CNA F stated that she had to stay in the bathroom with Resident #1 because the resident wiggled around when she was on the toilet. The CNA F stated that she always got briefs and wipes ready before she put a resident on the toilet. In interviews on 12/23/2019 at 3:22 PM, and 01/02/2020 Physical Therapy Assistant (PTA) G stated that Resident #1 was at high risk for falls because she had a history of [REDACTED]. She stated that Resident #1 did not have good trunk strength as evidenced by her being unable to sit for long in her wheelchair before she needed to lean back for support. PTA G stated that because of her trunk strength Resident #1 would probably not be safe sitting on a toilet alone. In an interview on 01/02/2020 at 11:05 AM, Occupational Therapist (OT) K stated that Resident #1 needed trunk support to sit up and would not be safe sitting alone on the toilet. In an interview on 12/23/2019 at 4:02 PM, LVN I stated that she would not leave Resident #1 alone in the bathroom because she was always confused and had behaviors of trying to stand up without assistance and had poor safety awareness. LVN I reported that the staff had been trained on Fall Prevention. She said the staff had been trained not to leave confused residents in the bathroom without supervision. In an interview on 01/02/2020 at 11:51 AM the Director of Nurses (DON) stated that the facility did not have a specific policy on fall risk assessments, and that the Fall Risk Assessment constituted their policy. The DON stated that based on Resident#1's Fall Risk Assessments she was at risk of falls. DON reported that Resident #1 had advanced dementia. DON reported that on 12/12/2019 the CNA C had stayed in the resident's room, just not in the bathroom. DON stated that CNAs had been trained to stand right outside by the bathroom door to provide privacy to the residents while the resident used the restroom. Review of the facility's policy on Falls and Fall Risk, Managing, revised (MONTH) 2007 documented: Policy Statement-Based on previous evaluations and current data, the staff would identify interventions related to the resident's risks and causes to prevent the resident from falling and to minimize complications from falling. Policy Interpretation and Implementation: The staff, with input of the attending Physician, will identify appropriate interventions to reduce the risk of falls.