Every finding on record at Barton Valley Rehabilitation and Healthcare Center

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 of 16 residents (Residents #17, #10, #1, and #63) reviewed for activities. The facility failed to ensure Residents #17, #10, #1, and #63, all of whom were completely dependent on staff, received activities that interested them. This failure placed residents at risk of depression and diminished quality of life.Findings Included:Review of the undated face sheet for Resident #17 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and often the face, causing significant muscle stiffness and motor impairment), severe intellectual disabilities, Rett syndrome (genetic disorder that typically becomes apparent after 6-18 months of age; symptoms include impairments in language and coordination, and repetitive movements), dysphagia (trouble swallowing), cognitive communication deficit (problems communicating due to cognitive impairment), protein-calorie malnutrition (lack of protein in the diet), epilepsy (seizure disorder), depressive episodes, gastrostomy status (feeding tube), and chronic pain. Review of the annual MDS assessment for Resident #17 dated 10/10/2025 reflected her cognitive impairment was so severe that she could not participate in a BIMS assessment for cognition. The staff assessment for activity preferences included listening to music and spending time outdoors. Review of the care plan for Resident #17 dated 06/06/2025 reflected the following: (Resident #17) requires one on one activities. (Resident #17) will accept and participate in 1: 1 visits such as listening to cartoon soundtracks Activity assistant will visit with me once a week. She enjoys watching cartoon movies. She likes sensory stimulation, hand massage, soft music to be played while in her room. Massage. Staff will assist me to morning stroll once a week. She likes to go outside when weather outside for fresh air permits. (Resident #17) does not like loud noises or big crowds. She likes observing when out in common areas. Review of POC documentation for Resident #17's activities from 03/17/2026 to 04/16/2026 reflected one 1:1 music/sensory visit on 03/28/2026 and no other activities of any type. Observation on 04/14/2026 at 10:21 AM revealed Resident #17 lay in her bed, peg tube disconnected. There was no music playing in the room, and her roommate's television was on a Western. Resident #17 made eye contact and made expressions (curiosity, [NAME], frustration) but could not speak. Identical circumstances (other than the peg tube being connected) were observed on the following dates and times:04/14/2026 11:48 AM04/15/2026 09:30 AM 04/15/2026 10:10 AM 04/15/2026 11:35 AM04/15/2026 01:47 PM04/15/2026 03:24 PMNeither the AA nor the AD were seen going into Resident #17's room from 04/14/2026 to 04/16/2026. Observation on 04/16/2026 at 11:35 AM revealed Resident #17 was up in a tilt-back wheelchair next to her bed. There was a western on her roommate's television, and her roommate was not in the room. She interacted non-verbally by making eye contact, making noises, and moving her face. Review of the undated face sheet for Resident #10 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to embolism of right middle cerebral artery, parkinsonism, epilepsy, aphasia, and gastrotomy status. Review of the annual MDS assessment for Resident #10 dated 02/26/2026 reflected she could not participate in the BIMS assessment for cognitive function. The staff assessment for cognition indicated she was severely impaired. The staff assessment for activity preferences indicated she enjoyed listening to music. Review of POC documentation for Resident #10's activities from 03/17/2026 to 04/16/2026 reflected no activities of any type documented. Observation on 04/14/2026 at 10:08 AM revealed Resident #10 lying in her bed, connected to her peg tube. There was no music playing in the room, and the television was off. Resident #10's eyes were open. Identical circumstances were observed on the following dates and times:04/14/2026 11:11 a.m. 04/15/2026 7:06 a.m. 04/15/2026 10:10 a.m. 04/15/2026 12:10 p.m.04/16/2026 9:34 a.m. 04/16/2026 11:31 a.m. 04/16/2026 1:35 p.m. Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, anxiety, disorder, depression, and muscle weakness. Review of the admission MDS assessment for Resident #1 dated 11/18/2025 reflected a BIMS score of 07, indicating severe cognitive impairment. Her activity interests included listening to music and participating in religious activities. Review of the care plan for Resident #1 dated 11/18/2025 reflected the following: Focus(Resident #1) enjoys observing while in common areas. She uses a tilt in space wheelchair and needs assistance to and from activities. Resident participates in (facility) furry friends program. (Resident #1) has a cat. Activity director to monitor for preferencesGoal(Resident #1) will accept and verbally engage during one-to-one visits for socialization and exploration of leisure interests 1 to 2 times weekly for next 90 days.InterventionsActivity staff will post monthly calendar in my room.Staff will encourage/assist me to activities of my preference. Observation on 04/16/2026 at 11:28 AM revealed Resident #1 lay in her bed, looking out the window. There was no music playing in the room. She was observed in her bed without any activity or interaction on the following dates and times:04/14/2026 11:40 AM04/14/2026 12:58 PM04/14/2026 2:12 PM04/15/2026 9:30 AM 04/15/2026 10:13 AM 04/15/2026 11:20 AM04/15/2026 1:44 PM04/15/2026 3:30 PM04/16/2026 10:01 AM04/16/2026 11:33 AMNeither the AA nor the AD were seen going into Resident #1's room from 04/14/2026 to 04/16/2026. Review of the undated face sheet for Resident #63 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included encephalopathy, cerebral infarction, protein-calorie malnutrition, aphasia, muscle weakness, dysphagia (trouble swallowing), gastrostomy status (feeding tube), cognitive, communication deficit, adult failure to thrive, and dysarthria and anarthria. Review of the admission MDS assessment for Resident #63 dated 04/06/2026 reflected her cognitive impairment was so severe that she could not participate in a BIMS assessment for cognition. The staff assessment for activity preferences included listening to music, participating in religious activities, and spending time outdoors. Review of the care plan for Resident #63 dated 04/06/2026 reflected the following: Focus(Resident #63) is dependent on staff for activities. She does need 1:1 visits for socialization. (Resident #63) does enjoy watching tv and listening to music in her room.Goal(Resident #63) will accept and participate passively in 1:1 visits such as sensory stimulation, music and going outside forfresh air, 1-2 times weekly over next 90 days.InterventionsActivity director will provide me with in-room activities as needed and required.Staff will assist me to activities of my preference. Observation on 04/14/2026 at 10:28 AM revealed Resident #63 lying in her bed. There was no music or television on in the room. Resident #63 did not respond to efforts to communicate with her. Identical circumstances were observed on the following dates and times:04/14/2026 11:50 AM04/14/2026 1:45 PM 04/15/2026 9:10 AM 04/15/2026 10:18 AM04/15/2026 11:40 AM04/15/2026 01:40 PM04/15/2026 03:19 PM04/16/2026 10:04 AM04/16/2026 11:26 AMNeither the AA nor the AD were seen going into Resident #63's room from 04/14/2026 to 04/16/2026. During an interview on 04/15/2026 at 02:13 PM the AA stated she documented activities in the POC. She said there were three types of activities: one-on-one, group, and independent activities. She stated sometimes she did not have the chance to document in the POC right away, so she wrote down the activities on a piece of paper and entered them in the POC at the end of the day. She stated she always documented the activities. During observation and an interview on 04/16/2026 at 09:03 AM, the AA was walking from the common area by the Unit 1 nurse's station and checking in with residents up and down the adjacent hall. She stated she had been letting everyone know about the group activity they were having. She stated the way she usually handled inviting residents to the group activities was to let the residents and nursing staff know and ask the CNAs to help get residents to the activities. She stated the CNAs did not always have time to get residents up and assisted to activities. She stated she had been assisting residents in their wheelchairs to activities but had just undergone surgery and was not able to do so for the present time. She stated the AD sometimes helped with transporting residents to activities, but there was no back up plan for assisting residents to Unit 1 while she (the AA) was unable to help. During an interview on 04/16/2026 at 01:22 PM, the AA stated when she had invited residents to activities that morning at 9:03 AM, a few of them had refused, but she had not addressed inviting Residents #17, #10, #1, or #63. She stated she relied on the staff to get those residents out of bed in order for her to bring them to activities, and the staff did not get them out of bed. She stated she did in-room activities with Resident #17, but she could not remember exactly when. She stated the last documented activity for Resident #17 was the last activity she did. She stated she did not do activities with Resident #1, because Resident #1 did not want to do activities with her. She stated she did not know Resident #63 or Resident #10 at all. During an interview on 04/16/2026 at 2:02 PM, CNA L stated he worked on the hall where Resident #1 lived. He stated anytime the activities department had a big party, like on a major holiday, they made sure everyone got up and attended for residents who wanted to. He stated Resident #1 did not like to participate in group activities and did not enjoy most of the staff, but she loved to listen to Spanish-language music. He stated he did not think she had a radio, but her roommate might not want to listen. He stated if she had a pair of headphones, she would probably love it. He stated no staff from activities had asked him to provide feedback about how to help Resident #1 enjoy activities. During an interview on 04/16/2026 at 2:10 PM, CNA M stated he worked on the hall where Residents #17 and #63 lived. He stated he had seen the AA and the AD go in Resident #17 and Resident #63's rooms, but he did not remember when. He stated he was never asked to bring residents to activities. During an interview on 04/16/2026 on 3:13 PM, the AD stated all visits and activities should have been documented by her or the AA in the POC. She stated she scheduled one or two 1:1 visits each week with residents who needed 1:1 visits.She stated Resident #1 loved conversation with her and lit up when the AD came in for a visit. She stated she was not sure when the last visit with Resident #1 was, but Resident #1 definitely needed more activities. She stated, in general, the 1:1 visits were not being utilized thoroughly and the residents needed more. She stated the CNAs did not get residents out of bed or bring them to activities, and she did not think she had asked them to. She stated the AA was always telling her Resident #10 was asleep every time she went by the room. She stated she did not really know Resident #63. During an interview on 04/16/2026 at 4:08 PM, the ADM stated the AD was responsible along with any of the IDT. He stated the nursing staff had a role in ensuring residents could get to activities. He stated he ensured compliance by monitoring and observation, interactions with the patient, and routine rounds. He stated the potential negative impact of not receiving activities could be depression. Review of facility policy dated June 2018 and titled Activity Programs reflected: Policy StatementActivity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.Policy Interpretation and ImplementationThe activities program is provided to support the well-being of residents and to encourage both independence and community interaction.Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health.Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote:self-esteem;comfort;pleasure;education;creativity;success; andindependence.Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members may also provide the activities.All activities are documented in the resident's medical record.Activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident # 2) reviewed for dialysis:The facility failed to ensure Resident #2 had a physician's order for hemodialysis (machine filters the blood when kidneys do not work) 3 x week on Mondays, Wednesdays, and Fridays.This failure could have placed residents on hemodialysis at risk of not receiving proper care and/or treatment.Findings Included:Record review of Resident #2' s admission MDS assessment, dated 03/30/2026, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 was diagnosed with end-stage renal disease and was dependent on renal dialysis (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood effectively) and hypertension (high blood pressure). The MDS did not reflect Resident #2 was receiving dialysis.Record review of Resident # 2's care plan, dated 3/30/2026, reflected Resident #2 attends dialysis Mondays, Wednesdays, and Fridays. Date Initiated: 04/01/2026.Record review of Resident # 2's Progress notes , dated 4/13/2026, reflected Resident # 2 was a [AGE] year-old female with past medical history including non-insulin dependent diabetes mellitus type 2, ESRD. When the resident was admitted on [DATE], records reflected the resident was Dependent on renal dialysis. Resident dependent on hemodialysis Monday, Wednesday, Friday for end-stage renal disease. Interview and observation on 04/15/2026, at 11:38 AM, revealed Resident #2 was waiting on her ride to go to dialysis, and she attended every Mondays, Wednesdays, and Fridays. She stated she had been going to these appointments for the last two years.Record review reflected on 4/15/2026, at 7:00 PM, the facility updated the EMR to reflect Resident received dialysis 3 days a week on M-W-F at a dialysis center under the care of a nephrologist.Interview on 04/16/2026, at 11:31 AM , MDS A revealed Resident #2 would need ordersInterview and observation on 04/16/2026, at 1:38 PM, revealed Resident #2 was sitting in her room. The resident had just finished lunch, and stated she attended Dialysis on Mondays, Wednesdays, and Fridays and had not had any issues with the facility getting her to these appointments.Interview on 04/16/2026, at 1:52 PM, NP N revealed she does not treat Resident #2 for Dialysis, this was all managed through the dialysis provider; however, all orders should have been entered into the EMR and she was not aware this had not been done.Interview on 04/16/2026, at 1:58 PM, DON, revealed initially she did not catch that Resident #2 did not have Physician orders for dialysis when admitted . It was discovered she had a dialysis order a few days later.Interview on 04/16/2026, at 2:56 PM, ADON A, revealed an Inservice was started today on Dialysis documents. Interview on 04/16/2026, at 3:54 PM, DON, revealed she could not provide insight into why the orders were not entered into the system. She went on to reveal if orders are not entered properly, it could affect a resident's plan of care and their continuity.Record review of facility Dialysis Management Policy, dated 03/12/2026, reflected the following:Goals of Dialysis ManagementThe facility will collaborate with the resident's dialysis provider and attending physician to support safe and effective dialysis care.Through ongoing communication with the dialysis center, the facility will ensure coordination regarding: Dialysis treatment schedules and attendance Resident weights and fluid status monitoring Laboratory monitoring as directed by the dialysis provider Medication adjustments related to dialysis treatment Dietary recommendations and restrictions Dialysis access care and monitoring Identification and reporting of changes in the residents' conditionThe facility will promptly communicate any significant changes in the residents' status, including symptoms, access site concerns, abnormal vital signs, or other clinical concerns, to the dialysis center and physician as appropriate.Procedures Physician Orders1. Nursing staff will verify and follow physician orders related to dialysis treatment.2. Orders may include: Dialysis schedule Medications Dietary restrictions

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 8 residents (Residents #19 and 78) reviewed for nail care. The facility failed to ensure Residents #19 and 78 had clean, trimmed fingernails on 04/14/2026 and 04/15/2026. This failure placed residents at risk of skin tears and infection.Findings Included: Review of the undated face sheet for Resident #19 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia with unspecified severity, muscle wasting and atrophy, age-related physical disability, persistent mood disorder, and chronic viral hepatitis C. Review of the quarterly MDS assessment for Resident #19 dated 01/16/2026 reflected a BIMS score of 09, indicating a moderate cognitive impairment. It reflected he required partial to moderate assistance with personal hygiene and had no rejection of care behaviors. Review of the care plan for Resident #19 dated 10/03/2025 reflected the following: Focus (Resident #19) has an ADL self-care performance deficit r/t Impaired balance, Limited Mobility, Pain (Bilateral knees). Goal (Resident #19) will maintain current level of function in (mobility) through the review date. Intervention BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the POC (documentation system for CNAs and activities staff) for Resident #19 reflected there was no task related to nail care being documented on the current system. Review of the undated face sheet for Resident #78 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cognitive communication deficit (problems communicating due to cognitive impairment), epilepsy, schizophrenia, weakness, contracture of muscle multiple sites, cerebral palsy, lack of expected normal physiological development in childhood, paraplegia, borderline personality disorder, intermittent explosive disorder, generalized anxiety disorder, bipolar disorder, and moderate intellectual disabilities. Review of the annual MDS assessment for Resident #78 dated 07/26/2025 reflected a BIMS score of 09, indicating a moderate cognitive impairment. It reflected he was completely dependent on staff for all ADLs, including personal hygiene. Review of the care plan for Resident #78 dated 06/06/2025 reflected the following: Focus The resident has an ADL self-care performance deficit r/t Confusion, Impaired balance, Limited Mobility, Limited ROM, Scoliosis, Paraplegia, DX CP, ID Goal The resident will improve current level of function in through the review date. Intervention BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the POC (documentation system for CNAs and activities staff) for Resident #78 reflected there was no task related to nail care being documented on the current system. Observation on 04/14/2026 at 10:04 AM revealed Resident #78's fingernails were long, jagged, and dirty. During observation and interview on 04/15/2026 at 09:02 AM, Resident #19 was observed with long fingernails (1/4 inch long). He stated he liked his nails trimmed short, but he was not able to cut them himself. He stated he sometimes bit his nails to get them short, because the staff had not offered to cut his nails for him. During observation and interview on 04/15/2026 at 12:55 PM, Resident #78 was sitting in his wheelchair near the nurse's station. His fingernails were long, jagged, and dirty. He stated he wanted his fingernails cut, but they had not done it yet. He stated he did not know when someone would cut his nails. He stated the staff did not help with that. During an interview on 04/16/2026 at 3:50 PM, the DON stated the aides usually provided nail care with showers if the resident did not have diabetes. She stated nail care should have been offered every time residents were bathed. She stated she oversaw the system to ensure compliance by interacting with residents and providing nail care if she saw it was needed. She stated nail care was supposed to have been documented when it was offered, even if residents refused. She stated the potential negative outcome was residents could scratch themselves. During an interview on 04/16/2026 at 4:08 PM, the ADM stated the DON was responsible for the system ensuring nail care was offered to residents. He stated the potential negative impact on residents was diminished quality of life and possible injury. Review of facility policy dated April 2025 and titled Activities of Daily Living reflected the following: Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (eating, including meals and snacks); and communication (including speech, language, and other functional communication systems).

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 Resident (Resident #10) reviewed for medication administration. RN C failed to administer medications and enteral feed safely to Resident #10 by: initiating medication administration without first checking for G-tube (a tube inserted through the abdominal wall into the stomach for the administration of medication and food) placement, forcefully pushing medications and the bolus feed through a connected syringe instead of gravity, shaking syringe from side to side and moving it in circular motions while it was attached to G-tube. These failures could place residents at risk of . aspirations and injuries to the stoma site.Findings include: Record review of Resident #10's face sheet, dated 04/15/2026, reflected a [AGE] year-old female initially admitted [DATE]. Resident #10 had diagnoses which included cerebral infarction due to embolism of right middle cerebral artery (a stroke caused by a clot blocking blood flow to the right side of the brain, causing sudden left-side weakness/paralysis, sensory loss, and potential behavioral changes), epilepsy unspecified, intractable, with status epilepticus (a temporary, uncontrolled surge of electrical activity in the brain that can cause convulsions, altered awareness, or behavioral changes), type 2 diabetes mellitus without complications (high blood sugar (hyperglycemia) due to insulin resistance without associated damage to nerves, eyes, kidneys, or blood vessels), aphasia (impaired ability to understand or produce speech), dysphagia oral phase (difficulty preparing food in the mouth and initiating a swallow), Gastrostomy status (presence of a functioning feeding tube (G-tube) inserted through the abdomen into the stomach for enteral nutrition, hydration, or medication administration). Record review of Resident #10's Comprehensive MDS dated [DATE] revealed, short- & long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia (brain damage that affects the person's ability to communicate), feeding tube while a resident, received 51% or more of her intake via tube feeding and 501 ml per day or more via tube feeding. Record review of Resident #10's order summary report reflected the following: NPO diet N/A - NPO texture, NPO consistency, for Dysphagia dated 01/20/2026 Enteral Feed Order every shift Flush with 10cc H2O between medications dated 04/03/2025 Enteral Feed Order every shift Flush with 30cc H2O before and after medications dated 04/03/2025 Enteral Feed Order every shift Verify G-tube placement and check for residual dated 04/03/2025 Enteral Feed Order five times a day Administer Glucerna 1.2 Cal / 285 Cal - Flush free water 100 ML with each feeding. An observation on 04/15/26 approximately at 07:00 a.m. revealed RN C preparing medication for administration to Resident #10. She popped out: Amlodipine, Cyanocobalamin, Aspirin, Aricept, Lisinopril, Hydrochlorothiazide, Escitalopram Oxalate, Vitamin D3 2 TABs, Metoprolol, Mirapex, and placed crushed medications into individual medication cups. She poured out 10 ml of Keppra and 7 ml of Ferrous Sulfate into individual medication cups and she diluted 1 packet of Juven in the cup adding 30 ml of water. At approximately 07:09 a.m. she crushed each medication separately and returned them to their individual medication cups and at approximately 07:14 a.m. RN C entered Resident #10's room with all the medications. Resident #10 was observed to be non-verbal. Resident displayed a flat face expression and some nonverbal sounds. RN C dissolved each medication with 10-15 ml of water and mixed each with the same spoon. At approximately 07:19 a.m. RN C washed her hands and put gown and gloves on. She connected syringe to Resident #10's G-tube port and poured a cup of the medication into the syringe's barrel. RN C did not check for placement of Resident #10's G-tube with auscultation (listening to sounds) or by checking residual (the amount of feed that can be withdrawn from the feeding tube that is used to determine stomach fullness) prior to administering the medications. Observation of the syringe when checked for residual by RN C revealed there was not any residual in the syringe. RN C stated that the residual was zero. RN C poured another cup of medication on top of the first medication; she did not flush the syringe before and after administering medications. RN C pushed medications using the syringe's plunger. After administering all crushed medications, RN C started administering enteral feeding Glucerna; she poured Glucerna directly into the syringe from the container. RN C wiggled the syringe from side to side and moved it in circular motion for Glucerna to go through. She used plunger to push Glucerna through and Glucerna went down the syringe. RN C added more Glucerna into syringe and continued to administer feeding. During an interview on 04/15/2026 at 12:24 p.m. with DON she stated she could not recall the last time she had training in administering medication through G-tube. She stated prior to administering medication or feeding via a resident's G-tube nursing staff were expected to check for resident's comfort, auscultate for bowel sound, pull back on plunger, check residual, put residual back; If there is no residual continue with the medication administration, Sometimes there is no residual. She stated that the syringe must be flushed with water before and between each medication. DON stated if medication is not going down the syringe the nursing staff can gently push the medication but not force it. DON did not answer this surveyor's question if there are consequences for a resident if the medication was forced down the tube when it encountered resistance. During an interview on 04/15/2026 at 12:34 p.m. with ADON B stated to administer medication or feeding via a resident's G-tube nursing staff must first check for placement by checking for auscultation with stereoscope and then pull back on the plunger, note the residual amount, and push the residual back in. Medication must be administered one by one and flushed before and after each medication. If there is resistance encountered during administration of medications, then nurse must check orders for amount to dilute the medication by adding liquid to the barrel, and then nurse can gradually push on a plunger. During an interview on 04/15/2026 at 2:38 p.m. with RN C she stated prior to administering medication or feeding via a resident's G-tube nursing staff were expected to do the following steps, Check for placement by auscultating and check the air, get each medication separately, give each medication with water in between, flush it again after administering all medications and give the feeding. I didn't auscultate [Resident #10] prior administering medications. She stated , if there was resistance during administration of the medications or flush was not going freely into the stomach by gravity then more water can be added, swirl the barrel to create centrifuge, give the plunger a gentle push. If the placement of the G-tube is not checked, I guess the patient could die. They'd be having medication go into the wrong area of the body. During an interview on 04/16/2026 at 1:24 p.m. the NP stated she is familiar with Resident #10 and that Resident #10 has PEG-tube. NP stated administering two medications through the syringe attached to Peg-tube without flushing the syringe after each medication is ok. She stated prior to administering medication or feeding via a resident's G-tube nurses were expected to verify placement of PEG-tube by Instilling air into a PEG-tube while listening over the stomach with a stethoscope. She stated if there is no residual when the tube content is aspirated it is ok to continue with administering of medications. NP stated residuals are checked to make sure that the body is processing feedings and medications. If the body is not processing, there is risk for potential aspiration. Wiggling the PEG-tube with attached syringe when medication or flush water is not going through is ok, but it depends on how extensive wiggling is. Record review of the facility's undated policy titled Administering Medications through an Enteral Tube with revision date 05/2024 and reviewed dates: 01/2023, 03/2024, 06/2025, 3/3/2026 reflected: 6. Verify placement of feeding tube: a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 10. Administer each medication separately. 12. Administer medication by gravity flow: a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. 13. If administering more than one medication, flush with 15 mL water (or prescribed amount) between medications.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 10 residents (Resident #99 and Resident #52)The facility failed to ensure the floor mat in Resident #99's room was beside his bed on 04/14/2026 and 04/15/2026.The facility failed to ensure the floor mat in Resident #52's room was beside his bed on 04/14/2026.This violation could place residents at risk of experiencing avoidable injuries from falls.The findings included: 1. Record review of Resident #99's admission Record, dated 04/15/2026, revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #99's Diagnosis Report, dated 04/15/2026, revealed diagnoses including multiple sclerosis (chronic disease where the immune system attacks the brain and spinal cord), type 2 diabetes mellitus (body does not produce enough insulin), COPD (a group of diseases that cause airflow blockage and breathing-related problems), unspecified protein calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss, weakness, and poor overall health). Record review of Resident #99's Annual MDS, dated [DATE], reflected Resident #99 had a BIMS score of 14, indicating intact cognitive function. Resident #99 was dependent on staff for his self-care needs and mobility needs. Record review of Resident #99 's Care Plan, accessed 04/14/2026, reflected Resident #99 was at high risk for falls. An intervention included having call light within reach, having bed in lowest position, and having fall mat in place beside bed. During an observation on 04/14/2026 at 9:30 AM, 10:30AM, and 11:42AM, Resident #99, was observed lying in his bed with the fall mat at foot of the bed folded up between the wall and dresser. During an observation on 04/15/2026, at 1:44 PM, Resident #99 was observed lying in his bed with the fall mat at foot of the bed folded up between the wall and dresser. 2. Record review of Resident #52's admission Record, dated 04/15/2026, revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #52's Diagnosis Report, dated 04/15/2026, revealed diagnoses including type 2 diabetes (body does not produce enough insulin), COPD (a group of diseases that cause airflow blockage and breathing-related problems, Muscle wasting and atrophy (loss of muscle tissue and strength), and osteomyelitis (a bone infection). Record review of Resident #52's Annual MDS, dated [DATE], reflected Resident #52 had a BIMS score of 07, indicating he was severely cognitively impaired. Resident #52 was dependent on staff for her self-care needs and mobility needs. Record review of Resident #52's Care Plan, accessed 04/14/2026, reflected Resident #52 was at risk for falls, initiated 01/23/2026. An intervention included having fall mat in place beside the bed and call light within reach. During an observation on 04/14/2026 at 9:38 AM and 10:35 AM. Resident #52, was observed lying in his bed. Resident #52's Fall mat was on the floor, but on the other side of the room away from the bed. During an interview on 04/16/2026, at 9:30 AM, LPN D stated that when a resident with fall precautions is in their bed, the bed should be lowered, the fall mat is right next to the bed, and the call light is in place. LPN D said the resident could get hurt if they fell out of bed and the fall mat was not in place. During an interview on 04/16/2026 at 9:40 AM with CNA I stated that if the resident has a fall mat it should be placed right next to the bed when the resident is in bed. CNA I said a resident could get hurt if they fell and the fall mat was not in place. During an interview on 04/16/2026 at 10:00 AM with DON she said her expectation is that the fall mat should be placed beside the bed when the resident is in bed. DON stated that both residents are on fall precautions and it is in their care plans to have fall mat beside their bed when they are in bed. During an interview on 04/15/2026 at 2:00PM with the ADM he stated he expects all staff to place fall mats beside the resident bed when the resident is in the bed. The ADM. stated it is nursing responsibility that the orders and care plan for fall precautions are carried out. Record review of facility policy, Fall Prevention and Management Program, dated as Reviewed and Revised 03/04/2026 reflected: Policy StatementThe facility maintains an interdisciplinary fall prevention and management program designed to identify resident-specific fall risk factors and implement individualized, least restrictive interventions that support safety while promoting mobility, independence, dignity and quality of life.Fall Prevention InterventionsInterventions may include but are not limited to .Bed in low position with bedside mat as appropriate

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for 1 of 1 residents (Resident #2) reviewed for dialysis.The facility failed to include nursing interventions for Resident #2's hemodialysis in her comprehensive care plan.This failure could put residents at risk for missed treatments, and inadequate care.Record review of Resident #2' s admission MDS assessment, dated 03/30/2026, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 was diagnosed with end-stage renal disease and was dependent on renal dialysis (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood effectively) and hypertension (high blood pressure). The MDS did not reflect Resident #2 was receiving dialysis.Record review of Resident # 2's care plan, dated 3/30/2026, reflected Resident #2 attends dialysis Mondays, Wednesdays, and Fridays. Created by: DM, Date Initiated: 04/01/2026. Interventions addressed Resident #2's dietary needs, but there was no dialysis focus developed by a doctor or nurse to address her nursing needs and no nursing interventions were included. Record review of Resident # 2's Progress notes , dated 4/13/2026, reflected Resident # 2 was a [AGE] year-old female with past medical history including non-insulin dependent diabetes mellitus type 2, ESRD. When the resident was admitted on [DATE], records reflected the resident was Dependent on renal dialysis. Resident dependent on hemodialysis Monday, Wednesday, Friday for end-stage renal disease. Interview and observation on 04/15/2026, at 11:38 AM, revealed Resident #2 was waiting on her ride to go to dialysis, and she attended every Mondays, Wednesdays, and Fridays. She stated she had been going to these appointments for the last two years.Interview on 04/16/2026, at 11:31 AM , MDS A revealed Resident #2 would need a Care plan from a Nurse or medical professional not the Dietary manager. According to the MDS A coordinator the baseline care plan should have included the DX of Dialysis.Interview and observation on 04/16/2026, at 1:38 PM, revealed Resident #2 was sitting in her room. The resident had just finished lunch, and she stated she attended Dialysis on Mondays, Wednesdays, and Fridays and had not had any issues with the facility getting her to these appointments.Interview on 04/16/2026, at 2:56 PM, ADON A, revealed she did not know why there was not a current care plan but stated MDS A would. She stated IDT meetings are held daily to check on these types of issues. If residents do not have a care plan, sites check, etc. related to Dialysis they could be at risk for infection.Record review of facility Dialysis Management Policy, dated 03/12/2026, reflected the following:Coordination with Dialysis Providers The facility will maintain appropriate communication and coordination with the dialysis provider. If residents are transported to an outpatient dialysis center: The facility will maintain a formal agreement or contract with the dialysis provider. Care coordination will follow standard operating procedures and dialysis center protocols. Dialysis center recommendations and treatment plans will be incorporated into theresident's care plan.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 8 residents (Resident #17) reviewed for pest control. The facility failed to ensure that Resident #17's room was free of flies on 04/16/2026. This failure placed residents at risk of infection and diminished quality of life.Findings Included:Review of the undated face sheet for Resident #17 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and often the face, causing significant muscle stiffness and motor impairment), severe intellectual disabilities, Rett syndrome (genetic disorder that typically becomes apparent after 6-18 months of age; symptoms include impairments in language and coordination, and repetitive movements), dysphagia (trouble swallowing), cognitive communication deficit (problems communicating due to cognitive impairment), protein-calorie malnutrition (lack of protein in the diet), epilepsy (seizure disorder), depressive episodes, gastrostomy status (feeding tube), and chronic pain. Review of the annual MDS assessment for Resident #17 dated 10/10/2025 reflected her cognitive impairment was so severe that she could not participate in a BIMS assessment for cognition. Review of the section on functional status reflected she was completely dependent on staff for bed mobility and personal hygiene. Review of the care plan for Resident #17 dated 10/03/2025 reflected the following: FocusResident is PASRR positive for IDD. Resident does have a custom W/C through PASRR, which she tolerates appropriately at this time. Resident requires total assistance from staff for all ADLs and mobility and is a part of the contracture management program.GoalResident will receive services that will be provided to benefit her well-being.FocusResident has alteration in ADL participation RT DX CP, ID, impaired mobility, spastic CP InterventionBED MOBILITY: The resident is totally dependent on staff for repositioning and turning in bed Q2H and as necessary. Observation on 04/16/2026 at 11:35 AM revealed Resident #17 was up in a tilt-back wheelchair next to her bed. There was a western on her roommate's television, and her roommate was not in the room. She interacted non-verbally by making eye contact, making noises, and moving her face. There was one housefly and at least seven fruit flies swarming around her and landing on her and the pillow on the bed next to her. During an interview on 04/16/2026 at 11:37 AM, ADON A stated it was the first time she had seen insects in Resident #17's room. She stated she did not know why the CNA who had visited Resident #17's room did not notice it. During an interview on 04/16/2026 at 11:45 AM, the MAINT stated he was aware they had been working on getting rid of fruit flies in the facility and had pest control coming out as needed. He stated he had not seen the flies on any residents with peg tubes and relied on the staff to report sightings like that. He stated if flies landed on a resident with a peg tube that could cause an infection. During an interview on 04/16/2026 at 11:59 AM, the service manager for the facility pest control company stated he was aware there was a fruit fly problem at the facility. He stated the facility had gone to twice monthly pest control instead of once monthly. He stated it was not a huge infestation and probably the fault of residents who did not allow staff to fully clean up their rooms. He stated the staff wrote pest sightings in the log and the technician read the log and treated those problems. He stated fruit flies were hard to control. During an interview on 04/16/2026 at 2:10 PM, CNA M stated he saw flies in the building once in a while but had never seen any in Resident #17's room. He stated he had been in her room that day but had not noticed the flies. He stated he was supposed to report the flies in the pest control book. He stated he did not know the potential negative outcome of flies being on Resident #17 and her belongings. During an interview on 04/16/2026 at 2:42 PM, ADON A stated the staff should have rounded on residents every two hours and she rounded on all the residents after lunch. She stated the procedure was for the staff to write any pest sightings in the pest control log. She stated she had spoken to CNA M who had denied seeing any flies in Resident #17's room when he rounded. During an interview on 04/16/2026 at 4:08 PM, the ADM stated the person responsible for ensuring there were no pests in the building was maintenance. He stated he monitored the system for compliance by doing rounds. He stated the potential negative impact of the flies being in Resident #17's room was they could land anywhere on her and cause an infection. Review of facility policy dated May 2008 and titled Pest Control reflected the following: Policy StatementOur facility shall maintain an effective pest control program.Policy Interpretation and ImplementationThis facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #10 and Resident #90) of 2 residents observed for infection control. The facility failed to ensure RN C performed hand hygiene and changed gloves during administration of medications and feeding via G-Tube to Resident #10. The facility failed to ensure RN C performed hand hygiene during administration of Resident # 90's medications. This failure could place residents at risk of cross contamination and the spread of infection. Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #10 and Resident #90) of 2 residents observed for infection control. The facility failed to ensure RN C performed hand hygiene and changed gloves during administration of medications and feeding via G-Tube to Resident #10. The facility failed to ensure RN C performed hand hygiene during administration of Resident # 90's medications. This failure could place residents at risk of cross contamination and the spread of infection. Findings include: Record review of Resident #10's face sheet, dated 04/15/2026, reflected a [AGE] year-old female initially admitted [DATE]. Resident #10 had diagnoses which included cerebral infarction due to embolism of right middle cerebral artery (a stroke caused by a clot blocking blood flow to the right side of the brain, causing sudden left-side weakness/paralysis, sensory loss, and potential behavioral changes), epilepsy unspecified, intractable, with status epilepticus (a temporary, uncontrolled surge of electrical activity in the brain that can cause convulsions, altered awareness, or behavioral changes), type 2 diabetes mellitus without complications (high blood sugar (hyperglycemia) due to insulin resistance without associated damage to nerves, eyes, kidneys, or blood vessels), aphasia (impaired ability to understand or produce speech), dysphagia oral phase (difficulty preparing food in the mouth and initiating a swallow), Gastrostomy status (presence of a functioning feeding tube (G-tube) inserted through the abdomen into the stomach for enteral nutrition, hydration, or medication administration). Record review of Resident #10's Comprehensive MDS dated [DATE] reflected short- & long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, aphasia (brain damage that affects the person's ability to communicate), feeding tube while a resident, received 51% or more of her intake via tube feeding and 501 ml per day or more via tube feeding, pressure ulcer stage 3. An observation on 04/15/26 approximately at 07:00 a.m. revealed Resident #10 had the Enhanced Barrier Precautions signs posted in English and Spanish languages on the right side of the door and PPE inside of the clear plastic drawers. At 07:00 a.m. RN C prepared medication for administration to Resident #10. At approximately 07:30 a.m. after administering all crushed medications, RN C started administering enteral feeding Glucerna; she poured Glucerna directly into the syringe from the container and spilled some of it on Resident #10's stomach. RN C picked up a paper towel from Resident #10's bedside table and wiped the spill off from Resident #10's stomach and continued administering enteral feeding without performing hand hygiene and changing her gloves. RN C wiped off a stain left from Glucerna's box on the medication table using the same paper towel she previously used to wipe off the spill on Resident #10's stomach. RN C wiped off the stain left from Glucerna's box on the medication table using the same paper towel another 2 times while she continued to administer Resident #10's feeding without performing hand hygiene and changing gloves. Record review of Resident #90's face sheet dated 04/15/2026 reflected a [AGE] year-old female with initial admission date 03/05/2025 with diagnoses that included: Quadriplegia unspecified (paralysis affecting all four limbs and the torso), Major depressive disorder, recurrent, moderate (mental disorder, depressed mood or loss of pleasure or interest in activities for long periods of time), Dysphagia (difficulty swallowing), cognitive communication deficit (communication impairment stemming from underlying cognitive issues), pain, unspecified (generalized pain, acute pain, or pain not otherwise specified that lacks a clear, localized, or diagnosed cause). Record review of Resident #90's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting she was cognitively intact. Resident #90 is in Hospice care. Resident #90 has absence of spoken words. Record review of Resident #90's order summary report reflected; Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 1 tablet via G-Tube three times a day for Pain related to Quadriplegia unspecified. dated 03/17/2026 Record review of Resident #90's undated care plan reflected the focus: The resident requires tube feeding r/t diagnosis of spastic quadriplegic cerebral palsy (extreme muscle stiffness and involuntary movements in all four limbs, the trunk, and the face). date initiated 03/18/2025. The goal The resident's insertion site will be free of s/s of infection. date initiated 03/18/2025. During an observation on 04/15/26 at 07:52 a.m. RN C pulled out Resident #90's Tramadol HCl 50 MG pill from her left pocket and placed the medication in a medication cup. RN C stated she will be administering Resident #90's morning medications next and started preparing Resident #90's medications on the NC C&D without performing hand hygiene. During an interview on 04/15/2026 at 12:24 p.m. with DON she stated she was working in the facility for 3 years. She stated she has been trained in infection control. DON stated that it is expected for nurses to perform hand hygiene before and after each patient, clean area, off gloves, hand hygiene again. She stated that wiping off resident's body and then cleaning the work area with the same paper towel without performing hand hygiene and changing gloves is not acceptable. During an interview on 04/15/2026 at 12:34 p.m. with ADON B she stated that it is unacceptable if nurse is cleaning a spill from resident's body and then wiping off the medication table repeatedly with the same paper towel while continuing administering feeding via G-tube without performing hand hygiene and changing gloves. It is an infection control issue; residents can get infection. During an interview on 04/15/2026 at 2:38 p.m. with RN C she stated that during medication administration to Resident #10 she used a paper towel from the resident's bedside table to wipe off a spill from Resident #10's stomach and then used the same paper towel to clean the medication table while continuing feeding the resident via G-tube without performing hand hygiene wearing the same gloves because she was only working in that resident's room and with that one resident only. RN C stated that she did not follow appropriate infection control practice. She stated that she should have properly discarded the Tramadol pill she pulled out of her pocket and pulled a new one. She stated that nurses must perform hand hygiene before administering medications to residents. Not performing hand hygiene may cause spread of infection. During an interview on 04/16/2026 at 7:35 a.m. with MA H she stated she has been trained in infection control, it is monthly in-service training. The infection control training covered how to protect residents while providing care to the residents; putting on the proper PPE when providing direct care to the residents on precautions; performing hand hygiene, gowning up, using gloves and face masks when required. This training also covered hand hygiene procedures when administering medications to the residents; Hands must be washed if they are visibly soiled. Hand sanitizing before starting pulling out residents' medications. Before going to the residents' rooms to administer medications and after leaving the residents' rooms, Sanitize hands in and out of the residents' rooms. She stated staff can give residents infections; they can get sick if the infection control protocol is not followed. During an interview on 04/16/2026 at 7:48 a.m. ADM stated his last training in infection control was in July of 2025. The training covered hand hygiene and when to do it, use of PPE when it is required. Washing hands when they are visibly soiled. Hand hygiene before and after giving medications to residents. Not following hand hygiene protocols can potentially increase the risk of infection. Record review of the facility undated policy titled Handwashing/hand Hygiene reflected: 1. Hand hygiene is indicated: a. immediately before touching a resident: d. after touching a resident. e. after touching the resident's environment; g. immediately after glove removal. Record review of the facility policy titled Medication administration with reviewed and revised dates: 03/05/2026, 06/2025, and with reviewed dates 7/8/2024, 4/1/2019 reflected: Infection Control Staff follow established infection control practices during medication administration, including: Hand hygiene Appropriate PPE use

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and ensure 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 1 resident (Resident #90) and 1 of 2 medication rooms observed for medications storage. The facility failed to document on Resident #90's MAR medication Tramadol (controlled opioid medication used to manage moderate to severe chronic pain) and sign it out on the controlled medication count sheet; The controlled medication count sheet did not indicate the medication was administered or wasted. The facility failed to ensure that Medication room at the C&D nurses' station did not have expired medications in the drawer/room. These failures could place residents at risk for overdose of medication, under-dose of medication, ineffective therapeutic outcomes, and drug diversion. Findings include: Record review of Resident #90's face sheet dated 04/15/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Quadriplegia unspecified (paralysis affecting all four limbs and the torso), Major depressive disorder, recurrent, moderate (mental disorder, depressed mood or loss of pleasure or interest in activities for long periods of time), Dysphagia (difficulty swallowing), cognitive communication deficit (communication impairment stemming from underlying cognitive issues), pain, unspecified (generalized pain, acute pain, or pain not otherwise specified that lacks a clear, localized, or diagnosed cause). Record review of Resident #90's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting she was cognitively intact. Resident #90 is in Hospice care. Resident #90 has absence of spoken words. Record review of Resident #90's order summary report reflected an order dated 03/17/2026: Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 1 tablet via G-Tube three times a day for Pain related to Quadriplegia unspecified. Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain. Record review of Resident #90's undated care plan reflected the focus: The resident has low back pain r/t chronic physical disability and The resident is on pain medication therapy related to disease process with interventions: Administer analgesia per physician's orders. Acetaminophen-Codeine Tablet. Tramadol and Administer analgetic medications as ordered by physician. Monitor and document side effects and effectiveness every shift. Tramadol During an observation on 04/15/26 at 07:52 a.m. of the NC C&D for medication storage revealed Resident #90's controlled substance record sheet indicated remaining amount of Tramadol HCl 50 MG was 19 tablets. Further observation revealed Resident #90's blister pack contained 18 tablets of Tramadol HCl 50 MG. RN C stated that the medication was given to Resident #90 at 08:00 am and this is charted in Resident#90's MAR. At 07:54 a.m. RN C logged in to Resident #90's MAR and the medication was not charted as given. RN C stated, It is not charted. I am screwed. RN C started looking for Tramadol looking inside of each NC's C&D drawers. RN C was complaining of her ribs hurting and touching the left side of her back. RN C pulled out a white oval shaped pill from her left pocket and showed it to the surveyor stating, I found it. I forgot that I put it to my pocket. RN C placed the medication in a medication cup. She stated she will be administering Resident #90's morning medications next and started pulling out her medication from the C&D nursing cart and went to Resident #90's room around 08:21 a.m. During an interview on 04/15/2026 approximately at 8:20 a.m. with ADON B stated she does not know the reason RN C kept the narcotic medication Tramadol in her pocket. She stated that the procedure to pull out narcotic medication from the nursing cart is to verify the order, pull out the medication from the locked box in the nursing cart. Document the pulled-out medication in the narcotics book, administer the medication and then chart the given medication in resident's chart. Not giving pain medication may increase pain and affect a resident negatively. During an attempted interview on 04/15/2026 approximately at 10:20 a.m. with Resident # 90 she was calm without agitation. Resident # 90 had unclear speech. She moved her head from side to side when she was asked if she had any pain. During an interview on 04/15/2026 at 2:38 p.m. with RN C stated she was working in the facility for 6 years. RN C stated she kept Resident #90's Tramadol tablet while she was administering Resident #10's medications and enteral feeding in her room. She stated there was a 4 hour window to administer this medication and she administered the medication to Resident #90. RN C could not explain the reason she kept Tramadol in her pocket. She stated the process of administering narcotics are: Check the order, sign out the medication, give the medication, and then sign it out in the chart. She stated not administering pain medication can increase pain. During an interview on 04/16/2026 at 7:48 a.m. with ADM he stated he cannot tell the reason for the narcotic medication being inside of the nurse's pocket. He stated that to his knowledge they need to be stored safely locked. If any narcotic is pulled out by LVN or RN, the narcotic medication must be documented, it is not acceptable to place narcotics in nursing staff's pockets. When narcotic medication is pulled out for administration to residents, the nurse should write down the name of the resident and the name of the narcotic on the medication cup. There are different reasons to do so, it can be lost, not given or given to wrong residents. Narcotic medications must be counted by 2 nurses at the end of the shift. DON is responsible for any narcotic medications. Record review of the facility policy titled Medication administration with reviewed and revised dates: 03/05/2026, 06/2025, and with reviewed dates 7/8/2024, 4/1/2019 reflected: Purpose: -To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. Record review of the facility in service titled Controlled Substances dated 04/13/2026, reflected: Controlled substances are drugs that are subject to strict government control because they may cause addiction or be misused and possibly lead to death. The government's control impacts how these substances are made, used, stored, and transported. Some examples of controlled substances that we administer here include opioids, antianxiety, and hypnotics. Whenever a controlled substance is given per MD orders, you must sign it out on the narc count sheet for that medication, and you must sign it out in PCC. This is the facility's policy and a law. Don't risk your license, job and possibly going to jail. It is mandatory that controlled substances are documented correctly at all times. An observation and audit conducted on 04/16/2026 approximately at 07:26 a.m. of Medication Room located at the nurses' station C&D revealed that inside a mini fridge was expired fluticasone prop 50 mcg (Flonase); the expiration date of the medication was 02/12/2026. During an interview on 04/15/2026 around 8:20 a.m. with ADON B stated that the pharmacy consultant and DON are responsible for removing expired medications from the nursing and medications carts. Expired medication possibly can lose treatment effectiveness. During an interview on 04/16/2026 at 7:35 a.m. with MA H stated that the CMAs are not responsible for removing expired medications out of the med carts but if a resident is discharged then CNAs CMAs are responsible to remove the medications of discharged residents and place them in medication room. She stated that expired medications potentially would not work as expected for residents' treatment. During an interview on 04/16/2026 at 7:48 a.m. with ADM he stated he has been trained in medications administration; his last training in medications administration was in July of 2025. This training covered basics, like 5 rights of medications administration and the training included the proper labeling of the medication bottle. When a new bottle of medication is opened the date should be written on the cup or on the bottom of the bottle if possible. For example, today's date: 4/16/26. ADM stated he is not sure of the reason for expired medication not being removed from nurses' carts and medication rooms. The charge nurses or ADONs are responsible for checking for expired medications. Expired medications can potentially be given to the residents and may have negative effect on the residents. During an interview on 04/16/2026 at 9:17 a.m. with CPh she stated she is not responsible for removing the expired medications from the medication carts and med rooms, she can recommend removing them if she locates expired medications. Expired medication may lose its strength, it is less potent, possibly affects cleanliness. Record review of the facility undated policy titled Storage of Medications with reviewed dates: 06/24/2025, 07/2024, reflected: 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for1 (Resident #1) of 1 reviewed for abuse and neglect. On 01/03/26, Resident #1 fell out of bed after the bed brakes/wheel locks were not set. Resident #1 sustained no injuries, but was sent to the ER. The facility failed to thoroughly investigate this incident, as well as failed to submit the investigation to the state agency. This deficient practice placed residents at risk of ongoing neglect due to not having a thorough investigation done for facility reported incidents.Record review of Resident #1's Care Plan dated 01/04/26 revealed a [AGE] year-old male who was admitted to the facility 03/01/22 and diagnosed with Other Seizures (temporary surge of uncontrolled activity in the brain/unspecified type), Insomnia (a sleep disorder), Obstructive Sleep Apnea (a sleep disorder), Epilepsy (a brain disorder causing recurrent seizures), Intractable w/Status Epilepticus (severe, prolonged seizure), Intellectual Disabilities (learns, things and develops slowly), Generalized Anxiety Disorder (extreme worry), Schizoaffective Disorder Bipolar Type (mental health condition blending symptoms of schizophrenia [hallucinations, delusions] and mood disorder [mania depression]), Persistent Mood Disorder (long-term, low-grade depression), Personality Disorder (a mental health disorder), , Acquired Absence of Right Leg Above Knee, Peripheral Vascular Disease (poor blood flow to limbs), Muscle Wasting (shrinking, weakening, loss) and Atrophy shrinking of tissue) Right/Left Upper Arm, Cognitive Communication Deficit and (a speech problem). Additional record review of Care Plan reflected, Keep bed in lowest position with wheels locked. Focus: Resident s a behavior problem of self-adjusting the [NAME] of his bed and keeps his bed in a high position. Interventions: Encourage/redirect Resident #1 to keep bed in low position as needed. Record review of facility incident report dated 01/03/26 reflected Resident #1 had a fall w/o injury. The report failed to include information related to an investigation of neglect, or notification to HHSC. Record review of ER Provider Note dated 01/03/26 reflected, Vitals of normal range; Exam: Constitutional - alert and oriented and responds appropriately to questions, well-appearing; well-nourished. CARD: Tachycardia. RESP: no respiratory distress. ABD/GI: non-distended. EXT: Tenderness to palpation of the left hip and left femur. SKIN: Normal color for age and race, warm, dry good turgor, no acute lesions noted. NEURO: Moves all extremities equally. PSYCH: Intermittently agitated. Re-Evaluation: (Resident #1) apparently prefers to sleep on his left side. He was rolling in the bed and rolled too far causing him to fall off the bed and landed onto his left side. Per EMS, (Resident #1) complaining of left hip pain since the fall. Otherwise at his baseline mentation per the nursing home. On attempts to assess (Resident #1), (Resident #1) continuously yelling: do not touch me, it hurts: multiple attempts made to try and understand what is hurting. (Resident #1) states his back and his hip is hurting. We will proceed with imaging including CT imaging of the back. (Resident #1) otherwise is hemodynamically stable at this time. We will also obtain head if (Resident #1) if (Resident #1) hit his head or not. UA is negative. Chest x-ray w/o any signs of infection. (Resident #1) at this time remains asymptomatic. He has family at base bedside who stated that he is at his baseline mentation. They are comfortable with the plan for discharge back to his facility. IMPRESSION: No acute abnormality. CT Brain: No acute intracranial abnormality. CT Cervical Spine: No acute fracture or traumatic malalignment. (Resident #1) reports pain after (pain medication). Imaging was without Any acute findings. Still is intermittently agitated on examination and yells that he is cold. Record review of Hospital Discharge Record dated 01/03/26 reflected, You were seen today for: fall. Patient instructions reviewed: Fall Prevention received 01/04/26. Activity Restrictions or Additional Instructions: Please follow up with the primary care for further evaluation. Return to the emergency department for any new or worsening symptoms. Follow-up Please contact the following to make an appointment for follow-up care: *Your Primary Care Physician Follow-up Plan: 1-2 Days Note: Your health care plan may require a referral from your primary care provider prior to making an appointment. Observation and interview on 01/20/26 at 11:45 AM revealed Resident #1 lying in a bed against the wall, closest to his left side. He had no visible marks/bruises. The bed wheels were locked, and the bed was unable to be moved. Resident #1 stated two white nurses failed to lock his bed wheels and he fell as a result. He stated he had pain from the fall but no longer had any pain from the fall. In an interview on 01/20/26 at 10:25 AM, the LG for Resident #1 stated Resident #1 had a fall due to Resident's bed wheels not being locked. She stated he was morbidly obese and an amputee. She stated he was fully dependent on the bed to be in place. She added he leaned on the wall for his best comfort. She stated he was bedfast and was at least a 2-person assist for transfer. She stated his amputation was on the right leg. She stated she was made aware of the information because she was his legal guardian. She stated he scraped his elbow during the fall and was complaining of pain. She stated nothing like this had occurred in the past. She stated date of fall was 01/03/26 at unknown time. She stated he had been to the hospital as a result of this but was not aware of any resulting injuries. In an interview with CNA C on 01/20/26 at 12:36 PM, she stated she ad been with the facility 3 years, and she worked hall A (Resident #1's hall). She stated beds always had to be locked. She stated the day of the incident, she was not at work, and added CNAs A and B worked with Resident #1 that evening. In an interview with the LVN on 01/20/26 at 01:45 PM, she stated the wheels on Resident #1's bed were not locked at the time of his fall. She stated she did not know if there was a policy related to locking bed wheels. She stated nurse aides were trained to unlock and re-lock bed wheels when they finished tasks. The LVN stated she was not working the day of the incident; however, staff have been in-serviced on that topic. She stated no incident of that nature had occurred since her start date of May 2025. She stated she was not sure which aides were involved. She stated risk for leaving resident beds unlocked included a resident falling out of the bed. She stated staff were usually really good at locking the wheels. The LVN stated Resident #1 was not injured when he fell. She stated she knew wheels were unlocked because the information was in the incident report. The LVN stated the charge nurse was responsible for ensuring aides completed tasks, and added ultimately, she was over the charge nurse. She stated Resident #1 saw the NP after ER visit. She stated on the 3rd, staff who worked with Resident #1 was CNA A, and added she was the only staff member assigned to his hall that day. The LVN stated other staff would have come and assisted her. In an interview with CNA A on 01/20/26 at 02:00 PM, he stated recent in-service training covered ANE, resident transfers and bed locks. CNA A stated the day of the incident, he was working a different hall. He stated he came to assist CNA B. CNA A stated when he arrived in the room, Resident #1 was on the floor, uninjured. CNA A stated CNA C worked 1st shift the day of the fall. In a telephone interview with CNA B on 01/20/26 at 02:13 PM, she stated she worked the day of 01/03/26 and responded to Resident #1 after he fell. She stated Resident #1 tended to lean left. CNA B stated she did not normally work that hall, but did that day. She stated she was helping another resident when the incident occurred. She stated her training on resident falls included gait belts, transfers and bed locks. She stated this type of incident had not occurred before. CNA B stated Resident #1 had a fall mat on the side of the bed but not against the wall. She stated when she came in that day, Resident #1 had already been cleaned up. She stated the wound care nurse and EMS said not to touch Resident #1. In an interview with the ADM on 01/20/26 at 02:20 PM, she stated no staff were written up or disciplined about the incident in which Resident #1 fell off his bed on 01/03/26, because she was unable to determine who had been responsible for failing to lock his bed wheels. She stated she in-serviced the staff on locking bed wheels and Resident #1 was sent to the ER to ensure he had no injuries. She stated he returned from the ER and had no injuries, so the incident was not reported to HHSC. She stated there was no facility policy related to bed wheels being locked. Record review of Abuse Prohibition policy dated 06/02/25 reflected, Policy: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. Record review of in-services dated 01/03/26 with the notation: Bed Brakes need to be locked at all times. If providing care brakes need to be relocked.

Based on observation, interview and record review, the facility failed to ensure that 1 (Resident #1) of 1 residents received adequate supervision that could prevent accidents when reviewed for supervision. On 01/03/26, Resident #1 fell out of bed and was found on the floor, uninjured, when his bed brakes were not locked. These failures placed residents at risk of accidents and injuries. Record review of Resident #1's Care Plan dated 01/04/26 revealed a [AGE] year-old male who was admitted to the facility 03/01/22 and diagnosed with Other Seizures (temporary surge of uncontrolled activity in the brain/unspecified type), Insomnia (a sleep disorder), Obstructive Sleep Apnea (a sleep disorder), Epilepsy (a brain disorder causing recurrent seizures), Intractable w/Status Epilepticus (severe, prolonged seizure), Intellectual Disabilities (learns, things and develops slowly), Generalized Anxiety Disorder (extreme worry), Schizoaffective Disorder Bipolar Type (mental health condition blending symptoms of schizophrenia [hallucinations, delusions] and mood disorder [mania depression]), Persistent Mood Disorder (long-term, low-grade depression), Personality Disorder (a mental health disorder), , Acquired Absence of Right Leg Above Knee, Peripheral Vascular Disease (poor blood flow to limbs), Muscle Wasting (shrinking, weakening, loss) and Atrophy shrinking of tissue) Right/Left Upper Arm, Cognitive Communication Deficit and (a speech problem). Additional record review of Care Plan reflected, Keep bed in lowest position with wheels locked. Focus: Resident has a behavior problem of self-adjusting the height of his bed and keeps his bed in a high position. Interventions: Encourage/redirect Resident #1 to keep bed in low position as needed. Focus: Resident #1 has had an actual fall. Goal: Resident #1 will have no injuries related to falls through the review date. Intervention/Tasks: (Resident #1) sent out to ER for eval and treat post fall. Upon return, no injuries per ER, neuros were initiated. Record review of Resident #1's MDS dated [DATE] reflected:*BIMS score of 05*Intellectual disability*Mobility device: wheelchair*Transfer status of 2 or more people Record review of facility incident report dated 01/03/26 reflected Resident #1 had a fall w/o injury. Record review of ER Provider Note dated 01/03/26 reflected, Vitals of normal range; Exam: Constitutional - alert and oriented and responds appropriately to questions, well-appearing; well-nourished. CARD: Tachycardia. RESP: no respiratory distress. ABD/GI: non-distended. EXT: Tenderness to palpation of the left hip and left femur. SKIN: Normal color for age and race, warm, dry good turgor, no acute lesions noted. NEURO: Moves all extremities equally. PSYCH: Intermittently agitated. Re-Evaluation: (Resident #1) apparently prefers to sleep on his left side. He was rolling in the bed and rolled too far causing him to fall off the bed and landed onto his left side. Per EMS, (Resident #1) complaining of left hip pain since the fall. Otherwise at his baseline mentation per the nursing home. On attempts to assess (Resident #1), (Resident #1) continuously yelling: do not touch me, it hurts: multiple attempts made to try and understand what is hurting. (Resident #1) states his back and his hip is hurting. We will proceed with imaging including CT imaging of the back. (Resident #1) otherwise is hemodynamically stable at this time. We will also obtain head if (Resident #1) if (Resident #1) hit his head or not. UA is negative. Chest x-ray w/o any signs of infection. (Resident #1) at this time remains asymptomatic. He has family at base bedside who stated that he is at his baseline mentation. They are comfortable with the plan for discharge back to his facility. IMPRESSION: No acute abnormality. CT Brain: No acute intracranial abnormality. CT Cervical Spine: No acute fracture or traumatic malalignment. (Resident #1) reports pain after (pain medication). Imaging was without Any acute findings. Still is intermittently agitated on examination and yells that he is cold. Record review of Hospital Discharge Record dated 01/03/26 reflected, You were seen today for: fall. Patient instructions reviewed: Fall Prevention received 01/04/26. Activity Restrictions or Additional Instructions: Please follow up with the primary care for further evaluation. Return to the emergency department for any new or worsening symptoms. Follow-up Please contact the following to make an appointment for follow-up care: *Your Primary Care Physician Follow-up Plan: 1-2 Days Note: Your health care plan may require a referral from your primary care provider prior to making an appointment. Observation and interview on 01/20/26 at 11:45 AM revealed Resident #1 lying in a bed against the wall, closest to his left side. He had no visible marks/bruises. The bed wheels were locked, and the bed was unable to be moved. Resident #1 stated two white nurses failed to lock his bed wheels and he fell as a result. He stated he had pain from the fall but no longer had any pain from the fall. In an interview on 01/20/26 at 10:25 AM, the LG for Resident #1 stated Resident #1 had a fall due to Resident's bed wheels not being locked. She stated he was morbidly obese and an amputee. She stated he was fully dependent on the bed to be in place. She added he leaned on the wall for his best comfort. She stated he was bedfast and was at least a 2-person assist for transfer. She stated his amputation was on the right leg. She stated she was made aware of the information because she was his legal guardian. She stated he scraped his elbow during the fall and was complaining of pain. She stated nothing like this had occurred in the past. She stated date of fall was 01/03/26 at unknown time. She stated he had been to the hospital as a result of this but was not aware of any resulting injuries. In an interview with the LVN on 01/20/26 at 01:45 PM, she stated the wheels on Resident #1's bed were not locked at the time of his fall. She stated she did not know if there was a policy related to locking bed wheels. She stated nurse aides were trained to unlock and re-lock bed wheels when they finished tasks. The LVN stated she was not working the day of the incident; however, staff have been in-serviced on that topic. She stated no incident of that nature had occurred since her start date of May 2025. She stated she was not sure which aides were involved. She stated risk for leaving resident beds unlocked included a resident falling out of the bed. She stated staff were usually really good at locking the wheels. The LVN stated Resident #1 was not injured when he fell. She stated she knew wheels were unlocked because the information was in the incident report. The LVN stated the charge nurse was responsible for ensuring aides completed tasks, and added ultimately, she was over the charge nurse. She stated Resident #1 saw the NP after ER visit. She stated on the 3rd, staff who worked with Resident #1 was CNA A, and added she was the only staff member assigned to his hall that day. The LVN stated other staff would have come and assisted her. In an interview with CNA A on 01/20/26 at 02:00 PM, he stated recent in-service training covered ANE, resident transfers and bed locks. CNA A stated the day of the incident, he was working a different hall. He stated he came to assist CNA B. CNA A stated when he arrived in the room, Resident #1 was on the floor, uninjured. CNA A stated CNA C worked 1st shift the day of the fall. In a telephone interview with CNA B on 01/20/26 at 02:13 PM, she stated she worked the day of 01/03/26 and responded to Resident #1 after he fell. She stated Resident #1 tended to lean left. CNA B stated she did not normally work that hall, but did that day. She stated she was helping another resident when the incident occurred. She stated her training on resident falls included gait belts, transfers and bed locks. She stated this type of incident had not occurred before. CNA B stated Resident #1 had a fall mat on the side of the bed but not against the wall. She stated when she came in that day, Resident #1 had already been cleaned up. She stated the wound care nurse and EMS said not to touch Resident #1. In an interview with the ADM on 01/20/26 at 02:20 PM, she stated no staff were written up or disciplined about the incident in which Resident #1 fell off his bed on 01/03/26, because she was unable to determine who had been responsible for failing to lock his bed wheels. She stated she in-serviced the staff on locking bed wheels and Resident #1 was sent to the ER to ensure he had no injuries. She stated he returned from the ER and had no injuries, so the incident was not reported to HHSC. She stated there was no facility policy related to bed wheels being locked. Record review of in-services dated 01/03/26 with the notation: Bed Brakes need to be locked at all times. If providing care brakes need to be relocked.

Based on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to document that Resident #1 had a care plan conference on 12/4/2025. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.Findings include: Review of Resident #1's face sheet reflected an [AGE] year-old man admitted on [DATE] and discharged on 12/20/2025 with diagnoses of unspecified systolic heart failure (heart does not contract forcefully to meet the body's need), personal history of poliomyelitis (viral disease that attacks central nervous system potentially leading to paralysis), cognitive communication deficit (difficulty speaking, listening, reading or writing caused by problems with thinking skills, memory and attention), dysphagia (difficulty swallowing), vascular dementia (occurs when damaged blood vessels reduce blood flow and oxygen to the brain impairing thinking, memory and behaviors), and peripheral vascular disease (circulation disorder where narrowed blood vessels reduce blood flow). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 13 which indicated no cognitive impairment. Review reflected Resident #1 was at risk of developing pressure ulcers. Review reflected Resident #1 had 5 venous and arterial ulcers (caused by poor blood flow from narrowed arteries creating punched-out wounds) and included infection of the foot and other open lesions on the foot. Review of Resident #1's baseline care plan reflected a date of 11/25/2025 and no discharge plans. Review of care conference note dated 11/26/2025 reflected an admission / baseline care plan conference was held on 11/26/2025 with Resident #1's RP via phone. Review reflected Resident #1's conditions were reviewed at admission and present conditioners were barriers to wound healing were reviewed. The care conference note was signed by MDS F. Review of Resident #1's progress notes reflected there was no care plan conference meeting documented for 12/04/2025. Review of Resident #1's assessments reflected there was no care plan conference meeting documented for 12/04/2025. During an interview on 01/02/2026 at 11:08 AM, LMSW stated a few care plan conference were held for Resident #1. LMSW stated there were at least 2 or 3. LMSW stated that MDS nurse was supposed to put in a note for the care plan conference and she did not put it in. LMSW stated that MDS nurse was no longer at the facility. LMSW stated there was a care plan meeting held on 12/04/2025 at 2:00 PM and LVN A, and DOR were present. LMSW stated that the nurse was responsible to put in care plan conference notes because it was a lot of medical questions. LMSW stated she sometimes had to remind the nurse. LMSW stated it was important that the note be put in each time and to document any concerns that were discussed. LMSW stated she reviewed the note was put in at least once every three more, but sometimes more frequently. LMSW stated what is the point of having the meeting if it's not going to be documented During an interview on 01/02/2026 at 11:26 AM, DOR stated he participated in the care plan conference on 12/04/2025. During an interview on 01/02/2026 at 11:42 AM, ADON stated that documentation of care plan meetings was supposed to be done by the MDS nurse or LMSW. ADON stated it was important to document meetings for the records. During an interview on 01/02/2026 at 1:07 PM, MDS F stated she has worked at the facility for about 2 months. MDS F stated she was in training until about 2 weeks ago. MDS F stated during a care plan conference each section in the note is put in by the respective discipline, but sometimes she had to fill in other departments' parts. MDS F stated she participated in a care plan conference for Resident #1 when he first admitted but not any other meetings. MDS F stated she thought there were more meetings but that those were not actual care plan meetings. MDS F stated what determined if a meeting was an actual care plan meeting was if there was an emergency circumstance or if something needed to be addressed. MDS F stated if there was a meeting it should have been documented at least in a progress note. During an interview on 01/02/2026 at 1:25 PM, the DON stated LMSW should document that the meeting occurred and who was present. The DON stated she hoped documentation was completed within a few days. The DON stated any care plan meeting should be documented even if it was brief note with concerns discussed. During an interview on 01/02/2026 at 1:56 PM, the ADM stated she knew there was a care plan meeting held on 12/04/2025 because Resident #1's RP came in to do admission paperwork that day. The ADM stated that she expected if any care plan is held there would be some kind of note. The ADM stated she expected MDS F or a nurse to document the note or LMSW should document. The ADM stated it was important to document because that is how the staff care for the resident and any family concerns should have been documented and who participated in the meeting. Review of facility policy dated July 2017 titled Charting and Documentation reflected all services provided to the resident, progress towards care plan goals, or changes in the resident's medical condition. shall be documented in the resident's medical record.

Based on , interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #3) of 4 residents reviewed for quality of care. The facility failed to provide wound care for Resident #1 in accordance with physician orders (three times a week on 11/27/2025, 11/29/2025 and 12/4/2025) and daily (12/10/2025, 12/11/2025 and 12/12/2025). The facility failed to change Resident #1's dressing when it appeared soiled according to physician's orders on 12/2/2025 and 12/11/2025 according to Resident #1's November 2025 and December 2025 TAR. This deficient practice could place residents at risk for not being provided the care/treatment required, and/or delayed treatment. Findings included: Review of Resident #1's face sheet reflected an [AGE] year-old male admitted on [DATE] and discharged on 12/20/2025 with diagnoses of unspecified systolic heart failure (heart does not contract forcefully to meet the body's need), personal history of poliomyelitis (viral disease that attacks central nervous system potentially leading to paralysis), cognitive communication deficit (difficulty speaking, listening, reading or writing caused by problems with thinking skills, memory and attention), dysphagia (difficulty swallowing), vascular dementia (occurs when damaged blood vessels reduce blood flow and oxygen to the brain impairing thinking, memory and behaviors), and peripheral vascular disease (circulation disorder where narrowed blood vessels reduce blood flow). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 13which indicated no cognitive impairment. Review reflected Resident #1 was at risk of developing pressure ulcers. Review reflected Resident #1 had 5 venous and arterial ulcers (caused by poor blood flow from narrowed arteries creating punched-out wounds) and included infection of the foot and other open lesions on the foot. Review of hospital discharge wound care orders dated 11/24/2025 reflected wound care instructions for bilateral lower extremity to clean wounds with saline and gauze, remove crusts, dress wounds with hydrofera blue foam, secure with kerlix and ace wrap and change twice weekly and prn. Review of Resident #1's physician orders dated 11/24/2025 reflected bilateral lower extremity and clean wounds with saline and gauze, remove crusts, dress wounds with hydrofera blue foam, secure with kerlix and ace wrap and to change twice weekly and prn and indicated every 72 hours for wound care. Review of Resident #1's physician orders dated 12/04/2025 reflected bilateral lower extremity and clean wounds with saline and gauze, remove crusts, dress wounds with xeroform (sterile mesh gauze dressing with treatment to fight bacteria), secure with kerlix and ace wrap, change twice weekly and prn every day shift every Tuesday and Friday. Review of wound assessment report by wound care NP dated 11/25/2025 reflected treatment as three times per week and PRN, cleanse with wound cleanser, xeroform, with ABD (abdominal pad) and kerlix as dressings for bilateral extremities. Review reflected exudate amount (how much fluid saturates the dressing) as heavy. Review of Resident #1's November 2025 TAR dated 11/24/2025 and discontinued on 12/04/2025 reflected bilateral lower extremity and clean wounds with saline and gauze, remove crusts, dress wounds with hydrofera blue foam(antibacterial wound dressing), secure with kerlix (gauze bandage) and ace wrap and to change twice weekly and prn and indicated every 72 hours for wound care. Review reflected wound care was performed on 11/25/2025. Review reflected Resident #1 refused wound care on 11/28/2025 and not performed. Review of wound assessment report by wound care NP dated 11/25/2025 reflected treatment as three times per week and PRN, cleanse with wound cleanser, xeroform(sterile mesh gauze dressing with treatment to fight bacteria), with ABD (abdominal pad) and kerlix as dressings for bilateral extremities. Review reflected exudate amount (how much fluid saturates the dressing) as heavy. Review of Resident #1's December 2025 TAR dated 11/24/2025 and discontinued 12/04/2025 reflected bilateral lower extremity and clean wounds with saline and gauze, remove crusts, dress wounds with hydrofera blue foam, secure with kerlix and ace wrap and to change twice weekly and prn and indicated every 72 hours for wound care. Review reflected Resident #1 refused wound care on 12/02/2025. Review reflected new order dated 12/04/2025 and discontinued 12/28/2025 for bilateral lower extremity, to clean wounds with saline and gauze, remove crusts, dress wounds with xeroform, secure with kerlix and ace wrap, change twice weekly and PRN every day shift every Tuesday and Friday. Review reflected wound care was performed on 12/05/2025 and 12/09/2025. Wound care was not performed on 12/04/2025 or 12/06/2025. Review reflected wound care was not provided on 12/10/2025, 12/11/2025 or 12/12/2025. Review of November 2025 and December 2025 MAR/TAR reflected no PRN wound care was completed. Review of Resident #1 progress notes reflected no PRN wound care was completed on 12/2/2025 or 12/11/2025. Review of wound assessment report by wound care NP dated 12/2/2025 reflected treatment as three times per week and PRN, cleanse with wound cleanser, xeroform, with ABD (abdominal pad) and kerlix as dressings for bilateral extremities. Review reflected exudate amount as heavy. Review of wound assessment report by wound care NP dated 12/09/2025 reflected treatment as daily and PRN, cleanse wound with wound cleanser, calcium alginate (natural gelatinous substance derived from brown seaweed) with ABD and kerlix as dressings for bilateral extremities. Review reflected exudate amount as heavy. Review of photo of Resident #1's right ankle with date of 12/2/2025 and timestamp of 2:50 PM, revealed dark spots on outside of bandage. Review of photo of Resident #1's right foot with date of 12/11/2025 and time stamp of 7:32 PM, revealed several dark black/brown spots on outside of bandage. During an interview on 12/30/2025 at 2:16 PM, FM stated the facility was supposed to keep Resident #1's legs clean so they could heal. FM stated that the wrapping around Resident #1's legs and feet had blood on them and felt that the same bandages were applied after wound care. FM stated that one nurse put xeroform on Resident #1's legs and felt that was against doctor's orders. During an interview on 12/31/2025 at 1:41 PM, LVN A stated that Resident #1 was not always compliant with dressing changes. LVN A stated that he refused wound care 2 or three times. LVN A described the wounds on Resident #1's legs as the same throughout his stay. LVN A stated that there was drainage and there was no odor or warmth. LVN A stated that at first the wound care NP had xeroform as part of the treatment but Resident #1's FM stated they could not use xeroform and the wound care nurse changed the order to utilize calcium alginate. LVN A stated Resident #1's FM felt xeroform would macerate it. LVN A stated macerated meant to turn the skin really soft and she did not observe this when she used xeroform for Resident #1's wound care. LVN A stated that Resident #1 received wound care twice a week per order from the wound care NP. LVN A stated the orders Resident #1 came with from the hospital were for every 72 hours. LVN A stated the wound care NP decided to change from every 72 hours to twice a week because hospital orders were clarified. LVN A stated she observed a small circle on Resident #1's dressing and denied any color was observed. LVN A stated Resident #1's wounds were open and had drainage. LVN A stated the drainage was clear and had some blood mixed with it. LVN A stated calcium alginate was a dressing pad. LVN A stated the wound would be cleaned, then calcium alginate would go on top. LVN A stated she then put ABD pads and an ace wrap. LVN A stated ABD was a dressing to help with drainage and then it would be wrapped. LVN A stated sometimes Resident #1 would have drainage seeping through his dressing but not very much. LVN A stated she would find the soiled dressing and it was usually when she was going to do the wound care. LVN A stated she did not recall when she saw the soiled dressing. LVN A stated if residents had drainage seeping through their dressing, they could get a dressing changed sooner than their scheduled wound care. LVN A stated she would have expected report from the CNA or charge nurse to report any soiled dressing to her. LVN A stated potential harm of soiled dressing that went unchanged was an infection. LVN A viewed the picture dated 12/11/2025 and stated she did see soiled dressing similar to the picture at least once or twice. LVN A stated that the wound care NP did not express any concerns about the soiled dressings and that she was usually with the wound care NP when LVN A saw the soiled dressing. LVN A stated that after the care plan meeting with Resident #1's FM she informed the wound care NP that the FM wanted the order to be changed to calcium alginate. LVN A stated that the meeting was held maybe the 2nd or 3rd week after Resident #1 was admitted . During an interview on 12/31/2025 at 2:00 PM, RN B stated that she observed drainage that seeped through Resident #1's dressing. RN B stated when she saw it, she thought it looked like blood. RN B stated she thought she reported it to LVN A and put a note in PCC (point click care, electronic health record). RN B stated Resident #1's FM asked why the wound was always like this and meant that the dressing was soiled. RN B stated she told Resident #1's FM she would tell LVN A. RN B stated it was maybe one drop on Resident #1's shin area. RN B stated Resident #1's dressing was not supposed to be changed each time there was soiled dressing on his wounds. RN B stated if she saw a lot of drainage she would report it to LVN A, but she never saw a lot of drainage through Resident #1's dressing. RN B stated it was important to report a soiled dressing because it could have been considered neglect and could potentially cause an infection. RN B stated if it was a lot of drainage she would have called LVN A and assessed if the dressing had just been changed or soaked through or needed to be changed. RN B observed the picture dated 12/11/2025 and denied that she ever observed Resident #1's dressing soiled as in the picture. During an interview on 12/31/2025 at 2:48 PM, NP stated she saw Resident #1 on 12/12/2025 and observed blood drainage on his dressing and stated Resident #1 was due for a dressing change. NP stated she asked LVN A to follow up and get the dressing changed. NP stated some wounds were going to drain and some dressing should not be changed too much to avoid disturbing the healing process. She stated she did not observe any odor or warmth to Resident #1's leg. NP stated she would default questions about wound care to the wound care NP. During an interview on 1/2/2026 at 8:57 AM, wound care NP stated she saw Resident #1 two or three times. Wound care NP stated Resident #1 had severe wounds on both of his legs from to the top of his feet. Wound care NP stated that when Resident #1 first arrived there were ABD pads wrapped in gauze. Wound care NP stated she believed the facility got ABD pads and put xeroform on Resident #1's wounds. Wound care NP stated that Resident #1's FM wanted his treatment switched to utilize calcium alginate so it was switched. Wound care NP stated from when she first saw Resident #1 to the last time his wounds appeared the same each visit. Wound care NP stated she did not recall any signs of infection. Wound care NP stated she did not recall Resident #1's dressings being soiled. Wound care NP stated that it would not be uncommon to have draining wounds with soiling on the outer bandage. Wound care NP stated if the outer bandage was soiled it should have been removed and reapplied. Wound care NP stated this included the ace bandage. Wound care NP stated she would not have changed wound care from three times a week to two times a week. Wound care NP stated that if anything she would have increased wound care from three times a week to daily. Wound care NP stated that if they used xeroform three times a week dressing change is recommended and if they used calcium alginate then wound care should have been done daily. Wound care NP stated that hydrofera blue foam is very different from xeroform. Wound care NP stated hydrofera blue foam is thicker and antimicrobial and xeroform would be changed three times a week because it helped dry out a wound. Wound care NP stated it would not have been suggested to only change dressings twice a week if xeroform was used. Wound care NP stated it was hard to answer if it would have made a difference that hydrofera blue foam was used versus xeroform. Wound care NP stated she expected the facility to follow hospital discharge orders and then evaluate with the wound care team if anything needed to be changed. Wound care NP stated she did not see hydrofera blue foam used on Resident #1's wounds. During an interview on 01/02/2026 at 9:22 AM, LVN A stated when a resident admitted from the hospital she tried to see the wound care discharge orders but did not see them all. LVN A stated the charge nurse put orders in PCC and she will go in and see that it matches hospital discharge orders. LVN A stated that she reviewed the wound care report and the notes were sent to her. LVN A stated that the treatment on the wound care report should be the same as the order in PCC. LVN A stated that change twice weekly prn and every 72 hours did not make sense as an order because twice weekly and every 72 hours were different. LVN A stated if something was changed twice a week versus three times a week it could have made a difference in wound healing and could have slowed wound healing. LVN A stated if xeroform was being used it should be changed three times a week, but it was dependent on what the wound care NP stated. LVN A stated the order was changed to twice a week because she and the wound care NP had discussed it in Resident #1's room and LVN A stated she guessed she missed the order being updated. LVN A stated looking back three times a week wound care would have been more appropriate. LVN A stated she tired to review the wound assessment report the day it was emailed to her. LVN A stated she sometimes received the reports the same day or following day. LVN A stated that there were no residents who received wound care twice a week. LVN A stated when she viewed the wound care report she tried to go into PCC to ensure the order matched. During a subsequent interview on 1/2/2026 at 9:41 AM, wound care NP stated she did not recall changing wound care to only twice a week and she would not have because of Resident #1's drainage. Wound care NP stated it would have been at least three times a week at minimum when using xeroform but when it changed to calcium alginate it would have been daily and as needed. Wound care NP stated when she changed an order she talked about it with LVN A and she sent a report from wound rounds the same day to show recommendations. Wound care NP stated she expected the facility to follow recommendations and if they had questions they could reach out. Wound care NP stated no residents received wound care twice a week and the standard was three times a week. During an interview on 01/02/2026 at 10:09 AM, LVN E stated that she worked with Resident #1. LVN E stated that LVN A provided wound care for Resident #1. LVN E stated that Resident #1's wound did drain and there were 2-3 spots of drainage that came through his dressing but it was not soaked. LVN E stated if the dressing were soaked it would have needed to be changed. LVN E viewed the picture dated 12/11/2025 and stated she never saw his dressings soiled like the picture, but if she did she would have changed it. LVN E stated wound care was done daily or three times a week and depended on what the wound care NP wanted. LVN E stated wound care orders were put in by LVN A. LVN E stated the charge nurse put admission orders for wounds in the system if LVN A was not at the facility, otherwise, LVN A would put the orders in. During an interview on 1/2/2026 at 11:43 AM, ADON stated that on 12/12/2025 Resident #1's dressing looked like he had fresh bleeding because wound care had not been done and was going to be done after lunch. ADON stated if staff saw that dressing was soiled there should have been an order for PRN changes so the nurse could have changed the dressing. ADON stated LVN A could have also changed the dressing if she was in the facility but if it was on the weekend the charge nurse could have changed the dressing. ADON stated when a resident was admitted , the charge nurse put the treatment orders in. ADON stated LVN A was to follow up on Mondays for any new admissions from the weekend. ADON stated that LVN A was responsible to review the wound care report and it should have been reviewed as soon as it was received. ADON stated the report usually was sent within 1-2 hours and at least on the same day after the wound care NP visit. ADON stated treatment orders should have matched the orders from the wound assessment report. ADON stated it was important that the orders matched so the resident can get the right treatment. ADON stated a risk for wound care being completed less than ordered is that the wound care NP had made decisions for treatment based on rounds and there was a risk for swelling, slowed healing and risk of infection. ADON stated any PRN dressing changes were to be documented on the TAR. During an interview on 01/02/2026 at 12:09 PM, CNA C stated that she worked with Resident #1 and recalled seeing dressing around both of his legs. CNA C stated that he had what looked like dried blood on the outside of the dressing but that LVN A had not done wound rounds at that time. CNA C stated she saw Resident #1's dressing like this at least two or three times. CNA C stated that when she saw his dressing like this, she let the nurse know and LVN A know. CNA C stated that the color on the dressing was dark red and there were one or two spots on each leg. CNA C stated anytime she saw a soiled bandage she would report it immediately to the nurse. During an interview on 01/02/2026 at 12:39 PM, LVN D stated that he did not work with Resident #1. LVN D stated that LVN A was responsible for wound care and if LVN A was not there the charge nurse was responsible. LVN D stated if the outer dressing was soiled or had dried blood it would need to be assessed to determine if it needed to be changed. LVN D viewed the picture dated 12/11/2025 and stated he would have removed the outer bandage and more than likely it would have needed to be changed. LVN D stated if it was changed PRN by the nurse it would have needed to at least be documented on a progress note and notate the type of discharge. LVN D stated wound care orders were put in by LVN A. LVN D stated orders from the provider should match what was in PCC. LVN D stated if wound care order was less frequent that what the provider ordered there was a risk because the nurse should ensured the dressing was not soiled or had signs of infection. During an interview on 01/02/2026 at 1:25 PM, the DON stated if a new admission came in after LVN A had left, the charge nurse put in wound care orders from the hospital. The DON stated that LVN A would assess and follow up the following day to ensure the hospital orders matched what was in the system and looked appropriate. The DON stated wound care NP came in once a week and sent a report by the following day at the latest. The DON stated the treatment orders in the wound report should have matched the orders that were in PCC. The DON stated that it was important that the orders matched because that was the provider's order. The DON stated that the order specified wound care for three times a week and if the order read twice a week there was a risk in infection. The DON stated she reviewed the order and the order stated twice a week and one for every 72 hours which was still considered twice a week. The DON stated LVN A reviewed the wound care report. The DON stated she tried to review things as well but did not review every single wound care report. The DON stated a lot of people should be laying eyes on stuff because we cannot always rely on one person. The DON stated if drainage could be seen, she expected staff to look for a PRN order and change the dressing. The DON stated first LVN A should have been called if she were there. The DON stated she never viewed Resident #1's wounds and never received a report that there was a lot of drainage. The DON stated if a PRN change was done, it would have been documented on the MAR/TAR or the nurse could have put in a progress note. During an interview on 01/02/2026 at 1:56 PM, the ADM stated that LVN A or the charge nurse put in wound care orders into PCC. The ADM stated if the charge nurse put wound care orders into PCC, then LVN A was expected to review and ensure they were accurate. The ADM stated that LVN A was expected to review the wound care report. The ADM stated it was expected to follow the order they had and she expected the orders to be up to date. During an interview on 01/02/2026 at 2:24 PM, the ADM stated there was no facility policy on following orders or updating orders from the physician.

Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 3 of 10 residents (Resident #58, Resident #63, and Resident #83) reviewed for personal privacy. The facility failed to knock on Resident #58, #63, and #83's room when going into the residents' rooms. This failure could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #58's Face Sheet dated 02/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #58's diagnoses included dementia (memory, thinking, difficulty), heart failure, muscle weakness, kidney disease, abnormalities with gait and mobility, pain, age related physical debility, weakness, dry eye syndrome, localized edema (swelling), hearing loss, tobacco use, and viral hepatitis C. Record review of Resident #58's Quarterly MDS dated [DATE] revealed Resident #58 had a BIMS score of 8 indicating severe cognitive impairment. The MDS also revealed that Resident #58 was independent with eating. Review of Resident #63's Face Sheet dated 02/25/2025 revealed he was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63's diagnoses included gastroesophageal reflux disease without esophagitis (reflux), cerebral infraction (Stroke), memory issue following stroke, hypertension (high blood pressure), hyperlipidemia (high cholesterol), kidney failure, weakness, history of falling, chronic pain, pain in joint, low back pain and chronic embolism and thrombosis of other specified veins (blood clots in the veins). Record review of Resident #63's Quarterly MDS dated [DATE] revealed that Resident #63 had a BIMS score of 11 indicating moderate impairment. The MDS also revealed that Resident #63 was set up and clean up assistance with eating. Review of Resident #83's Face Sheet dated 02/25/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83's diagnoses included dementia (memory, thinking, difficulty), hypothyroidism, , schizoaffective disorder (mental disorder with delusions, hallucinations, disorganized speech and grossly disorganized behavior), anxiety (intense or persistent worry and fear about everyday situations), weakness, major depressive disorder (feeling of sadness), protein-calorie malnutrition, myopia (near sightedness), pain and catatonic disorder (disorder that disrupts how the brain works). Record review of Resident #83's Quarterly MDS dated [DATE] revealed that Resident #83's BIMS score was a 14 indicating intact cognitive responses. The MDS also revealed that Resident #83 had supervision or touching assistance with eating. Observation of lunch hall trays being passed on 02/24/2025 at 12:49 p.m., revealed CNA A did not knock on Resident #83's door before entering. Observation of lunch hall trays on 02/24/2025 at 12:55 p.m., revealed CNA B walked into Resident #58, and Resident #83's rooms without knocking. During an interview with Resident #83 on 02/25/2025 at 2:27 p.m., revealed that staff do not always knock on his door before coming in. He said he would prefer for staff to knock all the time when they come to check on him. He said he does not get upset when staff do not knock. During an interview with Resident #63 on 02/26/2025 at 8:10 a.m., revealed that she did not want to talk to surveyor. She said staff aways knocked. During an interview with Resident #58 on 02/26/2025 at 8:15 a.m., revealed that staff do not knock on his door before entering. He said he tried to stop the staff but said staff do not listen to him. He said staff not knocking happened all the time. He said that it would really upset him when staff just came in his room. He said it especially upsets him if he is doing something or sleeping. He said he wanted staff to knock all the time. During an interview with CNA A on 02/26/2025 at 9:05 a.m., revealed that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to knock and wait for a response to come in. She also said if they do not answer to knock again. She said staff were to knock anytime they wanted to enter a resident's room. She said if staff do not knock the resident may feel like his or her rights are being violated. She said that management monitors to ensure staff are knocking on the resident's doors by observation and keeping an eye on staff. She said she realized after going in Resident #63's room that she did not knock on the door. She said that her mind was somewhere else, and she knew she should have knocked. During an interview with the DON on 02/26/2025 at 10:53 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock and wait for a response before entering the resident's room. She said all staff were required to always knock on the resident's door before entering. She said the resident may not feel like their privacy is being invaded. She said that all staff were responsible for monitoring to ensure staff are knocking when doing rounds. She said she did not know why staff were not knocking on the residents' doors. She said she thought the staff were just nervous about the surveyor being there. During an interview with CNA B on 02/26/2025 at 11:18 a.m., revealed that she had been trained on resident rights. She said that staff were supposed to knock on all residents' doors before entering. She also said that staff were supposed to introduce themselves and tell the resident what they were there for. She said there was no reason staff should not knock on the resident's door before entering. She said by staff not knocking the resident may feel as if their privacy is being invaded. She also said that she would want someone to knock on the door and staff should be respectful. She said the nurses usually sat at the nurse's station and watched to ensure staff were knocking. She said on Resident #58 and Resident #83 she just wanted to get their meal trays to them because the meal trays were late and sometimes the residents would get upset. During an interview with the ADM on 02/26/2025 at 11:33 a.m., revealed that she and staff had been trained on resident rights and knocking on residents' doors. she said the policy was to knock on the door and wait to be invited in, she said all staff were supposed to knock before entering the resident's room. She said that there was not a reason for staff not to knock on the resident's door. She said residents could feel like they did not have privacy if staff did not knock. She said that everyone should be monitoring that staff are knocking on the door but mainly management. She said management monitors it by reviewing grievances, resident council minutes, and observation. She said she did not know why staff were not knocking on resident's doors before entering. Record review of Resident Rights Policy revised 12/2016 revealed the resident has a right to a dignified existence; be treated with respect, kindness and dignity; privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #47) reviewed for transmission-based precautions, in that: The facility failed to provide Enhanced Barrier Precautions for Resident #47, who had a chronic wound with drainage that could not be covered with a dressing. This deficient practice could put the resident at risk for infection. Finding included: Review of Resident #47's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Diabetes Mellitus with Diabetic neuropathy (A condition results from insufficient production of insulin, causing high blood sugar, and decreased feeling in the hands and feet.), peripheral vascular disease (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and intellectual disabilities (A condition that limits intelligence and disrupts abilities necessary for living independently.). Review of Resident #47's quarterly MDS assessments dated 02/10/2025 reflected he was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #47 was further assessed to have applications of ointments or medications to areas other than feet. Review of Resident #47's comprehensive care plan reflected a focus area dated 08/05/2024 The resident has a wound to left posterior lateral upper thigh. Further review of his plan of care reflected a focus are dated 01/22/2025 Resident requires enhanced barrier precautions related to wounds. Interventions included: Apply signage outside resident room ; EBP (Enhanced Barrier Precautions) used during high-contact resident care activities as applicable, such as: dressing, bathing/showering, transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: (central line/urinary catheter/feeding tube/trach/vent); wound care (any skin opening requiring a dressing); other areas determined to require EBP . Review of Resident #47's consolidated physician orders reflected an order dated 01/27/2025 wound to left posterior lateral upper thigh, cleanse with wound cleanser, apply lotrisone cream and leave open to air. Further review of Resident #47's physician orders reflected an order dated 08/29/2024 enhanced barrier precautions - gown and gloves required for high-contact activities: dressing, bathing, transfers, providing hygiene, changing linens, incontinent care, toileting, therapy .and wound care every shift for infection control. Review of Resident #47's wound assessment report dated 02/24/2025 conducted by Resident #47's NP reflected his wound was on his left thigh, it was re-opened partial thickness wound (involves damage to the outer layers of the skin, specifically the epidermis and part of the dermis.) with sanguineous drainage (is the initial discharge produced after an injury or an open wound where the skin is broken.) Review of Resident #47's wound care MD assessment and progress note reflected Resident #47 had a wound on his left lateral thigh which had drainage and was greater than 122 days old. (A chronic wound is one that has failed to progress through the phases of healing in an orderly and timely fashion in 30 days.) Observation on 02/24/2025 at 9:42 AM, revealed Resident #47 did not have a sign for EBP outside of his room door. Observation on 02/25/2025 at 1:52 PM, revealed Resident #47 in room. The Treatment Nurse entered room to preform wound care with CNA D to assist. The Treatment nurse nor CNA D donned PPE prior to entering the room. The Treatment nurse exposed Resident #47's left thigh to reveal a wound that was approximately 8 X 4 region of scarred tissue with scattered, small, round open areas. Drainage was observed on the wound. In an interview on 2/26/25 at 9:20 AM, the Treatment nurse stated that Resident #47 had open areas on his wound. She stated it was her understanding of the facility's policy on EBP that it was used only for pressure sore wounds of stage 2 or above, and did not include skin tears, or any other types of wounds. The Treatment nurse stated after reviewing the facility policy, that the resident should have been on EBP for his current wound. She stated that not initiating EBP for Resident #47 could place him at risk of exposure to pathogens which could cause infections. In an interview on 2/26/25 at 9:25 AM, the DON stated that EBP should be initiated for patients with indwelling catheters, PEG tubes, and serious breaks in the skin, including some skin tears. She stated they have not been doing EBP for minor skin breaks. The DON stated that EBP have not been initiated on Resident #47. The DON stated after reviewing the facility policy, that I probably wouldn't have [started EBP], but I will look into it. The DON stated that the resident had behaviors of scratching that area and reopening the wound. She stated that the facility is in the process of doing additional training with quizzes and in-services regarding EBP. The DON stated she was unsure if the Treatment nurse has completed the training. Interview on 02/26/2025 at 12:23 PM, the Corporate Nurse IP, stated that she was the interim IP for the facility from August 2024 until approximately two weeks ago. She stated that it was her expectation that EBP be started for all residents with chronic wounds, PEG tubes, foley catheters. She stated she was familiar with Resident #47 and stated that he had several open areas on the left thigh region that would heal and reopen. She stated that the orders and care plan interventions were likely initiated from her instructions and not discontinued appropriately. She stated that if the wound had drainage with an order for OTA, that EBP should be initiated. She stated that not initiating EBP appropriately puts the resident at risk for infections. Review of the in-service dated 02/26/2025 reflected the Treatment nurse was in-serviced on EBP. Review of the facility's policy Enhanced Barrier precautions dated 04/01/2024 reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than one patient. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage, or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers . 51511

Based on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 2 of 6 residents (Resident #78 and Resident #85) whose records were reviewed for PASRR services. The facility failed to get PASRR eval when Resident #78's Level 1 PASRR screening indicated the resident had mental illness diagnoses of schizoaffective disorder bipolar type, and anxiety. The facility failed to complete a PASRR screening on Resident #85. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: 1. Record review of Resident #78's admission sheet, dated 02/25/2025, revealed a [AGE] year-old female who was readmitted to the facility on [DATE] and initial admission on 06/12/2024 with diagnoses including respiratory failure, encounter with tracheostomy (a procedure that puts a hole in the neck so air can get into the lungs, obstructive pulmonary disease (lung disease that blocks air flow making it difficult to breath, schizoaffective disorder bipolar type (mental disorder with delusions, hallucinations, disorganized speech and grossly disorganized behavior), morbid obesity, heart disease, tobacco use, high blood pressure, voice and resonance disorder (affects how your voice sounds and air flow through your nose and mouth) and anxiety (intense or persistent worry and fear about everyday situations). Record review of Resident #78's quarterly MDS assessment, dated 01/09/2025, noted the resident BIMS was 15, indicating intact cognitive response; mood indicators were present including feeling lonely or isolated from those around you, verbal behavioral symptoms directed towards other and not directed towards others. The MDS also had schizophrenia and anxiety as active diagnosis. Record review of Resident #78's care plan, updated on 01/24/2025 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. The resident uses psychotropic medications r/t schizoaffective disorder. One of the approaches were monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia (uncontrolled body movements), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Record review of Resident #78's PASRR 1 dated 06/10/2024 revealed that the facility marked no for mental illness. Attempted to interview Resident #78 on 02/24/2025, 02/25/2025 and 02/26/2025 resident was unavailable for interview. 2. Record review of Resident #85's admission sheet, dated 02/25/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] diagnoses including major depressive disorder (loss of interests in activities causing significant impairment in daily life), developmental disorder of scholastic skills (condition characterized by a significant discrepancy between an individuals perceived level of intellect and their ability to acquire new language and other cognitive skills), autistic disorder (lifelong developmental disability that affects how a person communicates interacts with others, learns and behaves), high blood pressure, lack of expected normal physiological development in childhood, cognitive communication deficit (difficulty communicating), weakness, and anxiety disorder (intense or persistent worry and fear about everyday situations). Record review of Resident #85's quarterly MDS assessment, dated 12/21/2024, noted the resident BIMS was 05, indicating severe cognitive impairment; mood indicators were not present. The MDS also had depression and anxiety as active diagnosis. Record review of Resident #85's care plan, updated on 01/15/2025 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. The resident uses psychotropic medications r/t behavior management. One of the approaches were monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia (uncontrolled body movements), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. The care plan also revealed the resident had impaired cognitive function or impaired thought process r/t developmentally delayed. One of the approaches was to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review revealed that Resident #85 did not have a PASRR completed. Interview attempted with Resident #85 on 02/24/2025 at 10:13 a.m., Resident #85 was not interviewable. During an interview with the ADM on 02/26/2025 at 11:40 a.m., revealed that she had been trained on PASRR. She said that the MDS nurse was responsible for doing PASRRs. She also said that corporate was doing the PASRRs because the facility does not have an MDS nurse. She said a PASRR I was done before admission and PASRR II is done if the PASRR I is positive. She said that for a PASRR I to be positive that the resident had to have a mental disorder or Intellectual and development disability (IDD), She said that it was important to do the PASRR so that the resident had the opportunity to receive services for which they are eligible. She said that for Resident #85 a PASRR was not done due to him coming from home. She said the facility rushed Resident #85's admission and was overlooked. She also said for Resident #78's PASRR was done at the hospital and was negative. She said the MDS person the facility was new at the time and did not flag her PASRR. During an interview with the CN C on 02/26/2025 at 12:07 p.m., revealed that she had been trained on PASRR. She said that for a PASRR I to be positive the resident had to have a mental illness. She said that a PASRR was done on all residents at the time they are admitted . She stated to be responsible for doing the PASRRs or individuals in the case mix. She said that she was responsible for completing the PASRR if the resident had a new mental illness diagnosis. She said the facility would complete form 1012 and determine if the individual has dementia, then complete mental health illness check to put in a PASRR. She stated it is important to do a PASRR for individuals that have a mental health illness to receive the extra support they need if the individual meet's certain criteria for services. She did not know why the PASRRs for Resident #78 and Resident #85 were not done. Record review of the PASRR Policy and Procedure revised on 07/18/2018 and reviewed 02/26/2025 revealed the facility uses the most current version of [NAME] Rules, TAC Title 26, Part 1 Chapter 554, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings. This TAC may be found on the Texas Health and Human Services website. Record review of the TAC Title 26, Part 1 Chapter 554, Sub-chapter BB dated 12/11/2020 revealed if an individual seeks admission to a nursing facility, the nursing facility: (1) must coordinate with the referring entity to ensure the referring entity conducts a PL1; and (2) may provide assistance in completing the PL1, if the referring entity is a family member, LAR, other personal representative selected by the individual, or a representative from an emergency placement source and requests assistance in completing the PL1. (b) A nursing facility must not admit an individual who has not had a PL1 conducted before the individual is admitted to the facility. (c) If an individual's PL1 indicates the individual is not suspected of having MI, ID, or DD, a nursing facility must enter the PL1 from the referring entity into the LTC Online Portal. The nursing facility may admit the individual into the facility through the routine admission process. (d) For an individual whose PL1 indicates the individual is suspected of having MI, ID, or DD, a nursing facility: (1) must enter the PL1 into the LTC Online Portal if the individual's admission category is: (A) expedited admission; or (B) exempted hospital discharge; and (2) must not enter the PL1 into the LTC Online Portal if the individual's admission category is pre-admission. (e) Except as provided by subsection (f) of this section, a nursing facility must not admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination. (f) A nursing facility may admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination only if the individual: (1) is admitted as an expedited admission. (2) is admitted as an exempted hospital discharge; or (3) has not had an interruption in continuous nursing facility residence other than for acute care lasting fewer than 30 days and is returning to the same nursing facility. (g) A nursing facility must check the LTC Online Portal daily for messages related to admissions and directives related to the PASRR process. 51115

Based on interview and record review the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #48's annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #48's Admission Record, dated 02/26/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had diagnoses which included respiratory failure, heart failure, weakness, long term use of blood thinners, edema (swelling), viral hepatitis C, retention of urine, protein-calorie malnutrition, insomnia (difficulty sleeping), morbid obesity, and high blood pressure. Record review of Resident #48's Annual/5 Day Assessment MDS with an ARD of 02/18/2025, revealed Section Z of the MDS, Z0400 revealed sections B, C, D, E, and Q were done by the SW and signed on 02/17/2025. Section K was done by the KM and F was completed by the AD and signed on 2/17/2025. Section M was the last section completed by the UM and signed on 02/18/2025. Section Z of the MDS, Z0400. Signature of RN Assessment Coordinator Verifying Assessment Completion had not been completed as of exit on 02/26/2025. During an interview with the DON on 02/26/2025 at 11:00 a.m., revealed that she had been trained on MDS. She said that corporate was doing the MDS's at this time. She said she knows there are certain times that the MDS had to be done in, but she would have to look it up to see the time for each MDS. She said an MDS was completed quarterly, annually, when the resident had a change in condition, discharge, admission and if the resident had a significate change. She said the negative outcome for not completing the MDS was that the facility would not get paid. She said the facility had a schedule, and policy and procedures and the facility were to follow them. She said corporate was responsible for doing the MDS's timely. She said that corporate would monitor it through the electronic records. She said she did not know why Resident #48's MDS had not been completed. During an interview with the ADM on 02/26/2025 at 11:36 a.m., revealed she had been trained on MDS. She said that the facility currently did not have a MDS coordinator. She said the MDS coordinator would have been the one to communicate with corporate about the MDS since corporate was doing the MDS. She said that the facility had 21 days to complete the MDS. She said a negative outcome was the facility would not get paid. She said she could not think how it would affect the resident. She said that the DON and herself were responsible for ensuring the MDS was done timely. She said that her and the DON monitored it through their morning meeting. She said that Resident #48's MDS was not late she said she had 14 days started from the time the facility closed the Entry MDS. She said that the facility had until 3/3/2025 to finish the MDS. During an interview with CN C on 02/26/2025 at 11:57 a.m., revealed that she had been trained on MDS. She said she had been doing MDS since 2013. She said she was responsible for doing the MDS's because the facility currently did not have an MDS nurse. She also said some of the other facilities the company had would also help. She said MDS were updated daily. She said the time for completing the MDS was at entry within 7 days of coming in, must be completed within 14 days of admission, 92 days for quarterly or significate change. She said if an MDS was not done, it would be considered late. She said it was important to have the MDS done timely as it reflected what treatment the facility was doing for the resident. She said it would also reflect their diagnosis or if there was a decline. She said it was an IDT team group effort. She stated she is responsible for monitoring to ensure MDS are done timely. She stated it was monitored by her Monday through Friday and she would look at the in-progress list of individuals who needed to have their MDS done. She said that the MDS for Resident #48 was not due until 3/3/2025. Record review of the CMS RAI Version 3.0 Manual Chapter 2: 5-Day Assessment and OBRA Admission assessment dated 0ctober 2024 revealed Comprehensive item set. o ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay. o Must be completed (item Z0500B) by the end of day 14 of the stay (admitted plus 13 calendar days). o See Section 2.7 and Chapter 4 for requirements for CAA process and care plan completion. Record review of MDS Coding Policy (not dated) revealed the facility utilized the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. The most current RAI manual may be found on the CMS,gov website.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for competent nursing services. CNA A was asleep during 1:1 care of Resident #1 who is legally blind, on evening shift of 01/28/2025 and 01/29/2025. These failures placed residents at risk of injury. Findings include: Review of resident face sheet reflected Resident #1 was a [AGE] year-old male with admitted [DATE]. Resident has a diagnoses of displaced comminuted fracture of shaft of ulna (a severe break in forearm bone that occurs when the bones shatters and the pieces move out of place), subsequent encounter for closed fracture with delayed healing (where the fracture is considered closed), autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn and behave), legal blindness (a significant visual impairment that meets specific criteria as defined by law), adult physical abuse, burn of second degree of right knew (refers to a partial-thickness burn on the right knee), burn of second degree of right elbow (a partial thickness on the skin of the right elbow, characterized by redness, swelling, blistering and significant pain), burn of second degree of upper back (the burn affect the top two layers of skin causing noticeable redness, painful blisters, swelling and potential skin discoloration), multiple fractures of ribs (can cause severe pain, chest wall deformity, and other complications), dysphagia (difficulty swallowing), weakness, limitation of activities due to disability, unspecified hearing loss, bilateral attention deficit hyperactivity disorder (a developmental disorder that affects a person's ability to focus, control their behavior and be still), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest and other symptoms that interfere with daily life) and impulse disorder (a group of mental health conditions characterized by difficulty controlling impulsive behaviors, often leading to harmful or disruptive consequences). Review of the most recent MDS dated [DATE] reflected Resident #1 had a BIMS score of 99 indicating Resident #1 was cognitively impaired. The MDS assessment for cognitive skills for daily decision-making reflected Resident #1 was severely impaired indicating Resident #1 never/rarely made decisions. Review of the care plan initiated 10/02/2024 with a goal date of 04/09/2025 reflected Resident #1 was susceptible to wandering risk related to decreased safety awareness, confusion and wandering behavior. Goal to remain free of injuries associated with wandering behaviors thru this review period. Record review of care plan reflected Resident #1 needs assistance as he has poor eyesight. Record review of care plan initiated 10/10/2024 with a goal date of 04/09/2025 reflected Resident #1 susceptible for ADL self-care performance deficit related to legal blindness. Intervention/task for toilet use: the resident requires extensive assistance by (x1) staff for toileting. Transfers: the resident requires extensive assistance by (1-2) staff to move between surfaces as necessary. Review of the care plan reflected Resident #1 is a wanderer related to disoriented to place, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on the privacy or activities. Goal reflects the residents' safety will be maintained through the review date. Record review of care plan reveals resident has a communication problem related to cognitive communication deficit, hearing loss. Intervention/task to ensure/provide a safe environment. Care plan revealed the resident is a high risk for falls related to confusion, incontinence, poor communication/comprehension, unaware of safety needs, vision/hearing problems, wandering. Goal: the resident will not sustain serious injury through the review date. Record review of a video revealed on 01/28/2025 at 10:46 pm that was 2:32 minutes long, revealed Resident #1 get out of bed and bump into chair that care aide was using for his feet as a recliner. Resident then goes toward the sink and the care aide woke up because of the noise from him bumping into furniture. CNA A reached over and grabbed a sandwich from the side table next to him and handed it to the resident. Resident #1 returned to his bed, sat down and began to eat his sandwich and laid back down with food in his mouth. CNA A was sitting in his chair on the opposite side of the room. The video only showed his feet propped on a second chair that was being used as a recliner. Record review of a video revealed on 01/29/2025 at 4:42 pm that was 4:15 minutes long revealed Resident #1 getting up out of bed and walked towards the restroom where care aide was sitting with his feet propped on another chair as a recliner set up. Resident #1 bumped into the chair and care aide woke up and began to wipe his eyes with his hands, he then reached over and grabbed Resident #1 by his t-shirt and directed him towards the restroom door. CNA A checked his personal phone and returned to sleep. Video Resident #1 was using the restroom with the door open, and his back was visible in the video as he was standing up urinating. CNA A was asleep in the video with his feet propped up in chair and the resident bed side table was in front of him. Video then revealed resident turn around, pulled his pants down and sat on the toilet. CNA A's eyes were closed. During telephone interview on 02/06/2025 at 12:51 PM CNA A stated he was not asleep during his 1:1 shift with Resident #1. CNA A voiced it was not good to fall asleep during shift. CNA A verbalized his boss has not told him when he can return to work and that he was not sure when they will call him back to work. CNA A stated he knows he didn't do anything when he was with the resident in the room. During an interview on 02/06/2025 at 1:21 PM LVN B stated it was not appropriate for staff to be asleep on the job. LVN B stated she has not noticed any staff sleeping on the job and negative effects that could happen to resident if staff were asleep on the job would be they could have choking hazards and residents could fall. During an interview on 02/06/2025 at 2:09 PM with housekeeper A and Housekeeper Supervisor A (Housekeeper Supervisor A was translating for housekeeper A), Housekeeper A voiced she did notice a staff member asleep in a resident's room on one occasion. Housekeeper A stated she was not sure how long ago that was but does recall mentioning it to her supervisor. Supervisor voiced he does recall housekeeper A reporting it to him but could not recall the date. Housekeeper supervisor A voiced that he did tell one of the nurses but does not know her name. Housekeeper supervisor A voiced he does recall it was sometime during the day around noon time. Housekeeper A voiced she went to knock on Resident #1 room to clean it and when no one answered she knocked again for a second time. Housekeeper voiced no one answered so she entered the room and noticed Resident #1 and CNA A were asleep. Resident #1 was in his bed and CNA A was in a chair by the restroom and CNA A woke up, looked at his phone and went back to sleep. Housekeeper voiced Resident #1 was asleep the whole time, so she was very quiet while cleaning up his room and then exited shortly after once completed. During an interview on 02/06/2025 at 2:33 PM CNA B stated it was not appropriate for staff to sleep on the job. A negative outcome for staff sleeping on the job would be that staff would not be there for residents if they're not alert. Residents could accidentally choke, and staff would not be aware if they fell asleep on the job or they can fall attempting to get up on their own. CNA B stated she has not noticed any staff sleeping on the job, if she did notice any staff sleeping on the job, she would report it immediately. CNA B voiced she has worked with Resident #1, and he was legally blind. CNA B said he has already gotten used to his room but sometimes he will bump into things, and staff just need to redirect him. If Resident #1 got out of bed, he could get out of the room and he could go into another room and get hurt. During an interview on 02/06/2025 at 2:48 PM with Resident #1 FM. The FM stated she was watching the monitoring device that is set up in resident #1 room. The monitoring device recorded CNA A asleep in Resident #1 room. FM stated CNA A sets up chair like a recliner and has a pillow and sleeps while providing 1:1 for resident #1. FM stated CNA A places furniture in the way and Resident #1 is blind and he has difficulties getting to the restroom and at one point resident #1 gets up and asks for a sandwich. FM verbalized she noticed can A grab Resident #1 by the shirt CNA stays put in his chair while redirecting Resident #1 to the restroom. The FM voiced she reported this to the facility ADM and sent her the videos. The ADM requested that FM send the videos again. FM stated she does not feel like Resident #1 was safe with CNA A working at the facility. FM stated Resident #1 has already had a stitch put in his head from hitting the wall. FM stated overnight was not good for Resident #1 . FM stated she does not know if the facility is still allowing CNA A to watch Resident #1. FM stated I prefer they don't. I've seen everyone care for resident #1 and it's okay it was just that one incident that was disturbing (when CNA A grabbed Resident #1 by the T-shirt) instead of just moving the furniture out of the way so resident #1 can pass thru to the restroom. In an interview on 02/06/2025 at 2:55 PM CNA C stated she was usually the staff member that provides 1:1 with Resident #1 . CNA C stated one morning when she arrived for her morning shift no one was in the room and Resident #1 was alone. CNA C voiced she was informed by other staff that CNA A left home early during his shift and no one went to sit in the room with Resident #1 for 1:1. CNA C stated she informed the ADON and Wound care nurse. CNA C voiced she has not seen CNA A asleep but voiced she has been informed by the housekeeper that CNA A was asleep. CNA C verbalized it was not appropriate for staff to sleep on the job. CNA C voiced if she ever noticed staff asleep on the job, she would bring it up to the staff member and then inform the charge nurse or ADON. CNA C stated that it could be very harmful to the resident if staff were asleep on the job because the residents could fall, get hurt or choke if they were eating something. In an interview on 02/06/2025 at 3:34 PM the ADON stated he has not been informed by staff that any staff were sleeping on the job or when watching resident #1 during 1:1. The ADON voiced resident #1 was active and required 24-hour care and there was no way someone can sleep in that room. The ADON verbalized it can be harmful if someone was asleep while watching resident #1 because a lot of things can happen because resident #1 needs assistance. The ADON voiced it was not appropriate for staff to be sleeping on the job. In an interview on 02/06/2025 at 3:42 PM the Wound care nurse stated no one has reported to her that staff have been sleeping on the job or while watching resident #1 during 1:1. The Wound care nurse voiced resident #1 was blind, autistic and had intellectual disabilities, therefore, resident #1 gets easily frustrated when he doesn't know where he was at. The Wound care nurse voiced that resident #1 can hurt himself if someone was asleep while watching him 1:1. The Wound care nurse voiced it was not appropriate for staff to sleep on the job and it can be harmful if someone was sleeping on the job. During an interview on 02/06/2025 at 4:18 PM the DON said she has not been informed of staff sleeping on the job. The DON voiced it was not appropriate for staff to sleep on the job and if she was informed of staff sleeping on the job she would investigate and put the staff member on suspension pending the investigation. If it was found to be true, the staff member would be terminated. The DON stated staff were expected to do their job, answer call lights and take care of residents while working. The DON voiced she has not given an in-service on sleeping on the job, but they do give Abuse and Neglect trainings and the topic of sleeping on the job is brought up as an example of abuse and or neglect. During an interview on 02/06/2025 at 4:30 PM the ADM stated that she has not ever been informed of staff sleeping on the job. The ADM stated staff were not allowed to sleep on the job and if staff did fall asleep during their shift several things could happen depending on where they were sleeping. If ADM was told that a staff member was sleeping on the job, she would get a hold of the staff member and suspend them with possible termination. The ADM stated an in-service for sleeping on the job was given this morning. The ADM stated the investigation for resident #1 was still on-going because she doesn't have any record or video showing CNA A asleep while providing 1:1 for resident #1. Record Review of Policy for resident 1:1 monitoring on 02/06/2025 at 3:45 PM revealed -Purpose: To prevent injury to patient by maximizing environmental safety. Procedure: Precautions will be implemented for patients/residents who have behaviors that has escalated, and immediate interventions are required for the safety of the resident, staff and/or other residents. If the nurse is concerned about the patient's safety, the following steps will be implemented: 1. Immediately place the resident on Constant Supervision At no time should the resident be left unattended Record review of in-service started on 02/06/2025 over no sleeping on the job has been initiated for staff. Resident #1 was not in the in-service since he was still on suspension from his job duties for the current investigation the facility was completing. Review of Hospitality Aid last updated 03/2020 Job Summary The Hospitality Aide performs non-nursing, non-direct resident care duties under the supervision of licensed nursing personnel and assists in maintaining a positive physical, social and psychological environment for resident. Job Description 1-on-1 with residents who have behavioral challenges or need socialization

Based on observations, interviews, and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 5 residents (Resident #1) reviewed for self-determination. The facility failed to allow Resident #1 to go on activity outings with his peers, only allowing him to utilize an outside vendor, which caused him to feel angry and viewed as less important as his peers because of his disability. This failure placed residents at risk for being denied the opportunity to exercise their autonomy regarding things that were important in their lives and a decrease in their quality of life. Findings included: Record review of Resident 1's EHR revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses that included dementia (defective memory), mild cognitive impairment (memory and/or thinking problems), acquired absence of left and right leg above the knee, and chronic pain. Resident #1 was noted to be his own RP. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed Resident #1's BIMS was not assessed. Section F interview for activity preferences included Resident #1 answered a question, replying it was very important that he did things with groups of people and that he did his favorite activities. Record review of the care plan last revised on 11/25/24 for Resident #1 reflected the following areas of focus: psychosocial wellbeing r/t the lack of family and friend visitation, and effectively cope with his feelings of isolation and loneliness. There was an intervention to, Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. Record review of Resident #1's Progress Notes reflected an entry dated 12/6/24, by the SW, which indicated Resident #1 had answered all the BIMs questions correctly, indicating Resident #1's cognition was intact. In an interview on 12/6/24 at 11:19 am with a resident of the facility who asked not to be identified for fear of retaliation, revealed concerns regarding a friend who also lived at this facility. This resident felt Resident #1 was not being treated fairly as he was no longer permitted to go with the rest of them on outings because he was a double amputee. The resident stated staff have told them it was because of something that happened at another facility. In an interview on 12/6/24 at 11:28 am Resident #1 stated his main concern was that he had been, discriminated against because of my disability. He stated he had been at the facility for years and all the sudden months ago, they told him he could not ride in the facility van because he was a double amputee. Resident #1 stated it was him watching his friends leave and go to the store without him, like I am some kind of loser. He was told it was now a policy because of something that happened at another facility when a double amputee got hurt and was now suing. Resident #1 stated he was mad because, we are not all the same person just because we are double amputees. He stated he cannot spend that time with his friends, it was fun and there was not a whole lot of fun available to him these days. Resident #1 stated Now they (the facility staff) say it is for my safety they know I'm mad I have let everyone know. In an additional interview at 12:30 pm with Resident #1, he stated he does know that he can take a hired van that is not the facility's. He asked, how is that supposed to make me feel? I am the only one here that is not allowed. He stated he just has not gone on outings since they started this new rule. In an interview on 12/6/24 at 2:02 pm with CNA A he stated Resident #1 has complained to him about not being allowed on the company van. CNA A stated if there was an outing, they would make sure he has a ride with a transportation company, but there was a policy that he cannot ride in the facility van. CNA A said it was for Resident #1' own safety. He stated he was not sure, but he thought that something had happened at another facility which caused the change in policy . In an interview on 12/6/24 at 2:35 pm, CNA B stated she was not sure how long ago it was when they started saying Resident #1 could not ride in the facility van, but she thought it was a few months ago. She stated she was told Resident #1 could not ride because it was a safety issue. She stated that he could not be protected by the seatbelt in the van and, that the new policy was to protect the resident. CNA B stated they would provide a safe ride with another transportation company . In an interview on 12/6/24 at 2:49 pm with ADON C he stated Resident #1 had not expressed any concern to him about the van policy. ADON C stated he was aware that Resident #1 was not supposed to ride in the facility van, but they could call a transportation service . In an interview on 12/6/24 at 3:01 pm with LVN D, she stated Resident #1 had not spoken to her about his concerns regarding not being allowed to ride in the facility van. LVN D stated the policy said he could not ride because it was a safety risk for someone that did not have at least one leg to balance themselves. In an interview on 12/6/24 at 4 :22 pm with the facility SW revealed she had worked at the facility for about 10 months and during that time Resident #1 had refused to do a BIMS assessment and stated the questions were stupid. The SW stated she asked today and told him the interviewer was asking what the results of a BIMs assessment were, so he agreed to answer the questions. She stated he answered all the questions correctly. The SW stated she knew Resident #1 was unhappy about not going on the trips to the local retail store, but that it was his choice. She stated she thought the facility would arrange transportation for him with the transport company, but he had refused to utilize the alternate transportation. She stated she went to the store for him every Friday and purchased the items he requested . In an interview on 12/06/24 at 12:00 pm, 3:10 pm, and 5:10 pm with the facility Adm, she stated Resident #1 was not allowed to ride in the facility van. She stated they could not ensure the safety of a double amputee. The Adm stated they had talked with Resident #1 about providing alternate transportation with a contracted medical transport company. The Adm stated she was not aware of any difference with how transportation was accomplished using the transport company, other than they (the facility) had a policy saying they could not transport the resident and the medical transport service would transport him. The Adm stated she did consider the policy to be for the protection of the resident and not for the facility's protection. In a continued interview at 3:10 pm, the Adm stated that their residents did not socialize on the van during trips. She stated the facility van manufacturer told the facility the seatbelts in the van were not adequate for a double amputee. Continued and final interview at 5:10 pm, prior to the exit, the Adm stated there was not a specific sentence in the policy that read double amputees were not allowed on the van, but she had highlighted in the policy a section that read about the facility ensuring the residents' safety . In an interview on 12/09/24 at 11:45 am with a driver/worker at the alternate transportation company used by the facility, she stated they used a normal van for transportation. They did not have special procedures or equipment for a person that was a double amputee. Record review of the facility's policy, last updated 8/2024 (with no date of the month noted) and entitled, Driver and Vehicle Safety Policy, with the subject highlighted Resident Wheelchairs in transportation revealed: Geri-chairs and scooters may NOT be used for transportation in the company vehicle. Wheelchairs, including tilt wheelchairs, used for transportation should meet current ANSI and Society of Automotive Engineers (SAE) standards for wheelchairs used in motor vehicles. Wheelchairs should have a frame which has four securement points for tie down straps and can withstand an impact or accident. Motorized wheelchairs may be used for transport; they should be turned off before loading the wheelchair into the lift or van, and should remain off for the entire trip, until the wheelchair has been completely unloaded from the van. Continued review revealed the 35-page policy did not contain any documentation about van use restrictions for residents with double amputations. Record review of the facility's policy, updated 2/2021 and entitled, Resident Rights, with the policy statement: Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation includes, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination On 12/6/2024, the facility failed to provide documentation of the van manufacturer's report to the facility that the van seatbelt was not adequate for a double amputate when this documentation was requested.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good toileting hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. The facility failed to change Resident #1's briefs and document all incontinent care performed on 03/07/24. This deficient practice could place residents at risk of a decreased quality of life. Findings included: Record review of Resident #1's undated face sheet revealed a female who was admitted to the facility on [DATE], readmitted on [DATE], and was her own RP. Record review of Resident #1's diagnoses report, dated 03/07/24, revealed she had diagnoses including unspecified degenerative disease of nervous system (affect many of the body's activities, such as balance, movement, talking, breathing, and heart function), unspecified severity of vascular dementia with other behavioral disturbance, age-related osteoporosis (A condition in which bones become weak and brittle) without current pathological fracture, weakness, unspecified anxiety disorder, left hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue), overactive bladder, restlessness and agitation, unspecified bipolar disorder, unspecified impulse disorder, unspecified single episode major depressive disorder, unspecified pain, and unspecified psychosis not due to a substance or known physiological condition. Record review of Resident #1's comprehensive MDS assessment, dated 02/09/24, revealed a BIMS score of 13, indicating she was cognitively intact. Resident #1 was dependent on staff with toileting hygiene. Resident #1 was always incontinent with urinary and bowel movements. Record review of Resident #1's care plan, dated 02/26/24, revealed she had functional bladder incontinence and bowel incontinence related to dementia, impaired mobility, and overactive bladder. CNAs, LPNs, and RNs were required to change Resident #1 every two hours and PRN. Record review of Resident #1's BIMS evaluation, dated 03/04/24, revealed a score of 14, indicating she was cognitively intact. Record review of Resident #1's quarterly bladder evaluation, dated 03/04/24, revealed she had functional incontinence contributing to her condition, was wheelchair bound, dependent, disoriented, had decreased manual dexterity, and varied in her voiding (to urinate) pattern. Record review of Resident #1's POC, dated 03/07/24, revealed staff assisted Resident #1 with toileting hygiene at 2:26 a.m. and 6:20 a.m. There were no other entries. During an observation and interview on 03/07/24 at 9:58 a.m., Resident #1 was lying on her back in her bed. Resident #1 appeared clean, comfortable, dressed, and had her call light resting on her stomach. Resident #1 revealed she wore briefs. Resident #1 stated staff changed her briefs. Resident #1 also stated she waited 15 minutes for staff to change her briefs. Resident #1 did not indicate when staff last changed her brief on 03/07/24. An observation on 03/07/24 at 10:18 a.m. revealed CNA A and B entered Resident #1's room to transfer Resident #1 from her bed to her wheelchair. As CNA A and B lifted Resident #1 using the gait belt and transferred her to her wheelchair, the surveyor observed Resident #1's pants were soaked from the buttocks to the hamstrings. The surveyor asked CNA A and B if they observed Resident #1's pants were soaked when lifting Resident #1 using the gait belt and transferring her to her wheelchair. CNA A and B lifted Resident #1 using the gait belt again, observed Resident #1's pants were soaked, transferred Resident #1 back into her bed, and changed Resident #1's brief and pants. The surveyor left the room before CNA A and B began changing Resident #1's brief. During an interview on 03/07/24 at 10:26 a.m., CNA A and B revealed they did not observe Resident #1's pants were soaked when they transferred Resident #1 from her bed to her wheelchair. CNA A stated she last changed Resident #1's brief one hour ago . CNA A did not indicate if she documented the incontinent care she performed on Resident #1. During an interview on 03/07/24 at 10:27 a.m., the ADON revealed she worked at the facility for five months. The ADON stated she was trained and in-serviced twice a month or more as needed on ADL care. The ADON stated she encouraged staff to round (check on residents) every 30 minutes. The ADON also stated nurses monitored residents' bladder and bowel movements according to the physician's orders. The ADON explained CNAs and nurses changed residents' briefs every two hours or more as needed. The ADON stated staff often changed Resident #1's briefs. The ADON did not indicate how often staff changed Resident #1's briefs. The ADON also stated Resident #1 was her own RP, had dementia, increased confusion, no urge to ask staff to change her briefs, and did not have any skin breakdown. During an interview on 03/07/24 at 11:22 a.m., Nurse C revealed she worked at the facility for 7 1/2 months. Nurse C also stated she previously worked as a CNA at the facility for 2-3 years. Nurse C stated she was trained and in-serviced on ADL care by the ADON, DON, and ADM weekly or as needed. Nurse C also stated CNAs, MAs, and nurses changed residents' briefs every two hours. Nurse C stated CNAs documented ADL care performed in residents' POC. During an interview on 03/07/24 at 12:09 p.m., Nurse D revealed she worked at the facility for 10 months. Nurse D also stated she was trained and in-serviced on ADL care daily. Nurse D stated CNAs changed residents' briefs every two hours or more as needed. During an interview on 03/07/24 at 12:40 p.m., CNA A revealed she worked at the facility for six months. CNA A also stated she was trained and in-serviced on ADL care by the DON. CNA A stated she changed residents' briefs every two hours. CNA A also stated ADL care provided to or refused by the resident was documented in POC and reported to the charge nurse . CNA A stated she put Resident #1 in bed one hour before the surveyor observed Resident #1's pants were soaked. CNA A did not indicate if she documented the incontinent care she performed on Resident #1 one hour before the surveyor made an observation of Resident #1's soaked pants. CNA A explained Resident #1's briefs were changed 3-4 times daily or more as needed. During an interview on 03/07/24 at 1:45 p.m., CNA E revealed she worked at the facility for three years. CNA E also stated she was trained and in-serviced on ADL care every month. CNA E stated CNAs changed residents' briefs every two hours daily. CNA E also stated ADL care provided to or refused by a resident was documented in a resident's POC. CNA E stated she rounded every two hours or more. During an interview on 03/11/24 at 11:08 a.m., Nurse F revealed she worked at the facility for seven months. Nurse F stated she was trained and in-serviced on ADL care. Nurse F also stated CNAs and nurses conducted rounds. Nurse F did not indicate how often CNAs and nurses conducted rounds. Nurse F stated CNAs and nurses checked residents to determine if they were soiled and changed residents' briefs every two hours. Nurse F also stated CNAs documented the care performed in residents' POC and nurses documented residents' refusals for care in nurse's notes. Nurse F stated residents could develop skin issues, become embarrassed, and have a foul odor if CNAs did not observe a resident was soiled. During an interview on 03/11/24 at 11:22 a.m., Nurse G revealed she worked at the facility for 10 months. Nurse G stated she was trained and in-serviced on ADL care by the ADM weekly. Nurse G also stated CNAs, MAs, or nurses could change residents' briefs every two hours or more as needed. Nurse G stated CNAs documented the care performed in residents' POC. Nurse G also stated resident were checked on every two hours or more. Nurse G stated residents could develop skin issues if CNAs did not observe a resident was soiled. During an interview on 03/11/24 at 1:34 p.m., the ADM revealed there was no policy and procedure for when to perform incontinent care, but she would check. During an interview on 03/11/24 at 1:37 p.m., the DON revealed she worked at the facility for one year. The DON stated she was trained and in-serviced on ADL care by the regional clinical specialist. The DON also stated she expected CNAs and nurses to change residents' briefs and round every two hours. The DON stated she also expected CNAs and nurses to change residents' briefs if the briefs were wet. The DON also stated ADL care was documented in residents' POC. The DON explained not all ADL care was documented in residents' POC due to the restriction in residents' electronic health records that only allows one entry per shift for ADL care performed per shift. The DON stated she did not know how staff confirmed ADL care was being performed as needed if the electronic health records allowed them to input one entry per shift. The DON stated she expected staff to observe residents' clothes. The DON also stated it was a dignity issue if a resident had food or stains all over their clothes. The DON stated residents could develop skin breakdowns if they were left sitting in their wheelchairs with soiled or wet pants over a duration. The DON also stated residents could also have dignity issues, feel embarrassed, and sad. During an interview on 03/11/24 at 2:00 p.m., the ADM revealed there was no policy and procedure for when to perform incontinent care. The ADM stated there was a universal understanding that incontinent care was performed every two hours. The ADM did not indicate if staff needed to document incontinent care. Record review of the facility's in-services revealed staff were trained on checking residents' clothes/shoes when getting residents out of bed and dressed on 02/13/24 and taught all staff must pay attention to the residents as they passed them in hallways and to look at clothing/shoes. Staff were also trained on rounding on 02/20/24 and taught that CNAs and nurses should not leave their shift without doing a walking round or giving a report to the upcoming shift, another CNA and nurse from another hallway could round if the person relieving were running late, rounds should be done every shift and purpose was to ensure residents were being taken care of properly. Staff were also trained on daily work assignments on 02/20/24 and taught when the assignment says a staff member will be late or called in, the halls were then split, staff were responsible for rounding on the 'split' hall, and late staff member was to round immediately when they arrive. Record review of the facility's Pericare-Incontinent Care checklist, revised in January 2023, revealed a step-by-step guidance on how to perform perineal care on male, female, and indwelling catheter residents. The checklist did not indicate how often to round and perform incontinent care on residents. Record review of the facility's ADL policy and procedure, revised in March 2018, revealed the following, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) has a debilitating disease with a known functional decline; (2) has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or (3) refuses care and treatment to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative interventions to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions: e. Total dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, comfortable, and homelike environment for ten (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) out of 13 residents on the A-100 hall reviewed for temperature of the environment, in that: The facility failed to ensure residents at the end of the A-100 hall, Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10, were provided interventions to receive get relief from the heat when the AC (air conditioner) broke down on 7/28/22. These residents were not being screened for signs and symptoms of dehydration or heat stroke . The temperature in the residents' rooms was 88 degrees and the temperature outside was 95 + degrees. This failure placed residents at risk of dehydration, heat stroke, dizziness, fatigue, and a diminished quality of life. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/2/22 at 3:30 PM. While the IJ was removed on 8/5/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of dehydration, heat stroke, dizziness, fatigue, and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who resides in room A-104 and was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep), type II diabetes, [CONDITION(S)], hypertension (high blood pressure), and severe obesity. Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. It further reflected he required no assistive devices and could ambulate independently. Review of Resident #1's care plan, revised 2/24/22, reflected he and an impaired gas exchange related to obstructive sleep apnea which required he use a [CONDITION(S)] (Continuous Positive Airway Pressure) machine. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who resides in room A-107 and was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), type II diabetes, restlessness and agitation, [CONDITION(S)] (trouble sleeping), and hypertension (high blood pressure). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. It further reflected she required extensive assistance with all ADL's. Review of Resident #2's care plan, revised 4/12/22, reflected she had a terminal diagnosis related to a [CONDITION(S)] (stroke) and was on hospice services. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who resides in room A-109 and was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disease, adult failure to thrive, and major depressive disorder. Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS of 11, indicating a mild cognitive impairment. It further reflected she required extensive assistance with all ADL's. Review of Resident #3's care plan, revised 7/10/22, reflected she had limited mobility related to [CONDITION(S)] disease. Review of Resident #4's undated face sheet reflected an [AGE] year-old female who resides in room A-111 and was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), wheezing, major depressive disorder, and weakness. Review of Resident #4's quarterly care plan, dated 5/29/22, reflected a BIMS of 6, indicating a severe cognitive impairment. It further reflected she required extensive assistance with all ADL's. Review of Resident #4's care plan, revised 4/5/22, reflected she had limited physical mobility related to weakness and cerebral palsy. Review of Resident #5's undated face sheet reflected a [AGE] year-old male who resides in room A-108 and was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, obstructive sleep apnea, morbid obesity, and a history of pneumonia. Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. It further reflected he required extensive assistance with all ADL's and is on oxygen therapy. Review of Resident #5's care plan, revised 2/25/22, reflected he had an altered respiratory status/difficulty breathing related to sleep apnea and acute and chronic respiratory failure with an intervention of receiving continuous oxygen via nasal cannula at 2 LPM. Review of Resident #6's undated face sheet reflected a [AGE] year-old female who resides in room A-117 and was admitted to the facility on [DATE] with diagnoses including fracture of left pubis (pelvic), brain cancer, and polyneuropathy (damage to multiple peripheral nerves). Review of Resident #6's admission MDS, dated [DATE], reflected it had not been completed. Review of Resident #6's care plan, revised 7/26/22, reflected she had limited physical debility related to disease process of brain cancer and weakness. Review of Resident #7's undated face sheet reflected a [AGE] year-old male who resides in room A-110 and was admitted to the facility on [DATE] with diagnoses including shortness of breath, [CONDITION(S)], [CONDITION(S)], type II diabetes, and hypertension. Review of Resident #7's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. It further reflected he has a current stage IV pressure injury. Review of Resident #7's care plan, revised 4/15/22, reflected he had limited physical mobility related to left BKA (below knee amputation). Review of Resident #8's undated face sheet reflected a [AGE] year-old female who resides in room A-106 and was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] (seizures), type II diabetes, morbid obesity, and chronic obstructive pulmonary disease ([CONDITION(S)]). Review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. It further reflected she needed extensive assistance with all ADL's and required a wheelchair and hoyer lift for transferring. Review of Resident #8's care plan, revised 6/30/22, reflected she required supervision for upper body ADL's and extensive assistance for lower body ADL's and bed mobility. Review of Resident #9's undated face sheet reflected a [AGE] year-old female who resides in room A-115 and was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and polyneuropathy (damage to multiple peripheral nerves). Review of Resident #9's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. It further reflected she was independent with all ADL's and utilized a walker. Review of Resident #9's care plan, dated 6/21/22, reflected she had an ADL self-care performance deficit related to adult failure to thrive. Review of Resident #10's undated face sheet reflected a [AGE] year-old female who resides in room A-113 and was admitted to the facility on [DATE] with diagnoses including morbid obesity, pressure injuries, muscle weakness, and [CONDITION(S)] (Swelling caused due to excess fluid accumulation in the body tissues). Review of Resident #10's quarterly MDS, dated [DATE], reflected a BIMS of 7, indicating a moderate cognitive impairment. It further reflected she required extensive assistance with all ADL's. Review of Resident #10's care plan, revised 3/25/22, reflected she had an indwelling catheter and [CONDITION(S)] related to impaired mobility and pressure injuries. During an observation and interview on 8/2/22 at 9:32 AM, this Surveyor walked down the A-100 hall and felt it to be considerably warmer past room 106 and beyond than the rest of the facility. There was a portable AC unit in an empty room at the beginning of the hallway, in Resident #1's room (A-104), and in Resident #6's (A-117) room. These units did not assist with cooling down the hall. Resident #1's room was cooler because his door was closed. Surveyor observed CNA A walking down the hall sweating and wiping sweat from her forehead. She stated, It is so hot on this hall. The residents are so hot. It is unbearable. She stated it had been like that for several days. She led the Surveyor to Resident #6's room, (room 117). Resident #6 was sleeping but was clammy and there was sweat on her forehead. Her room was warm, and Surveyor started to sweat. During an observation and interview on 8/2/22 at 9:35 AM, with Resident #7 (room A-110), he was in his room with the door and blinds closed. His room was warm, and he stated it had been that way for several days and that was why he kept his blinds closed - to try and keep the room cooler. During an observation and interview on 8/2/22 at 9:52 AM, with Resident #8 (room A-106), she was sitting in bed watching TV. She had an oscillating fan that was on its highest speed. She stated it had been so unbearably hot that she could hardly sleep at night. During an interview on 8/2/22 at 10:01 AM, with the MAINTD, he stated the AC for the A-100 hall went out the previous Thursday, 7/28/22. He stated he called a company to come out to diagnosis the issue the following day, 7/29/22. He stated they company kept pushing back their appointment and they did not come until the day before, 8/1/22. He stated they determined the compressor was out and he was still waiting on a quote fromor them. He stated he had not contacted any other AC companies because they had used (company) consistently in the past for their AC needs. He stated he had been taking the temperature in the residents' rooms daily and they had been at an average of 78 degrees. He stated he had not been documenting/logging the temperatures . He stated he initially notified the ADM on 7/28/22 that the AC went out, but did not notify her that the AC company had been unable to come out to the facility. He ordered the portable AC units and determined where to place them due to the space available in the residents' rooms. He stated for example, if a resident required a hoyer lift, a portable AC unit could not be placed in that room. During an interview on 8/2/22 at 11:05 AM with Resident #1, he stated he had to make a big deal to the MAINTD about how hot it was on the hallway for him to get portable AC units on the hall, which took about two days before they arrived. He stated they put one of the portable AC units in his room probably to shut him up. He stated it felt better in his room because he kept his door closed. He stated the other two portable AC units on the hall were not helping. He stated that even though he felt better in his room, he was worried about all of the other residents on the hall who did not have an AC unit or were not able to get up and walk to another part of the facility like he was. He stated it was so hot especially at the end of the hall where the sun shone through the windows/door. He stated all of the residents were so hot and it broke his heart. During an observation and interview on 8/2/22 at 11:13 AM with Resident #5, he was a larger man lying in his bed while utilizing oxygen. His skin was clammy and there wasere sweat beads on his forehead. He stated it was so hot in his room. He stated he was miserable, and it was difficult to sleep at night. He stated he heard they had put portable AC units on the hall, but he did not feel it, nor did they make a difference. During an interview on 8/2/22 at 11:16 AM with the ADON, she stated she had heard the residents had been complaining of being hot, but that was why they got the portable AC units on the hall. During an observation and interview on 8/2/22 at 11:36 AM with the MAINTD, this Surveyor asked if he would check the temperature of some of the rooms on the A-100 hall as he would when he tested the temperatures normally. He took his temperature gauge gun, and we went to Resident #6's room. He pointed the gun at the wall, and it read 88 degrees. He then pointed it at the air vent, and it read 83 degrees. We went to Resident #5's room where the temperature read 88 degrees. Surveyor requested he put regular thermometers in the last three rooms on the hall (A-108, A-110, and A-117) so they could ensure the temperatures taken by the temperature gun were accurate. At this time of the day, it was 95 degrees outside. Since 7/28/22, the day the AC went out, it had been 95 + degrees outside each day. During an interview on 8/2/22 at 12:28 PM with the DON, she stated she was not aware the AC was broken or that it was as hot as it was on the A-100 hall. She stated she normally did her rounds in the morning and since it was not that hot outside at the time of day, she never noticed that it was warmer than it should be. She stated no interventions had been done to ensure the residents were comfortable because she nor the ADM knew about it. When asked what a negative outcome could be for residents to be existing in that hot of temperature, she stated it could lead to dehydration and disrupting their over-all comfort. During an observation and interview on 8/2/22 at 12:45 PM with Resident #10 (room A-113), she was in bed with just a sheet covering her. The room was noticeably warm. Her skin was clammy, and her cheeks were flushed pink. She stated it was so hot in her room and on the hall and that she was always sweating. She stated even when a staff member or doctor was in her room, they would say, Oh my gosh, it is so hot! and would wipe sweat off their forehead. She stated when she was taken down to the therapy gym on another hall, it was nice and cool. Observation on 8/2/22 at 1:12 PM, revealed all three rooms at the very end of the hall (108, 110, and 117) to have a reading of approximately 85 degrees on the thermometers placed in them by the MAINTD. On 8/2/22 at 3:06 PM, a voicemail was left for the facility's NP requesting a call back. Review of a grievance form made by Resident #1 and completed by the SW, dated 7/28/22, reflected the following: Resident states that his room and entire Unit 1 hall is very hot. Temp is reading 81 degrees on the hall. There was no resolution documented. Review of a grievance form made by Resident #8 and completed by the SW, dated 7/28/22, reflected the following: Resident states that she was unable to sleep the last two nights as her room and hall are very hot. There was no resolution documented. During an interview on 8/2/22 at 3:12 PM with the SW, she stated when she received the grievances she notified the MAINTD and was told that he would be ordering portable AC units and would contact the AC company. Review of the facility's Quality of Life - Homelike Environment Policy, revised May 2017, reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment . 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: . h. comfortable and safe temperatures The DON was notified on 8/2/22 at 3:30 PM, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the DON on 8/2/22 at 3:30 PM. A Plan of Removal was first submitted by the CCS on 8/2/22 at 6:17 PM and the following POR was accepted on 8/4/22 at 3:55 PM and read as follows: Summary of Details which lead to outcomes On 08/02/2022 an abbreviated survey was initiated at (Facility) at (Address). 08/02/2022 a surveyor provided a IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the immediate jeopardy states as follows: Environmental F584 - The facility failed to provide a safe, clean, comfortable, and homelike environment in accordance with professional standards of practice. Identify residents who could be affected 100 A Hall residents Problem 1: The Air Conditioning on unit 100 A hall is not working. Action Taken: Residents were offered to be relocated off of 100 Hall A to alternate places within the facility at 1:52pm. Any residents that have refused to move rooms will have once a day visits starting 8/2/2022 by social worker to advocate and provide ongoing education on their safety and well-being these visits will be documented in resident medical record, this will continue until A/c is repaired/replaced. Residents on 100 hall A were assessed for possible signs or symptoms of dehydration, dizziness, or heat exhaustion by Director of Nursing on 8/2/2022. This assessment will continue until A/C is repaired/replaced q shift by licensed nurse and will be documented in resident medical record. Notified families of 100 Hall A that were affected on 8/2/2022. Social Worker met with each resident on 100 Hall A to offer supportive counseling and reassurance on 8/2/22. Portable units were ordered by Maintenance Director and corporate support on 8/2/22. Two have been received and facility is awaiting the third unit. Facility obtained 13 window units that were successfully installed on 8/3/2022 by Maintenance Director and corporate support team. Facility is in process of obtaining multiple bids for repairing/replacing A/C unit to determine most expedient option. Regional Director of Operations provided in-service for Maintenance Director, Administrator, and Director of Nurses on importance of comfortable temperatures as well as how to address mechanical failures that may result in resident dissatisfaction on 8/2/2022. Any changes in leadership position, Regional Director of Operations will in-service the new hires. In-service all staff on reporting concerns regarding resident comfort levels, health, and well-being immediately to Administrator, and processes of escalations of concerns to include contacting regional support staff or compliance hot line on 8/2/22. For those unavailable to attend Administrator conducted phone in-service. New hire will be in-serviced and incorporated into orientation. Inservice conducted by Corporate Clinical Specialist on 8/3/2022 on signs and symptoms on heat stroke for all staff. The in-service will be ongoing until all staff is trained by 8/3/22. For those unavailable to attend Administrator conducted phone in-service. New hire will be in-serviced and incorporated into orientation. In addition, CDC posters on signs and symptoms of a heat stress were posted around the facility at 9:49 am at 8/3/2022. Monitoring: Temperature will be taken on effected unit every shift, mid-shift, and PRN by charge nurse until A/c unit is repaired or replaced. Documentation will be maintained by licensed nurses by a temperature monitoring log. Any issues that impact resident health, well-being, or safety will be immediately reported to Administrator or DON. The Administrator and DON will immediately evaluate risk and implement intervention that include promptly moving resident to alternate location. Administrator will review for compliance daily. Residents on 100 Hall A will be monitored each shift for 7 days or until A/C is fixed, by Licensed nurse for signs or symptoms of dehydration, dizziness, or heat exhaustion. After A/C is fixed the assessment will continue 3 days post repair. Compliance will be monitored by DON. Any issues will be reported to MD and RP immediately. All findings will be reported to QAPI committee. Administrator will review for compliance daily. Compliance with in-servicing will be monitored by Administrator and DON by reconciling in-service attendees to payroll roster. Any employee identified not to have received education will not be allowed to work until training is received. In-service will be incorporated into orientation for new hires. All findings will be reported to QAPI committee. Administrator will review for compliance daily. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 8/2/22. The Administrator will review the daily temperatures and any updates to the air conditioning system on a daily basis until the Air Conditioner is repaired with the Medical Director. Involvement of QA On 8/2/22 an Ad Hoc QAPI meeting will be held with the Regional Director of Operations, Regional maintenance director, Facility maintenance director, Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? The Administrator and Maintenance Director will be responsible for implementation of New Process. The New Process/ system will be started on 8/2/22. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/2/22. The Surveyor monitored the Plan of Removal on 8/5/22 as follows: Observations on 8/5/22 from 1:14 PM - 2:50 PM revealed every resident room that was occupied had a working window unit on the A-100 hall (13 AC units). There was a large portable AC unit at the beginning of the hall and the end of the hall that were blowing cool air down the hall. The portable units were set at 65 degrees. The wall thermostat in the middle of the hall read at 71 degrees. Every resident room had a thermometer in their room that read between 71 - 74 degrees, based on their preference. All employees had a list created by the CDC with symptoms to look out for when it was hot and to avoid heatstroke (sweating, dehydration, etc.) that was taped to their nametags. During an observation and interview on 8/5/22 at 2:17 PM with Resident #10, she was in her room watching TV. She had a window AC unit that was on and her thermometer read 73 degrees. She stated it felt so much better and pleasant in her room. She stated she was so happy and was so much more comfortable. During an observation and interview on 8/5/22 at 2:20 PM with Resident #5, he was in his room watching TV. He had a window unit that was on and his thermometer read 73 degrees. He stated he felt so much better because it was so much more comfortable in his room. During an interview on 8/5/22 at 2:24 PM with MA B, she stated signs and symptoms to look for when the temperature was high was the resident experiencing dizziness, dry lips, or an upset stomach. She stated if she noticed a resident experiencing any of these symptoms, she would offer the resident water and notify the nurse immediately. She stated if a resident was to get to hot it could lead to dehydration or headaches. During an interview on 8/5/22 at 2:32 PM with Resident #8, she was in the dining room getting ready to play Bingo. She stated she loved how cool it was in her room. She stated she was so comfortable the night before and she slept like a baby. During an interview on 8/5/22 at 2:35 PM with LVN C, she stated symptoms to look for when it was hot was sweating, dizziness, not feeling good. She stated it would not be acceptable for residents to be residing in temperatures above 80 degrees because it could lead to passing out, falls, or confusion. She stated if she noticed residents experiencing these symptoms or the facility to be warm, she would notify the ADM immediately. During an interview on 8/5/22 at 2:38 PM with LVN D, he stated extreme heat could cause residents to experience dehydration, a decreased urine output, or sweating. He stated it would not be acceptable for residents to be residing in their rooms with a temperature of 88 degrees. He stated some interventions, should this kind of incident happen again, would be moving residents to another room, offer hydration, and letting the ADM know. Interviews were conducted on 8/5/22 from 1:14 PM - 2:50 PM with three additional CNA's and one RN that worked on the other side of the facility. All four interviews revealed they had been in-serviced on signs and symptoms of heat stroke/heat exhaustion. All four staff members stated that if they noticed any residents experiencing any of these signs and symptoms, they would notify the ADM immediately. During an interview on 8/5/22 at 2:40 PM with the MAINTD, he was asked why he did not contact another AC company when the one he called could not get to the facility right away. He stated he usually went through their preferred vendor, but admitted he could have called additional companies, and in the future that was what he would do. He stated extreme heat could cause residents to experience heat stroke, dehydration, or dizziness. He stated in the future he would notify and updated the ADM and their Regional staff if the ADM was unavailable. During an interview on 8/5/22 at 2:43 PM with the ADM and CCS, the ADM stated she was notified the AC had broken on the A-100 hall on 7/28/22 when Resident #1 notified her of the temperature on the hall. She stated the MAINTD called their AC vendor and was told they would be out that afternoon. She stated she found out later that they never showed up. She stated she was out sick from Friday (7/29/22) - Wednesday (8/3/22) and was not updated by anyone at the facility, so she was unaware of the condition of the A-100 hall. She stated she failed to follow-up with the MAINTD. The CCS stated after the IJ was called on 8/2/22, all residents at the end of the A-100 hall were moved into other rooms in the facility that were not experiencing AC issues. The ADM stated the MAINTD purchased 13 window units on 8/2/22 and with the help of three staff members and three maintenance directors from sister facilities, they were able to get them all installed by 2:45 AM the following morning (8/3/22). The ADM stated they printed a list of signs and symptoms of heat stroke/heat exhaustion that was created by the CDC and they were given to all staff to put on their nametags. She stated all in-servicing on heat exhaustion and reporting such issues to her was started on 8/2/22 and was completed on 8/3/22. She stated staff were not allowed to work their shift until they were in-serviced. The staff that were not scheduled to work were in-serviced by phone, as well as e-mails/texts that were sent out. She stated an internet video was created regarding signs and symptoms to look for and the importance of notifying the ADM in situations like these and was sent via text message to all employees as well. She stated it was unacceptable that the residents were residing in the hot temperature and negative outcomes of this could be heat stroke, dizziness, vomiting, or change in condition. The ADM stated the replacement AC unit was delivered on 8/4/22 and was scheduled to be installed that day (8/5/22). She stated the window units would remain in the residents' rooms, should something like this happen in the future. Review of an in-service conducted by the CCS to the ADM, DON, and MAINTD, dated 8/2/22, reflected she discussed the importance of comfortable temperatures as well as the process to address mechanical failures: When a mechanical failure occurs resulting in resident dissatisfaction, actionable steps need to be taken to ensure that resident needs are addressed. All regional support needs to be notified to ensure guidance can be provided. Review of a mass text message that was sent out to all staff (89 recipients), dated 8/3/22, reflected the following: Hello (facility) team. Here is a video to guide you on how to identify signs and symptoms of heat stress. It is important that each of you watches this quick training video and respond back that you have watched and understand it. Review of in-services on Heat Stroke/Heat Exhaustion, dated 8/2/22 and 8/3/22, provided to all staff reflected the following: Know the signs and symptoms of heat stroke and heat exhaustion. Heat Stroke: very high body temperature; red, hot, and dry skin; rapid, strong pulse; throbbing headache; dizziness; upset stomach; confusion; passing out Heat Exhaustion: heavy sweating; paleness; muscle cramps; tiredness; weakness; dizziness; headache; upset stomach or vomiting; [CONDITION(S)] Review of an invoice from the facility's Director of Plant Operations, dated 8/2/22, reflected three additional portable AC had been purchased. Review of Nursing notes for Resident #1 - Resident #10, from 8/3/22 - 8/5/22, reflected they were being monitored for signs of dehydration, dizziness, and heat exhaustion every shift. None of the residents had been experiencing any signs or symptoms. Review of August TAR's for Resident #1 - Resident #10, on 8/5/22, reflected each resident was being monitored for signs and symptoms of dehydration, dizziness, and heat exhaustion every shift. None of the residents had been experiencing any signs or symptoms. Review of Social Services notes for Resident #1 - Resident #10, from 8/2/22 - 8/5/22, reflected the SW was meeting with the residents daily to offer supportive counseling and reassurance. There were no adverse side-effects voiced by the residents to the SW. Review of the room temperature binder, on 8/5/22, reflected the following posted on the front of the binder: Each room and the hall must be temp checked Q shift. Please call (ADM) each shift with temp reading for each room and hall. The binder further reflected logs that were being filled out Q shift of the temperature of each room and hall. During an interview on 8/5/22 at 2:55 PM with the CCS and ADM, the CCS stated she would be calling the ADM each day to get the status on the temperature readings of each room and hall as well as ensuring residents are being screened each shift for signs and symptoms of heat stroke/heat exhaustion. The CCS and ADM were notified on 8/5/22 at 3:00 PM that the IJ had been removed. lowered. While the IJ was removedlowered on 8/5/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident and hazards when: , A. The facility failed to maintain hot water temperatures within a safe temperature range for 12 of 88 resident rooms (Rooms 106, 109, 110, 111, 120, 121, 123 125, 127, 145, 221, and 223). Hot water temperatures ranged from 112 to 143 degrees F with the potential of 3rd degree burns within two seconds at 140 degrees F This failure resulted in an identification of an IJ on 3/21/16. While the IJ was removed on 3/22/16, the facility remained out of compliance at a scope of pattered and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy. This failure could place 49 residents that resided in Unit 1 Halls A, B, and C, and 10 residents that resided in Unit 2 Hall B at risk of burns related to hot water temperatures. B. Two of 88 resident rooms (Rooms 227, and 110) reviewed for hazords. Resident Room 110's light fixture electrical cord was frayed by the outlet and Resident Room 227 had a pair of unattended scissor on the resident's bed. This failure could place 16 residents that resided in Unit 1 Halls A and 10 residents that resided in Unit 2 Hall B at risk of cuts, and scrapes, C. One of seven residents reviewed for falls (Resident #1). Resident #1 had two falls since admission to the facility and the facility did not modify interventions to prevent further falls. This failure could place 15 residents, who are at risk for falls, at risk for injuries and diminished quality of life. Findings include: A. Observation on 3/21/16 revealed hot water temperatures in Resident occupied Room personal Sinks as follows: Unit 1 Hall A 9:30 a.m. · Room 127 - 118 degrees F (two residents resided in this room) · Room 120 - 120 degrees F (two residents resided in this room) · Room 125 - 118 degrees F (two residents resided in this room) 9:45 a.m. · Room 121 - 113.6 degrees F (one resident resided in this room) · Room123 - 112 degrees F (one resident resided in this room) Unit 1 Hall B 9:45 a.m. · Room 109 - 113 degrees F (one resident resided in this room) 10:15 a.m. · Room 106 - 142.6 degrees F (When testing the water in room 106, the surveyor placed her right forefinger in the water flow while turning on the hot water, and jerked her finger back immediately as the water was extremely hot coming out of the faucet. The distal tip of her right forefinger remained tender and reddened for the rest of the day) (two residents resided in this room) · Room 111 - 115 degrees F (no residents resided in this room) · Room 110 - 117 degrees F (one resident resided in this room) Unit 1 Hall C 10:23 a.m. · Room 145 - 128 degrees F (one resident resided in this room) Unit 2 Hall B 10:03 a.m. · Room 221 - 126.6 degrees F (one resident resided in this room) 10:07 a.m. · Room 223 - 129.6 degrees F (one resident resided in this room) An observation on 03/21/16 at 10:30 a.m., revealed the water temperature in room 106 was measured by the surveyor and Maintenance Supervisor. Both thermometers read the hot water temperature at 138 degrees F. In an interview on 3/21/16 at 11:25 a.m., the Maintenance Director stated he was aware of the water temperature problems before the survey team arrived on this day and was changing the mixing valves this morning on Unit 2 Hall B, because the water was too hot, and on Unit 2 Hall A, because the water was too cold. The Maintenance Director stated that he expects the resident water temperatures to be between 100 and 110 degrees, +/- 5 degrees. Review of the facility's Water temperature Logs for March 2016, reflected all hot water temps logged by the Maintenance Director were between 98 degrees and 110 degrees F although the temperatures were above 110 degrees F in resident rooms. The Maintenance Director logged temperatures in random resident rooms. Review of the facility's plumbing service, dated 06/08/15 reflected the facility had installed a new 50 gallon gas water heater and replaced a pump mixing valve for Unit 1 Hall C. Review of the facility's Immediate Pay Request dated 02/02/16, reflected the facility paid to have the hot water heater replaced on Unit 1 Hall A. No additional documentation was provided to the survey team for hot water temps. In an interview on 03/21/16 at 11:55 a.m., Resident #25 stated that the water in his room gets too hot, but he is careful not to put his hand under just the hot water. He said he has let the staff know that the water is too hot. In an interview on 3/21/16 at 12:00 p.m., the Maintenance Director stated he stated that the facility has been having problems with the high and low water temperatures for years. The Maintenance Director added that the facility had paid approximately $3000 to have all new plumbing and a new water heater installed on Unit 1 Hall A; this had fixed the fluctuating water temperatures in this hall. The Maintenance Director further stated that he has spoken with the corporate office about replumbing the whole facility since changing out the mixing valves is just a temporary fix. In an interview on 03/23/16 at 9:30 a.m., the Administrator stated they were aware the facility was having problems with water temperatures. The Administrator stated Unit 1 had a broken mixing valve that was replaced a few weeks ago. The new valve had a malfunction. The Administrator stated there were no extreme variances in water temperature that would have placed the facility in a panic mode. The Administrator stated that after the survey team found the hot water temps, specifically the one in Room 106, they found that a pipe from the hot water tank ran directly to that room. The Administrator stated no other room in the facility had a direct line to the water heater like Room 106. The Administrator stated they were not aware of this until 03/22/16. In an interview on 3/23/16 at 12:20 p.m., the Maintenance Director stated they have fixed all the valves for the water heaters. The Maintenance Director stated he checked the hot water temperature in Room 106 and could not believe it was that hot. The Maintenance Director further stated the facility had been fighting with that hall (Unit 1 Hall A) for years and finally replaced a defective valve. Review of the facility's In-service Training Report, dated 01/26/16, reflected the MD trained the Maintenance Director on proper water temperature Logs. Review of the facility's Baths, Bed, Tub or Showers Policy, dated 06/2015, reflected: Policy It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. Precautions for Tub or Shower Bath 1. Be sure water temperature is regulated to avoid burns. Procedures 4. Regulate temperature and flow of water before resident gets into water and as needed during bath. a. Water temperature should be comfortable warm (about 105 degrees Fahrenheit). Before use, test water temperature for comfortable warmth on your wrist or forearm or use bath thermometer. Have resident test water for comfort before bathing. c. For shower, regulate temperature and flow for comfort and safety. Review of the facility's controlling water temperature mixing valves policy, dated 02/2012, reflected All mixing valves that are currently in place on any resident use water heater must be cleaned at least every thirty (30) days. If you find that the mixing valve is giving you temperatures on a daily basis that vary from three (3) to six (6) degrees, the valve is typically indicating that it needs to be cleaned. A schedule of regular cleaning will ensure proper water temperatures on a consistent basis. Document mixing valve cleaning and repairs on Water Temperature log. Cleaning the mixing valve components requires from three (3) to four (4) hours of down time if spare cartridges or components are not available. Pre-planning is very necessary so that bathing activities are not interrupted. Standards for water temperatures for resident usage area: 100 degrees F. minimum 110 degrees F. maximum An upper limit deviation of 5 degrees F is allowed at the tank for fluctuation in supply water temperature, temperature variance due to distance between water heater and the fixture, as well as the volume and timing of hot water usage. NOTE: Consistent water temperatures of 115 degrees to maintain acceptable temperatures throughout the loop is an indication that the system requires evaluation for a more satisfactory means of providing hot water. Water temperatures will be taken DAILY in the following manner: 1. Select the appropriate logs for your building (i.e., 4 hall for resident areas and 2 hall for kitchen and laundry). Use as many copies as necessary to complete logging requirements. 2. Take water temperatures in resident rooms at the beginning, middle and the end of each water heater loop. (Take temperatures in different rooms each day.) 3. Check each shower and whirlpool area. This should include both the sink and the bathing fixture. 4. Check the laundry and kitchen areas. Minimum temperature to dish machines and clothes washers is 140 degrees F and a maximum temperature of 150 degrees F. Hand washing sinks must be tempered to 100F - 110F. The facility Administrator was notified on 03/21/16 at 1:08 PM that an IJ situation had been identified due to the above failures. The Following Plan of Removal was submitted by the Administrator on 03/21/16 at 4:06 PM. The final Plan of Removal was accepted by the survey team on 03/22/16 at 9:32 AM. The Facility ' s Plan of Removal is as follows: Plan of removal for the Nursing Home: IJ regarding hot water temperatures throughout facility. 1. The hot water to all rooms in facility and shower rooms was terminated by facility maintenance. Completed 3/21/2016 @ 1:15 pm. 2. Facility administrator called plumber to assess situation. Plumber arrived at 2:30 pm and determined the mixing valve needed to be adjusted, then determined it needed to be replaced. Mixing valve will be replaced by Plumber on 3/21/2016. 3. All residents were assessed by DON to determine if resident had sustained any burns related to hot water burns from the resident room sink. Completion date: 3/21/2016. 4. All residents who received showers in the facility were assessed for redness or burns by the facility wound care nurse. Completion date: 3/21/2016. 5. Nursing staff (LVN ' s, RN ' s, Nursing Administration, CMA ' s, C.N.A. ' s, and RNA ' s) were in-serviced by the DON: All nursing staff that are not scheduled will be in-serviced prior to their next shift. a. On not giving showers until hot water issue was corrected b. Items out of policy and procedure manual: Regulate water temperature and flow of water before resident gets into water and as needed during bath. c. Water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. 6. Using a thermometer, the water temperature will be checked on all halls by facility maintenance, checking 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms. a. Temperatures will be logged by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperatures logs resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. c. Administrator in-serviced Facility Maintenance on Controlling Water Temperatures on 3/22/2016. 7. The hot water on the offending halls once re-started will not be used for resident care until the water is consistently between 100 and 110 degrees. Administrator or designee will monitor BID after valves are replaced and temperature is at 110 or below. Facility Maintenance will adjust mixing valves when temperature is not correct and document on the temperature logs. Regional Maintenance Director and Plumber will be informed and make further recommendations. a. Temperatures will be logged daily by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperature logs, resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. 8. Daily temperature checks will be performed on 4-6 rooms per hall and shower rooms. a. Done by facility maintenance Director using the appropriate thermometer daily and ongoing. b. Monitoring will be done by the facility administrator during morning stand up meeting daily and ongoing. c. QAPI Committee will review and make further recommendations for the next 60 days beginning 3/21/2016 and ending 5/21/2016. 9. MD was notified on 3/21/2016 of IJ situation. The Survey Team monitored the current plan of removal as follows: Observations on 03/21/16 at 1:00 p.m. were made of the facility ' s Administrator calling the plumber to assess situation. The plumber arrived at 2:30 pm on 03/21/16 and determined the mixing valve needed to be adjusted, then determined it needed to be replaced, and replaced it. The Maintenance Director checked the water temperature for 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms on 03/22/16 to 03/24/16 Observations on 03/22/16 at 3:00 PM revealed the following: · Room 127 - 108 degrees Fahrenheit · Room 120 - 105 degrees Fahrenheit · Room 125 - 106 degrees Fahrenheit · Room 106 - 110 degrees Fahrenheit · Room 111 - 102 degrees Fahrenheit · Room 110 - 103 degrees Fahrenheit · Room 221 - 107 degrees Fahrenheit · Room 223 - 108 degrees Fahrenheit. · Room 145 - 107 degrees Fahrenheit Record reviews revealed all residents were assessed by the DON to determine if the residents had sustained any burns related to hot water burns from the resident room sink. All residents who received showers in the facility were assessed for redness or burns by the facility Wound Care Nurse. Record Reviews revealed Temperatures were logged by the facility Maintenance Director daily on 03/21/16 to 03/22/16. Record Reviews revealed the Administrator in-serviced the facility Maintenance Director on Controlling Water Temperatures on 3/22/2016. All staff were in-serviced on 03/21/16 on not giving showers until hot water issue was corrected, regulate water temperature and flow of water before resident gets into water and as needed during bath, and water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. In an interview 03/22/16 at 9:00 AM, the Administrator stated the facility assessed all the residents in Unit 1 for burns and skin assessments. He stated all the residents on Unit 2 would be assessed by the end of the day. Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding, On not giving showers until hot water issue was corrected, Regulate water temperature and flow of water before resident gets into water and as needed during bath, and water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. On 03/22/16 at 4:50 PM, the Administrator was informed the IJ was removed; However, the facility remained out of compliance at a scope of pattered and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy due to the facility requiring additional time to monitor. B. Review of Face Sheet undated for Resident #10 reflected a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on 03/21/16 at 10:11 a.m. during initial tour revealed Room 227, later identified as the room of Resident #10, who was not in the room had a small shallow box on the bed with a small pair of pointed scissors laying in view. In an interview on 03/21/16 at 10:11 a.m., LVN K stated the resident in Room 227 has scissors because she does crafts. LVN K picked the scissors up and looked at them, then placed them where she found them. In an interview on 03/22/16 at 4:00 p.m., Resident #10, who was using a large pair of pointed scissors to cut something, said she has three pair of scissors and keeps them locked in her nightstand. When asked about the pair of scissors seen in her room earlier when she was not present, she said she forgot to lock them up and knows that is not acceptable. Resident said the nurse must have taken that pair of scissors because they were gone. Observation 3/21/16 at 10:15 in Room 110, revealed a frayed electrical cord connected to the light fixture in the A bed. The cord was frayed adjacent to the plug. Interview on 3/23/16 at 12:15 pm, the Facility Maintenance director stated, I repaired the frayed cord in Room 110 on Monday, 3/21/16, soon after it was reported to me. The Life Safety representative saw the repaired cord. I plan to also add a metal brace to secure the cord close to the wall to prevent further damage from furniture, etc. C. Review of Resident #1's face sheet reveals he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS dated [DATE], revealed a BIMS of 0 (poor cognition/non interviewable) and he was triggered as a falls risk, with poor balance on transferring, walking and turning around. Review of Resident #1's chart revealed that Resident #1 had suffered one fall prior to admission, a second fall on 1/28/16 and a third fall on 2/18/16. Review of the incidents log revealed that Resident #1 had suffered one fall prior to admission; a second fall on 1/28/16, when his pants got wrapped around his ankles after using the bathroom independently, that was associated with fever, resulting in hospital admission; and a third fall on 2/18/16 with no injury, that was caused by wearing flip flops in the courtyard. Review of Resident #1's care plan dated 12/14/15 indicated Resident #1 triggered for falls and included a plan to keep call light within reach, provide prompt assistance, provide good lighting, minimize clutter, use a low bed and fall mat, encourage the use of no slip socks, and provide physical therapy as needed. Review of an update on 2/2/16 and 2/18/16 to the falls care plan revealed that the facility had not made any modifications to the previous interventions, following the falls on 1/28/16 and 2/18/16. Observation on 3/22/16 at 3:42 pm during medication pass, Resident #1 is lying in bed asleep. Resident #1 was disoriented, confused, agitated and unable to recall why this surveyor and the medication aide were in his room. During an interview on 3/24/16 ADON B stated that Resident #1 had two recent falls and that the interventions had not been changed because Resident #1 was noncompliant, despite reinforcement and encouragement from staff. ADON B stated that Resident #1 was often agitated, refused to wear the non slip socks and could not remember to ask for help from staff before independently performing activities of daily living himself. Review of the facility's CMS form 802 reflected 49 residents who resided who resided in Unit 1 Halls A, B, and C, and Unit 2 Hall B. Review of the facility's CMS form 802 reflected 15 residents with falls.

Based on observation, interview, and record review, the Maintenance Director failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practible physical, mental, and psychosocial well-being of each resident for 12 of 88 Resident Rooms (Rooms 106, 109, 110, 111, 120, 121, 123 125, 127, 145, 221, and 223) reviewed for hot water temps when: The Maintenance Director failed to ensure the facility had the resources to maintain hot water temperatures in Resident Room sinks within a safe temperature range. On 03/21/16 hot water temperatures ranged from 112 to 143 degrees Fahrenheit with the potential of 3rd [MEDICAL CONDITION] two seconds at 140 degrees Fahrenheit. This failure resulted in an identification of an IJ on 3/21/16. While the IJ was removed on 3/22/16, the facility remained out of compliance at a scope of pattered and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy. This failure could place 49 residents that resided in Unit 1 Halls A, B, and C, and 10 residents that resided in Unit 2 Hall B at risk [MEDICAL CONDITION] to hot water temperatures. Findings include: A. Observation on 3/21/16 revealed hot water temperatures in Resident occupied Room personal Sinks as follows: Unit 1 Hall A 9:30 a.m. · room [ROOM NUMBER] - 118 degrees F (two residents resided in this room) · room [ROOM NUMBER] - 120 degrees F (two residents resided in this room) · room [ROOM NUMBER] - 118 degrees F (two residents resided in this room) 9:45 a.m. · room [ROOM NUMBER] - 113.6 degrees F (one resident resided in this room) · Room123 - 112 degrees F (one resident resided in this room) Unit 1 Hall B 9:45 a.m. · room [ROOM NUMBER] - 113 degrees F (one resident resided in this room) 10:15 a.m. · room [ROOM NUMBER] - 142.6 degrees F (When testing the water in room [ROOM NUMBER], the surveyor placed her right forefinger in the water flow while turning on the hot water, and jerked her finger back immediately as the water was extremely hot coming out of the faucet. The distal tip of her right forefinger remained tender and reddened for the rest of the day) (two residents resided in this room) · room [ROOM NUMBER] - 115 degrees F (no residents resided in this room) · room [ROOM NUMBER] - 117 degrees F (one resident resided in this room) Unit 1 Hall C 10:23 a.m. · room [ROOM NUMBER] - 128 degrees F (one resident resided in this room) Unit 2 Hall B 10:03 a.m. · room [ROOM NUMBER] - 126.6 degrees F (one resident resided in this room) 10:07 a.m. · room [ROOM NUMBER] - 129.6 degrees F (one resident resided in this room) An observation on 03/21/16 at 10:30 a.m., revealed the water temperature in room [ROOM NUMBER] was measured by the surveyor and Maintenance Supervisor. Both thermometers read the hot water temperature at 138 degrees F. In an interview on 3/21/16 at 11:25 a.m., the Maintenance Director stated he was aware of the water temperature problems before the survey team arrived on this day and was changing the mixing valves this morning on Unit 2 Hall B, because the water was too hot, and on Unit 2 Hall A, because the water was too cold. The Maintenance Director stated that he expects the resident water temperatures to be between 100 and 110 degrees, +/- 5 degrees. Review of the facility's Water temperature Logs for March 2016, reflected all hot water temps logged by the Maintenance Director were between 98 degrees and 110 degrees F although the temperatures were above 110 degrees F in resident rooms. Review of the facility's plumbing service, dated 06/08/15 reflected the facility had installed a new 50 gallon gas water heater and replaced a pump mixing valve for Unit 1 Hall C. Review of the facility's Immediate Pay Request dated 02/02/16, reflected the facility paid to have the hot water heater replaced on Unit 1 Hall A. No additional documentation was provided to the survey team for hot water temps. In an interview on 03/21/16 at 11:55 a.m., Resident #25 stated that the water in his room gets too hot, but he is careful not to put his hand under just the hot water. He said he has let the staff know that the water is too hot. In an interview on 3/21/16 at 12:00 p.m., the Maintenance Director stated he stated that the facility has been having problems with the high and low water temperatures for years. The Maintenance Director added that the facility had paid approximately $3000 to have all new plumbing and a new water heater installed on Unit 1 Hall A; this had fixed the fluctuating water temperatures in this hall. The Maintenance Director further stated that he has spoken with the corporate office about replumbing the whole facility since changing out the mixing valves is just a temporary fix. In an interview on 03/23/16 at 9:30 a.m., the Administrator stated they were aware the facility was having problems with water temperatures. The Administrator stated Unit 1 had a broken mixing valve that was replaced a few weeks ago. The new valve had a malfunction. The Administrator stated there were no extreme variances in water temperature that would have placed the facility in a panic mode. The Administrator stated that after the survey team found the hot water temps, specifically the one in room [ROOM NUMBER], they found that a pipe from the hot water tank ran directly to that room. The Administrator stated no other room in the facility had a direct line to the water heater like room [ROOM NUMBER]. The Administrator stated they were not aware of this until 03/22/16. In an interview on 3/23/16 at 12:20 p.m., the Maintenance Director stated they have fixed all the valves for the water heaters. The Maintenance Director stated he checked the hot water temperature in room [ROOM NUMBER] and could not believe it was that hot. The Maintenance Director further stated the facility had been fighting with that hall for years and finally replaced a valve that malfunctioned. Review of the facility's In-service Training Report, dated 01/26/16, reflected the MD trained the Maintenance Director on proper water temperature Logs. Review of the Administrator's Job Description dated 07/2011, reflected: Position Summary: The overall purpose of the administered position is to assure the provision of the best available quality of care for facility residents. Incumbents plan, develop, direct, and control facility operation within the bounds of established policies, procedures, programs and budgets Dimensions and Scope: Incumbent(s) · Functions independently with extensive latitude in the operation of the facility. · Assumes responsibility/authority for decisions regarding all aspects of facility operations, but may consult with regional director, director of nursing, department heads, consultants, and other resource. Review of the Maintenance Supervisor's Job Description dated 02/15/2012, reflected: Position Summary: The overall purpose of the maintenance supervisor position is to plan, direct, and control the overall maintenance of the facility ' s physical plant. Incumbents perform or oversee, electrical, plumbing, carpentry, heating, ventilation, air conditioning, refrigeration, and or other technical tasks. Dimension and Scope: Incumbent(s) · Functions, within the constraints of established policy, practice, and procedure. · Is assigned responsibility/authority for decision regarding maintenance and related tasks, but may consult with administrator, environment consultants, or other resources as may be appropriate. Review of the facility's Baths, Bed, Tub or Showers Policy, dated 06/2016, reflected: Policy It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. Precautions for Tub or Shower Bath 1. Be sure water temperature is regulated to avoid burns. Procedures 4. Regulate temperature and flow of water before resident gets into water and as needed during bath. a. Water temperature should be comfortable warm (about 105 degrees Fahrenheit). Before use, test water temperature for comfortable warmth on your wrist or forearm or use bath thermometer. Have resident test water for comfort before bathing. c. For shower, regulate temperature and flow for comfort and safety. Review of the facility's controlling water temperature mixing valves policy, dated 02/2012, reflected All mixing valves that are currently in place on any resident use water heater must be cleaned at least every thirty (30) days. If you find that the mixing valve is giving you temperatures on a daily basis that vary from three (3) to six (6) degrees, the valve is typically indicating that it needs to be cleaned. A schedule of regular cleaning will ensure proper water temperatures on a consistent basis. Document mixing valve cleaning and repairs on Water Temperature log. Cleaning the mixing valve components requires from three (3) to four (4) hours of down time if spare cartridges or components are not available. Pre-planning is very necessary so that bathing activities are not interrupted. Standards for water temperatures for resident usage area: 100 degrees F. minimum 110 degrees F. maximum An upper limit deviation of 5 degrees F is allowed at the tank for fluctuation in supply water temperature, temperature variance due to distance between water heater and the fixture, as well as the volume and timing of hot water usage. NOTE: Consistent water temperatures of 115 degrees to maintain acceptable temperatures throughout the loop is an indication that the system requires evaluation for a more satisfactory means of providing hot water. Water temperatures will be taken DAILY in the following manner: 1. Select the appropriate logs for your building (i.e., 4 hall for resident areas and 2 hall for kitchen and laundry). Use as many copies as necessary to complete logging requirements. 2. Take water temperatures in resident rooms at the beginning, middle and the end of each water heater loop. (Take temperatures in different rooms each day.) 3. Check each shower and whirlpool area. This should include both the sink and the bathing fixture. 4. Check the laundry and kitchen areas. Minimum temperature to dish machines and clothes washers is 140 degrees F and a maximum temperature of 150 degrees F. Hand washing sinks must be tempered to 100F - 110F. The facility Administrator was notified on 03/21/16 at 1:08 PM that an IJ situation had been identified due to the above failures. The Following Plan of Removal was submitted by the Administrator on 03/21/16 at 4:06 PM. The final Plan of Removal was accepted by the survey team on 03/22/16 at 9:32 AM. The Facility ' s Plan of Removal is as follows: Plan of removal for the Nursing Home: IJ regarding hot water temperatures throughout facility. 1. The hot water to all rooms in facility and shower rooms was terminated by facility maintenance. Completed 3/21/2016 @ 1:15 pm. 2. Facility administrator called plumber to assess situation. Plumber arrived at 2:30 pm and determined the mixing valve needed to be adjusted, then determined it needed to be replaced. Mixing valve will be replaced by Plumber on 3/21/2016. 3. All residents were assessed by DON to determine if resident had sustained [MEDICAL CONDITION] to hot [MEDICAL CONDITION] the resident room sink. Completion date: 3/21/2016. 4. All residents who received showers in the facility were assessed for redness [MEDICAL CONDITION] the facility wound care nurse. Completion date: 3/21/2016. 5. Nursing staff (LVN ' s, RN ' s, Nursing Administration, CMA ' s, C.N.A. ' s, and RNA ' s) were in-serviced by the DON: All nursing staff that are not scheduled will be in-serviced prior to their next shift. a. On not giving showers until hot water issue was corrected b. Items out of policy and procedure manual: Regulate water temperature and flow of water before resident gets into water and as needed during bath. c. Water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. 6. Using a thermometer, the water temperature will be checked on all halls by facility maintenance, checking 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms. a. Temperatures will be logged by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperatures logs resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. c. Administrator in-serviced Facility Maintenance on Controlling Water Temperatures on 3/22/2016. 7. The hot water on the offending halls once re-started will not be used for resident care until the water is consistently between 100 and 110 degrees. Administrator or designee will monitor BID after valves are replaced and temperature is at 110 or below. Facility Maintenance will adjust mixing valves when temperature is not correct and document on the temperature logs. Regional Maintenance Director and Plumber will be informed and make further recommendations. a. Temperatures will be logged daily by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperature logs, resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. 8. Daily temperature checks will be performed on 4-6 rooms per hall and shower rooms. a. Done by facility maintenance Director using the appropriate thermometer daily and ongoing. b. Monitoring will be done by the facility administrator during morning stand up meeting daily and ongoing. c. QAPI Committee will review and make further recommendations for the next 60 days beginning 3/21/2016 and ending 5/21/2016. 9. MD was notified on 3/21/2016 of IJ situation. The Survey Team monitored the current plan of removal as follows: Observations on 03/21/16 at 1:00 p.m. were made of the facility ' s Administrator calling the plumber to assess situation. The plumber arrived at 2:30 pm on 03/21/16 and determined the mixing valve needed to be adjusted, then determined it needed to be replaced, and replaced it. The Maintenance Director checked the water temperature for 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms on 03/22/16 to 03/24/16 Observations on 03/22/16 at 3:00 PM revealed the following: · room [ROOM NUMBER] - 108 degrees Fahrenheit · room [ROOM NUMBER] - 105 degrees Fahrenheit · room [ROOM NUMBER] - 106 degrees Fahrenheit · room [ROOM NUMBER] - 110 degrees Fahrenheit · room [ROOM NUMBER] - 102 degrees Fahrenheit · room [ROOM NUMBER] - 103 degrees Fahrenheit · room [ROOM NUMBER] - 107 degrees Fahrenheit · room [ROOM NUMBER] - 108 degrees Fahrenheit. · room [ROOM NUMBER] - 107 degrees Fahrenheit Record reviews revealed all residents were assessed by the DON to determine if the residents had sustained [MEDICAL CONDITION] to hot [MEDICAL CONDITION] the resident room sink. All residents who received showers in the facility were assessed for redness [MEDICAL CONDITION] the facility Wound Care Nurse. Record Reviews revealed Temperatures were logged by the facility Maintenance Director daily on 03/21/16 to 03/22/16. Record Reviews revealed the Administrator in-serviced the facility Maintenance Director on Controlling Water Temperatures on 3/22/2016. All staff were in-serviced on 03/21/16 on not giving showers until hot water issue was corrected, regulate water temperature and flow of water before resident gets into water and as needed during bath, and water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. In an interview 03/22/16 at 9:00 AM, the Administrator stated the facility assessed all the residents in Unit 1 [MEDICAL CONDITION] skin assessments. He stated all the residents on Unit 2 would be assessed by the end of the day. Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding, On not giving showers until hot water issue was corrected, Regulate water temperature and flow of water before resident gets into water and as needed during bath, and water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. On 03/22/16 at 4:50 PM, the Administrator was informed the IJ was removed; However, the facility remained out of compliance at a scope of pattered and a severity level of No Actual Harm with the Potential for more than Minimal Harm that is not an Immediate Jeopardy due to the facility requiring additional time to monitor. Review of the facility's CMS form 802 reflected 49 residents who resided in Unit 1 Halls A, B, and C, and Unit 2 Hall A. Observation on 3/21/16, revealed hot water temperatures in Resident Room Sinks as follows: Unit 2 Hall A 9:30 a.m. · room [ROOM NUMBER] - 118 degrees F: · room [ROOM NUMBER] - 120 degrees F: · room [ROOM NUMBER] - 118 degrees F: 9:45 a.m. · room [ROOM NUMBER] - 113.6 degrees F: · Room123 - 112 degrees F: Unit 2 Hall B 9:45 a.m. · room [ROOM NUMBER] - 113 degrees F: 10:15 a.m. · room [ROOM NUMBER] - 142.6 degrees F (When testing the water in room [ROOM NUMBER], the surveyor placed her right forefinger in the water flow while turning on the hot water, and jerked her finger back immediately as the water was extremely hot coming out of the faucet. The distal tip of her right forefinger remained tender and reddened for the rest of the day) · room [ROOM NUMBER] - 115 degrees F: · room [ROOM NUMBER] - 117 degrees F: Unit 2 Hall C 10:23 a.m. · room [ROOM NUMBER] - 128 degrees F: Unit 1 Hall A 10:03 a.m. · room [ROOM NUMBER] - 126.6 degrees F: 10:07 a.m. · room [ROOM NUMBER] - 129.6 degrees F: An observation on 03/21/16 at 10:30 a.m., revealed the water temperature in room [ROOM NUMBER] was measured by the surveyor and Maintenance Supervisor. Both thermometers read the hot water temperature at 138 degrees F. In an interview on 3/21/16 at 11:25 a.m., the Maintenance Director stated he was aware of the water temperature problems before the survey team arrived on this day and was changing the mixing valves this morning on Unit 2 Hall B, because the water was too hot; and on Unit 2 Hall A, because the water was too cold. The Maintenance Director stated that he expects the resident water temperatures to be between 100 and 110 degrees, +/- 5 degrees. Review of the facility ' s Water Temperature Logs for March 2016, reflected all hot water temps logged by the Maintenance Director were between 98 degrees and 110 degrees Fahrenheit. Review of the facility's plumbing service dated 06/08/15, reflected the facility had installed a new 50 gallon gas water heater and replaced a pump mixing valve for Unit 1 hall C. Review of the facility's Immediate Pay Request dated 02/02/16, reflected the facility paid to have the hot water heater replaced on Unit 1 Hall A. No additional documentation was provided to the survey team for hot water temps. In an interview on 03/21/16 at 11:55 a.m., Resident #25 stated that the water in his room gets too hot; but he is careful not to put his hand under just the hot water. He said he has let the staff know that the water is too hot. In an interview on 3/21/16 at 12:00 p.m., the Maintenance Director stated he stated that the facility has been having problems with the high and low water temperatures for years. The Maintenance Director added that the facility had paid approximately $3000 to have all new plumbing and a new water heater installed on Unit 1 Hall A; this had fixed the fluctuating water temperatures in this hall. The Maintenance Director further stated that he has spoken with the corporate office about replumbing the whole facility, since changing out the mixing valves is just a temporary fix. In an interview on 03/23/16 at 9:30 a.m., the Administrator stated they were aware the facility was having problems with water temperatures. The Administrator stated Unit 1 had a broken mixing valve that was replaced a few weeks ago. The new valve had a malfunction. The Administrator stated there were no extreme variances in water temperature that would have placed the facility in a panic mode. The Administrator stated that after the survey team found the hot water temps, specifically the one in room [ROOM NUMBER], they found that a pipe from the hot water tank ran directly to that room. The Administrator stated no other room in the facility had a direct line to the water heater like room [ROOM NUMBER]. The Administrator stated they were not aware of this until 03/22/16. In an interview on 3/23/16 at 12:20 p.m., the Maintenance Director stated they have fixed all the valves for the water heaters. The Maintenance Director stated he checked the hot water temperature in room [ROOM NUMBER] and could not believe it was that hot. The Maintenance Director further stated the facility had been fighting with that hall (Unit 1 Hall A) for years and finally replaced a defective valve. Review of the facility's In-service Training Report, dated 01/26/16 reflected the MD trained the Maintenance Director on proper water temperature Logs. Review of the Administrator's Job Description dated 07/2011, reflected: Position Summary: The overall purpose of the administered position is to assure the provision of the best available quality of care for facility residents. Incumbents plan, develop, direct, and control facility operation within the bounds of established policies, procedures, programs and budgets Dimensions and Scope: Incumbent(s) · Functions independently with extensive latitude in the operation of the facility. · Assumes responsibility/authority for decisions regarding all aspects of facility operations, but may consult with regional director, director of nursing, department heads, consultants, and other resource. Review of the Maintenance Supervisor's Job Description dated 02/15/2012, reflected: Position Summary: The overall purpose of the maintenance supervisor position is to plan, direct, and control the overall maintenance of the facility ' s physical plant. Incumbents perform or oversee, electrical, plumbing, carpentry, heating, ventilation, air conditioning, refrigeration, and or other technical tasks. Dimension and Scope: Incumbent(s) · Functions, within the constraints of established policy, practice, and procedure. · Is assigned responsibility/authority for decision regarding maintenance and related tasks, but may consult with administrator, environment consultants, or other resources as may be appropriate. Review of the facility's Baths, Bed, Tub or Showers Policy, dated 06/2016, reflected: Policy It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. Precautions for Tub or Shower Bath 1. Be sure water temperature is regulated to avoid burns. Procedures 4. Regulate temperature and flow of water before resident gets into water and as needed during bath. a. Water temperature should be comfortable warm (about 105 degrees Fahrenheit). Before use, test water temperature for comfortable warmth on your wrist or forearm or use bath thermometer. Have resident test water for comfort before bathing. c. For shower, regulate temperature and flow for comfort and safety. Review of the facility ' s controlling water temperature mixing valves policy, dated 02/2012, reflected All mixing valves that are currently in place on any resident use water heater must be cleaned at least every thirty (30) days. If you find that the mixing valve is giving you temperatures on a daily basis that vary from three (3) to six (6) degrees, the valve is typically indicating that it needs to be cleaned. A schedule of regular cleaning will ensure proper water temperatures on a consistent basis. Document mixing valve cleaning and repairs on Water Temperature log. Cleaning the mixing valve components requires from three (3) to four (4) hours of down time if spare cartridges or components are not available. Pre-planning is very necessary so that bathing activities are not interrupted. Standards for water temperatures for resident usage area: 100 degrees F. minimum 110 degrees F. maximum An upper limit deviation of 5 degrees F is allowed at the tank for fluctuation in supply water temperature, temperature variance due to distance between water heater and the fixture, as well as the volume and timing of hot water usage. NOTE: Consistent water temperatures of 115 degrees to maintain acceptable temperatures throughout the loop is an indication that the system requires evaluation for a more satisfactory means of providing hot water. Water temperatures will be taken DAILY in the following manner: 1. Select the appropriate logs for your building (i.e., 4 hall for resident areas and 2 hall for kitchen and laundry). Use as many copies as necessary to complete logging requirements. 2. Take water temperatures in resident rooms at the beginning, middle and the end of each water heater loop. (Take temperatures in different rooms each day.) 3. Check each shower and whirlpool area. This should include both the sink and the bathing fixture. 4. Check the laundry and kitchen areas. Minimum temperature to dish machines and clothes washers is 140 degrees F and a maximum temperature of 150 degrees F. Hand washing sinks must be tempered to 100F - 110F. The facility Administrator was notified on 03/21/16 at 1:08 PM that an IJ situation had been identified due to the above failures. The Following Plan of Removal was submitted by the Administrator on 03/21/16 at 4:06 PM. The final Plan of Removal was accepted by the survey team on 03/21/16 at 9:32 AM. The Facility ' s Plan of Removal is as follows: Plan of removal for the Nursing Home: IJ regarding hot water temperatures throughout facility. 1. The hot water to all rooms in facility and shower rooms was terminated by facility maintenance. Completed 3/21/2016 @ 1:15 pm. 2. Facility administrator called plumber to assess situation. Plumber arrived at 2:30 pm and determined the mixing valve needed to be adjusted, then determined it needed to be replaced. Mixing valve will be replaced by Plumber on 3/21/2016. 3. All residents were assessed by DON to determine if resident had sustained [MEDICAL CONDITION] to hot [MEDICAL CONDITION] the resident room sink. Completion date: 3/21/2016. 4. All residents who received showers in the facility were assessed for redness [MEDICAL CONDITION] the facility wound care nurse. Completion date: 3/21/2016. 5. Nursing staff (LVN ' s, RN ' s, Nursing Administration, CMA ' s, C.N.A. ' s, and RNA ' s) were in-serviced by the DON: All nursing staff that are not scheduled will be in-serviced prior to their next shift. a. On not giving showers until hot water issue was corrected b. Items out of policy and procedure manual: Regulate water temperature and flow of water before resident gets into water and as needed during bath. c. Water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. 6. Using a thermometer, the water temperature will be checked on all halls by facility maintenance, checking 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms. a. Temperatures will be logged by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperatures logs resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. c. Administrator in-serviced Facility Maintenance on Controlling Water Temperatures on 3/22/2016. 7. The hot water on the offending halls once re-started will not be used for resident care until the water is consistently between 100 and 110 degrees. Administrator or designee will monitor BID after valves are replaced and temperature is at 110 or below. Facility Maintenance will adjust mixing valves when temperature is not correct and document on the temperature logs. Regional Maintenance Director and Plumber will be informed and make further recommendations. a. Temperatures will be logged daily by the facility maintenance director daily and ongoing and inform administrator immediately when temperatures are out of range. b. Temperature logs, resident room temperatures and shower room temperatures for all halls will be reviewed daily by the facility administrator for the next 60 days beginning 3/21/2016 and ending 5/21/2016 and weekly thereafter. 8. Daily temperature checks will be performed on 4-6 rooms per hall and shower rooms. a. Done by facility maintenance Director using the appropriate thermometer daily and ongoing. b. Monitoring will be done by the facility administrator during morning stand up meeting daily and ongoing. c. QAPI Committee will review and make further recommendations for the next 60 days beginning 3/21/2016 and ending 5/21/2016. 9. MD was notified on 3/21/2016 of IJ situation. The Survey Team monitored the current plan of removal as follows: Observations on 03/21/16 at 1:00 p.m. were made of the facility ' s Administrator calling the plumber to assess situation. The plumber arrived at 2:30 pm on 03/21/16 and determined the mixing valve needed to be adjusted, then determined it needed to be replaced, and replaced it. The Maintenance Director checked the water temperature for 4-6 rooms on each hall at the beginning, middle and end of the hall and shower rooms on 03/22/16 to 03/24/16 Observations on 03/22/16 at 3:00 PM revealed the following: · room [ROOM NUMBER] - 108 degrees Fahrenheit ·room [ROOM NUMBER] - 105 degrees Fahrenheit ·room [ROOM NUMBER] - 106 degrees Fahrenheit ·room [ROOM NUMBER] - 110 degrees Fahrenheit ·room [ROOM NUMBER] - 102 degrees Fahrenheit ·room [ROOM NUMBER] - 103 degrees Fahrenheit ·room [ROOM NUMBER] - 107 degrees Fahrenheit ·room [ROOM NUMBER] - 108 degrees Fahrenheit. ·room [ROOM NUMBER] - 107 degrees Fahrenheit Record reviews revealed all residents were assessed by the DON to determine if the residents had sustained [MEDICAL CONDITION] to hot [MEDICAL CONDITION] the resident room sink. All residents who received showers in the facility were assessed for redness [MEDICAL CONDITION] the facility wound care nurse. Record Reviews revealed Temperatures were logged by the facility Maintenance Director daily on 03/21/16 to 03/24/16. Record Reviews revealed the Administrator in-serviced the facility Maintenance Director on Controlling Water Temperatures on 3/22/2016. All staff were in-serviced on 03/21/16 on not giving showers until hot water issue was corrected, regulate water temperature and flow of water before resident gets into water and as needed during bath, and water temperature should be comfortably warm (105 degrees F). Before use, test water temperature for comfortable warmth on your wrist or forearm. In an interview on 03/22/16 at 9:00 AM, the Administrator stated the facility assessed all the residents in Unit 1 [MEDICAL CONDITION] skin assessments. He stated all the residents on Unit 2 would be assessed by the end of the day. Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents for one of nine residents reviewed for risk self-infliction of injuries (Residents #1). (A) The facility failed to ensure residents with suicidal ideations did not have access to hazardous items (i.e. razors) and failed to provide adequate supervision and interventions to Residents #1, who had a history of [REDACTED]. (B) The facility failed to supervise, monitor, implement interventions, and effectively communicate concerns involving Resident #1, who had a known history of suicide attempts, with direct care and nursing staff. On 2/23/2014 Resident #1 attempted suicide in the facility by cutting his arm with a razor, and required admission to a psychiatric facility. This deficient practice could place 9 residents with known suicide attempts at risk for injury and psychiatric trauma. The Findings Include: (A) Observation on 7/3/2014 between 9 and 10 a.m. revealed safety razors, plastic and disposable, (1 in each cabinet unless otherwise noted) were in the unlocked medicine cabinets in the following: Resident room 130 B, Resident room 110 - 3 razors, Resident room 229 and Resident room 221. Interview with CNA E on 7/3/2014 at 9:15 a.m. revealed that razors are kept in the shower rooms and the razors were too be disposed of after use. Interview on 7/3/2014 at 1:10 p.m. LVN G stated she was not aware of the history for Resident #1. LVN G stated the staff was to look in the rooms for sharp objects the residents could injure themselves with, such as a razor. Interview on 7/3/2014 at 1:20 p.m. MA A stated that sharp objects such as razors and knives are to be removed from the resident's room and secured by staff. Interview with CNA F on 7/3/2014 at 1:40 p.m. revealed the staff was expected to remove and secure the dangerous items from the room when a resident was on 1:1 observation. Interview with LVN I on 7/3/2014 at 1:50 p.m. the facility staff were to remove sharp objects from resident's rooms and given to the ADON to be secured. The findings were to be documented on the 24 hour report and on the inventory sheet if found at time of admission. Interview with CNA G on 7/3/2014 at 2:00 p.m. revealed she works both units in the facility. The care of the resident's is dependent upon paying attention to what they say, their body language, and attempts to hide sharp objects that could be used to injure themselves.The CNA stated that sharp and dangerous items are to be removed from residents and their rooms on admission. If the resident refuses to allow the CNA to have the item in question, the Charge Nurse is advised. The facility had provided an inservice on whom to report concerns to after the attempted suicide by Resident #1, but not on how to deal with these residents. Interview with LVN H on 7/3/2014 at 2:20 p.m. revealed any time that a resident is found with sharp and dangerous items, the items are to be removed and secured. Interview on 7/3/2014 at 5:10 p.m. with the DON revealed wehen a resident is admitted the staff makes an inventory of the resident's possessions. If the staff identifies a possession that is not allowable upon admission, such as a razor, we will ask family to remove the item from the facility. If that is not possible, we will secure the items at the Nurses Station behind a locked door. (B) Record review of the clinical record for Resident #1 revealed the resident was admitted on [DATE] and discharged on [DATE]. The residents date of birth was 07/22/1960. The face sheet revealed the following Diagnoses: [REDACTED]. A hospital History and Physical, dated 2/12/2014 revealed additional [DIAGNOSES REDACTED]. Record review of the MDS concerning Resident #1 was completed on 2/23/2014. The BIMS was 12 out of 15 (cognitively intact scores are greater than 12). Minimal mood disturbance was documented. The resident was independent as regarded ADLs except for eating. The resident required set up assistance with meals due to blindness. Schizophrenia was identified as a diagnosis. The resident was on antipsychotic and antidepressant medications. Record review of the PASRR for Resident #1 dated 2/17/14 revealed a history of mental illness. Review of the Admission Care Plan for Resident #1, dated 2/17/2014, revealed the following had been identified on the form: delirium, cognitive loss, communication, psychosocial well-being, mood state, behavior symptoms, and psychotropic drug use. The Care Plan reflected there was a need to monitor the resident's moods. Review of the Incident Report concerning Resident #1, dated 2/23/2014 at 4:30 p.m. revealed a CNA heard a strange noise from the resident's room. On entering, CNA A observed the resident being face down on the floor and bleeding from the left forearm. The resident reported that he cut himself with the razor because " he is no good ". Resident stated he was trying to kill himself. The resident had approached CNA A earlier in the shift seeking oral sex, but was rebuffed by the CNA. First Aid was provided. The resident was transferred to a local hospital. The form Titled Safety Assessment Informed Consent (attached to the Incident Report), dated 2/13/2014, revealed the resident had impaired decision making abilities and issues with anger. The LVN responsible for the resident's care revealed that there had been a report earlier in the shift about issues between the resident and CNA A. A witness statement, attached to the Incident Report, obtained from Resident #1's roommate, Resident #4, revealed Resident #1 was telling the roommate that he was a horrible person and had never done anything right in his life. Resident #1 never stated a desire or intent to harm himself per Resident #4. Interview on 6/17/2014 at 3:25 p.m. with CNA A stated Resident #1 requested a shower from this aide on 2/23/2014. CNA A scrubbed his back and shampooed his head. The resident then asked her to perform "Peri-Care " on him. CNA A told the resident he was capable of cleaning his personal areas. CNA A stated the resident stood and approached her in a manner that she felt was threatening and the resident asked her to perform oral sex on him. At this point, CNA A stated she stepped out of the shower room and had a male aide finish the resident's shower. The male aide completed the shower and returned Resident #1 to his room. CNA A stated she was writing the Incident Report concerning this event when she heard a scream. CNA A stated she and a nurse went to the room for Resident #1. On entering the room, CNA A stated the resident was on the floor and bleeding from his left arm. CNA A stated the nurse assessed the resident and found five lacerations on his arm. CNA A stated the resident had expressed no intention of self-harm to any staff member prior to the event. The resident was always happy. The CNA did not know where the razor blade came from. Interview on 6/19/2014 at 2:55 PM, CNA A stated she was not aware of Resident #1's history of suicide attempts until the resident told her about them as she was holding pressure on the wounds that the resident inflicted upon himself. Interview on 6/18/2014 at 12:15 p.m., SW stated she was sure that she had passed on the information about Resident #1 suicidal history and his being on parole in a morning meeting attended by the facility department heads. The SW stated the resident was admitted to the facility from a local hospital where the resident had been treated for [REDACTED].#1 had burned the skin with battery acid in order to prevent himself from using intravenous drugs in the future. Review of the Social Services Assessment, dated 2/18/2014, revealed the resident made three attempts at suicide when he was in prison. The resident revealed to the SW that he had attempted to hang himself, cut his throat, and starve himself to death. The resident was also documented as having burned his arm with battery acid to prevent the use of drugs intravenously prior to his admission to the nursing facility. Interview on 6/16/2014 at 11:40 a.m., the DON stated he had no recall of being advised that Resident #1 had a history of [REDACTED]. No reports were received that documented any other issues such as aggressiveness, violence, or suicidal history. The DON stated if we had been aware of the prior history we would have put additional interventions in place to protect him. Interview on 6/18/2014 at 12:25 p.m., LVN B/ADON stated that she did remember the SW reporting the history of suicide attempts of Resident #1 in a morning meeting. The LVN stated there was no follow-up on the report from the SW by the nursing department. Interview on 6/18/2014 at 12:45 p.m., LVN C/MDS Coordinator stated that she also recalled the report from the SW concerning Resident #1 and the history of suicide attempts. LVN C stated she did not recall writing a care plan related to this history. The LVN C stated that the MDS coordinators are responsible for ensuring the care plans are completed, but they do not write every care plan for the residents. Care Plans can be written by the floor nurse. Interview on 6/19/2014 at 3:15 p.m. the Director of Nursing stated that if an individual is admitted with a known psych history we have the psychiatric services evaluate them within a week after admission. The psych services are to order the appropriate medications to address the resident's needs. Residents are screened at time of admission by reviewing the SW notes from the admitting facility. We then discuss with the admitting physicians the resident's needs and whether or not we can meet those needs. Record review of Physician's Orders for Resident #1 revealed no physician's orders for psych services between admission and discharge of February, 2014. Record review of the Nursing Assistant Care Plan for Resident #1 for February, 2014 revealed no instructions to observe for suicidal behaviors. Interview with the DON on 7/3/2014 at 10:40 a.m. revealed he did not recall if the facility had started the process of obtaining psych services for Resident #1. The DON stated the process would be in the resident's chart. The DON was given the chart for Resident #1 to review. After review, the DON stated that no psych services were obtained for Resident #1 because his status was Medicaid pending. The psych services that the facility uses do not accept resident's that have Medicaid pending. Interview with LVN J/MDS Nurse on 7/3/2014 at 10:55 a.m. revealed a resident with a suicidal history should have a written Care Plan to address this issue. Interview with LVN B/ADON on 7/3/2014 at 11:05 a.m. revealed that the DON and the ADON's would be responsible for following up on a need for psych assessment and identifying appropriate interventions. The history of Resident #1 should have triggered a care plan. The ADON stated she had no insight as to why the report of Resident #1 ' s psych history was not followed up on. The development of the Care Plans was the responsibility of the RN to initiate. The DON is responsible to assure that the Care Plans are written and implemented. The ADON stated there should be nothing in the resident ' s room that qualifies as a sharp object, this includes knives and razors. Review of the physician's orders for Resident #1 revealed in February, 2014 the resident was being administered the following medications: [REDACTED]. The physician had also written an order for [REDACTED]. Record review of the Nurses ' Notes for 02/26/2014 revealed the resident has been admitted to the psychiatric unit of a local hospital. Interview on 7/3/2014 at 1:10 p.m. LVN G stated that changes in the resident are to be reported to the DON and the PCP. The facility had inserviced the LVN regarding suicidal residents. We are to document those resident's that express suicidal ideations. At a minimum they would be on every 15 minute observation and documentation. They are more likely to be placed on 1:1 observation. The information is also written in the 24 hour report. Resident's with a history of suicidal attempts should have Care Plans written to address this history. The ADON and the DON are responsible for the creation of Care Plans. The DON, the ADON, and the SW are all responsible to inform staff about suicidal ideations and history of suicide attempts. Interview on 7/3/2014 at 1:20 p.m. MA A stated she was unaware of the history if suicidal attempts concerning any of the resident's documented by the SW as having a history of suicidal attempts. The MA stated that the facility has placed resident's on 1:1 observation however there has not been specific training addressing what happens if a resident is suicidal. Interview with CNA F on 7/3/2014 at 1:40 p.m. revealed he was not aware of suicidal attempts by current residents or Resident #1. The CNA stated he had not received training on how to deal with resident's with suicidal ideations. The CNA stated the staff was not told about residents with a history of suicide attempts. Interview with LVN I on 7/3/2014 at 1:50 p.m. revealed the staff was to monitor residents for mood changes, verbal expressions of desire to harm self, and depression. The LVN stated that the facility should develop a care plan for this type of history. The LVN stated that information from the morning meetings was not well communicated and, in her opinion, inservices were not " up to snuff " . Interview with LVN H on 7/3/2014 at 2:20 p.m. revealed residents with suicidal histories should have a care plan that addresses suicidal histories. The LVN stated this type of history should be care planned. The whole team is responsible for the creation of Care Plans. The responsibility for the writing of a Care Plan is the nurses. The LVN stated that the flow of information from the morning meetings is " hit and miss " . " Communication is limited " . Interview on 7/3/2014 at 4:50 p.m. with the SW revealed the responsibility for passing on information to staff should be the responsibility of the ADON for each side. The SW stated that the history of suicide attempts should have had a Care Plan written to address the issue. The writing of Care Plans has been performed by the MDS Coordinators and the floor nurses. The SW had no insight as to why the issue of the resident's suicidal history was not addressed for Resident #1. Interview on 7/3/2014 at 5:10 p.m. with the DON revealed the facility should have had Care Plans for all residents with a history of suicide attempts including Resident #1. The DON stated that he can write care plans as well as the MDS Nurses, the ADON ' s, the floor nurses, and the Social Worker. Resident # ' 1's issues were not followed up on because of a communication issue between the SW and the administrative team. Once the issue had been reported to the department heads, the DON, the ADONs, and the MDS Nurses, should be conducting inservices to ensure resident concerns are communicated to the floor nurses and the CNAs. When an issue is reported/identified these are reviewed in the morning meeting. If an issue is identified, a Care Plan is to be developed; the Care Plans are then discussed in the morning meeting for accuracy. The information about the Care Plans is then passed on verbally to the staff. The floor staff is responsible to monitor resident's behaviors and identify signs of depression. The Social Worker provided the surveyor with a list of resident's with a history of suicidal attempts or ideations on 7/3/2014 that identified 9 residents with the described history.