Every finding on record at Baybrooke Village Care and Rehab Center

Based on interview and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure that Resident #1's personal information was kept private and confidential when a pre-filled affidavit of heirship containing the resident's information was sent to the family of Resident #2. This failure could place residents at risk of having their sensitive information accessible to unauthorized individuals.Findings included:Record review of Resident #1's admission MDS Assessment, dated [DATE], reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident's cognition was intact with a BIMS score of 15, and her active diagnoses included: chronic obstructive pulmonary disease (lung disease), respiratory failure, and Type 2 diabetes (the body's inability to regulate blood glucose levels). Record review of Resident #1's Discharge MDS Assessment, dated [DATE], reflected the resident expired at the facility on [DATE]. Record review of Resident #1's care plan, revised [DATE], reflected the resident had an advanced directive with a goal to honor and review annually and upon significant change in condition. Interventions included: ensuring the advanced directive was discussed with resident and/or RP and appropriate paperwork obtained. Record review of Resident #2's Discharge MDS Assessment, dated [DATE], reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and expired at the facility on [DATE]. Record review of a document provided by Resident #2's RP titled Affidavit of Heirship- [Resident #1], undated, reflected the document was pre-filled with Resident #1's personal information that included in part the following: [Resident #1's RP] (hereafter the Affiant), having been duly sworn, states upon oath:That her [family], [Resident #1], (hereinafter the . Decedent .) died on February 24, 2026.That at the time of her death, the Decedent was domiciled in Texas.That at the time of her death, the Decedent was not married. In an interview on [DATE] at 4:20 p.m., Resident #1's RP stated Resident #1 expired at the facility on [DATE] and the family had to complete an affidavit of heirship to receive the medical records from the facility. Resident #1's RP stated about 2 months later a stranger reached out to her via social media and informed her that she received a document with Resident #1's information on it, and that was how she found Resident #1's RP. Resident #1's RP stated the stranger informed her that she was Resident #2's RP. Resident #1's RP stated although it was kind for Resident #2's RP to reach out, she was concerned that the facility violated HIPAA and was irresponsible with sensitive information. Resident #1's RP stated she was worried about what other information was exposed and who else had it, especially since it was so easy for Resident #2's RP to find her. In an interview on [DATE] at 4:45 p.m., Resident #2's RP stated Resident #2 expired at the facility on [DATE] and the family was also requesting medical records when they received documents with Resident #1's information on it. Resident #2's RP stated the facility's Attorney contacted her and asked that she disregard and destroy the document because it was accidentally sent to her. Resident #2's RP stated the message seemed suspicious and she knew she had to notify Resident #1's RP and the state agency. Resident #2's RP stated this was a HIPAA violation, and she did not want this to happen to other residents. In an interview on [DATE] at 11:00 a.m., the Administrator was asked to provide the facility's policy regarding privacy and confidentiality. He stated that the facility followed the HIPAA rules per federal law. In an interview on [DATE] at 1:00 p.m., the Administrator stated to his knowledge, a new affidavit of heirship was created when Resident #2's RP requested medical records. He stated he did not have any additional information to provide and advised the surveyor to speak with the facility's Attorney. In an interview on [DATE] at 1:48 p.m., the facility's Attorney stated he was outside council, and the process for requesting medical records was done at the facility level. The Attorney stated the affidavit of heirship was not prepared at his office, and he had not reviewed it to state whether or not it included information that violated HIPAA. The Attorney stated he reached out to Resident #2's RP and advised her to destroy any documents that were accidentally sent to her with incorrect information. However, he could not confirm what information was included. The Attorney advised the surveyor to speak with the facility's compliance officer to determine if there was a HIPAA violation. An attempted interview on [DATE] at 2:46 p.m. with the Compliance Officer was unsuccessful due to no response to call. This surveyor left callback information on the voicemail. In an interview on [DATE] at 3:45 p.m., the Administrator stated he was made aware that there were two pieces of information on the document sent to Resident #2's RP that violated HIPPA, and that was Resident #1's name and date of death . The Administrator stated violating a resident's privacy and confidentiality could pose the risk of unauthorized parties having knowledge of private information. Review of the U.S. Department of Health and Human Services website, < https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html >, reflected in part the following: .Protected Health Information. The Privacy Rule protects all individually identifiable health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information protected health information (PHI).12Individually identifiable health information is information, including demographic data, that relates to:the individual's past, present or future physical or mental health or condition,the provision of health care to the individual, orthe past, present, or future payment for the provision of health care to the individual,and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.13 Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number)

Based on interview and record review, the facility failed to permit residents from returning to the facility after a hospitalization for 1 of 3 residents (Resident #3) reviewed for discharge rights. The facility failed to allow Resident #3 to return to the facility after the resident discharged from the hospital. The facility issued Resident #3 a discharge notice on 01/23/26 for non-payment of services rendered; however, the resident appealed the discharge and the discharge was reversed after a fair hearing on 03/26/26. This failure could place residents at risk of not receiving appropriate ongoing care, which could lead to worsening conditions or serious harm.Findings included:Record review of Resident #3's Quarterly MDS Assessment, dated 03/19/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 3, and her active diagnoses included: stroke (blood supply to brain blocked or reduced) and Type 2 diabetes (the body's inability to regulate blood glucose levels). Record review of Resident #1's care plan, revised 02/10/26, reflected the resident had an advanced directive with a goal to honor and review annually and upon significant change in condition. Interventions included: ensuring the advanced directive was discussed with resident and/or RP and appropriate paperwork obtained. Record review of Resident #3's discharge notice reflected the resident was issued the notice on 01/23/26 for non-payment of services rendered with a discharge date of 02/21/26. Record review of a document from Texas HHS regarding Resident #3's fair hearing results, dated 05/08/26, reflected that the nursing facility did not provide evidence to determine if applicable law and polices were followed when issuing the discharge notice so the action was reversed during a fair hearing that was conducted on 03/26/26. The nursing facility was instructed to rescind the discharge notice of 01/23/26. Record review of Resident #3's progress notes, dated 03/29/26 by RN A, reflected the following: [An aide] alerted [RN A] to [Resident #3] change in condition. Upon immediate assessment [Resident #3] noted to have rapid, loud gurgling respiration and was nonresponsive to physical stimuli. Immediate vital signs were obtained. Initial:67/50, HR 123, RR 45. Repeat: 70/45 HR 145. RR 32. [Resident #3] Full code verified. 911 activated immediately. [RN A] remained at bedside to assess and monitor [Resident #3's] condition. crash cart positioned at bedside. [MD] notified at [8:50 a.m.] of [Resident #3's] condition and confirmed to 911 out via emergency response. EMS arrived on sight on [8:55 a.m.]. Verbal report given to EMS personnel. EMS verbalized [Resident #3] would be sent to [local hospital]. [ADON] notified at [8:58 a.m.]. In an interview on 06/17/26 at 11:13 a.m., the Administrator stated Resident #3 was sent to the hospital in March 2026 where she remained for a while before being transferred to an LTAC hospital. The Administrator stated Resident #3 was issued a discharge notice on 01/23/26 for non-payment and was at the hospital when a decision was made on the appeal. The Administrator stated the facility received a referral from the LTAC when Resident #3 was ready to be discharged , and they informed the resident's family that she could return if they provided payment towards the balance. The Administrator stated there was a toxic dynamic between Resident #3's family, and they had a hard time agreeing on the resident's care. The Administrator stated after having a conversation with the family about Resident #3's balance there was no further communication. An attempted interview on 06/17/26 at 11:35 a.m. with Resident #3's RP was unsuccessful due to no response to call. This surveyor left callback information on the voicemail. In an interview on 06/17/26 at 12:04 p.m., the Ombudsman stated the facility notified her of Resident #3's discharge notice on 01/23/26, and she filed an appeal. The Ombudsman stated during the appeal process, Resident #3 was transferred to the hospital, and reportedly was not expected to survive, but the resident did. The Ombudsman stated she proceeded with the appeal process and Resident #3 won. However, the facility reported that the resident would not be returning to the facility, so she closed the case. The Ombudsman stated she was unaware that the LTAC attempted to send Resident #3 back to the facility and they refused her. In an interview on 06/17/26 at 3:52 p.m., the Administrator stated Resident #3's appeal was filed timely. He stated, to his knowledge, there was a hearing scheduled around February 2026. However, the hearing decision had not been issued prior to the resident's discharge from the hospital. The Administrator stated the facility did not deny Resident #3's return to the facility, but they did require payment first. The Administrator stated he could not state the risk of not allowing a resident to return to the facility in this case. Review of the facility's policy titled Discharge/Transfer Policy, review date on 04/24/24, reflected in part the following: Policy: The resident will be discharged /transferred (home/another entity) by order of his/her attending physician in accordance with standard practice guidelines.Procedure:.E. Involuntary: 1) A resident may be discharged involuntarily for the following reasons:c. Resident has refused to pay their bill after reasonable and appropriate notice to pay or to have paid under Medicare or Medicaid 2) In order to process an involuntary discharge, the Community designee will: a. Develop a safe discharge plan, including but not limited to securing an alternate location, and will have the plan approved by the resident's physician.b. Obtain a physician's order for the discharge.c. Complete the state's Notice of Transfer/Discharge and forward via hand delivery to the resident and/or via certified mail/return receipt requested to the resident's legal representative or interested family member. Where required by law, a copy will also be sent to the state's OmbudsmanThe facility's Discharge/Transfer policy did not address appeals and discharge reversals.

Based on interview and record review, the facility failed to have physician orders for the resident's immediate care, at the time the resident was admitted for 1 of 5 residents (Resident #1) reviewed for admission orders.The facility failed to have Physician orders to provide wound care for Resident #1 who admitted on [DATE] until 2 days later on [DATE].This failure could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health. Findings included:Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old male admitted on [DATE] with a diagnosis of Malignant Neoplasm of thyroid gland (thyroid cancer). Record review of Resident #1's discharge MDS, dated [DATE], revealed that he expired in the facility on [DATE]. Record review of Resident #1's care plan , dated [DATE], revealed that he required a 1-2-person assistance with ADLs, and a 2-person assistance transfer with a mechanical lift due to his malignant neoplasm of thyroid gland. Resident #1's care plan further revealed that he was at risk of pain related to cancer.Record review of Resident #1's admission Skin Assessment completed by the Wound Care Nurse, dated [DATE], revealed that he had a tumor wound on his neck. Record review of Resident #1's progress note, completed on [DATE] at 6:12 PM from ADON B revealed the following, Resident arrived via [Transport company]. Residet [sic] vitals are stable. 123/78 BP 97.7 T, 79P, 98 O2. Resident DX thyroid cancer. Resident lungs are clear. BS are present. Turgor good. Skin intact. PRN O2 at 2-4 liters. Resident is on a liquid diet and uses straw. Residents' family present. Teaching provided on neck. Do not get up out of bed, do not get dressed, resident will stay in hospital gown per request of family. Care to neck provided multiple times throughout the day depending on amount of blood noted. Resident is a hospice pt. [Hospice Company]Record review of Resident #1's progress note, completed on [DATE] at 10:52 PM by LVN A revealed the following, Wound dressing changes per family. MD notifiedRecord review of Resident #1's progress note, completed on [DATE] at 1:24 PM by LVN A revealed the following, Taking care of patient, [AGE] year old thyroid cancer patient. Family has a procedure on how they want the wound done. I wrote down the steps and texted it to [Facility MD]. Hospice Nurse has been here twice but does not have any wound orders. One of the Nurses even told me that they don't do wounds. However, the family insisted that the wound care be performed at least 2x daily. I spoke to [Facility MD] and she asked me to call the hospice to confirm the order. I called the hospice and they said they are still working on the Order.Record review of Resident #1's physician orders, dated [DATE], revealed the following, ([START [DATE] [2:45 PM] Information Only.Wound care orders as follows' [Hospice Company]. Cleanse area with normal saline, pat dry, apply bleed stop powder to area of wound, cover with dry dressing . Change dressing daily or PRN as needed if soiled. During an interview on [DATE] at 2:21 PM with Resident #1's Family Member revealed she brought Resident #1 to the facility because he was getting closer to the end, was on hospice services, and required full time care. She stated when they brought Resident #1 to the facility on [DATE], she educated the staff and wound care nurse on how to care for Resident #1's tumor wound. The Family Member stated Resident #1 had thyroid cancer that was protruding through the skin. She stated the wound care provided at home required a powder to stop the bleeding and was the only thing that was effective. The Family Member stated the Wound Care Nurse did not complete Resident #1's wound care that she was aware of. The Family Member stated herself, the weekend hospice nurse, or the floor nurses at the facility did the wound care. The Family Member stated hospice provided the facility with the wound care orders when Resident #1 admitted but it was not completed the proper way unless she was at the facility. During an interview on [DATE] at 12:22 PM, the Wound Care Nurse revealed she worked at the facility since 2007. The Wound Care nurse stated Resident #1 admitted on a Friday and she saw him the following Monday, [DATE]. She stated she did his wound care 1 or 2 times. The Wound Care Nurse stated she updated the wound care order on Monday and Tuesday because the family wanted it done differently. The Wound Care Nurse stated she contacted the Facility MD and updated the wound care orders according to the family member's request. The Wound Care Nurse stated the floor nurses did the wound care on the weekends because she was not at the facility. The Wound Care Nurse stated she never saw the tumor bleeding, but that the Family Member would not allow staff to clean it, so they applied a powder to it. She stated she was not aware that there were no wound care orders at the time of admission. The Wound Care Nurse stated hospice should have provided the order at the time of admission, but the facility MD could have been contacted for one, if not. She stated the risk of not having a wound care order at the time of admission was an infection risk. During an interview [DATE] at 12:50 PM, the Hospice Nurse revealed she was the nurse who admitted Resident #1 to the facility on [DATE]. She stated Resident #1 was admitted on a Friday ([DATE]) then passed away the following Tuesday ([DATE]). The Hospice Nurse stated she provided the facility with written orders on [DATE] that included wound care orders. She stated there was a daily and a PRN order if it was soiled. The Hospice Nurse stated the wound care order was updated on Monday ([DATE]) or Tuesday ([DATE]) to 3 times a day due to it bleeding.During an interview on [DATE] at 1:18 PM, LVN A revealed she worked at the facility PRN since [DATE]. She stated Resident #1 was admitted to the facility with hospice services. LVN A stated she completed the wound care on Resident #1 twice a day. LVN A stated she called hospice because the wound care the Family Member wanted was not in their system. LVN A stated she was not there when Resident #1 admitted , but that the hospice must not have provided them with wound care orders. LVN A stated Hospice wound not give the wound care orders and she had to pressure them to finally give the orders, and that was when she put them in their system. She stated she could not recall the specific dates. LVN A stated she notified the Facility MD on [DATE] before hospice provided the order and the MD told her to confirm the order with hospice. She stated she did not notify the Facility MD about hospice not providing the wound care order. LVN A stated there should have been an order for wound care, but that the Family Member was present teaching her how to do it. LVN A stated the risk of not having a wound care order was not providing proper care. During an interview on [DATE] at 4:22 PM, the ADON B revealed she worked at the facility for 4 months. ADON B stated she was working the floor when Resident #1 admitted to the facility on [DATE]. ADON B stated she recalled pulling the Wound Care Nurse into Resident #1's room to complete the wound care and to get orders from hospice. ADON B stated she did not recall getting wound care orders from hospice initially, but the Family Member wanted the wound care completed according to her steps. ADON B stated she was not sure why the wound care orders were not put in their system until [DATE]. ADON B stated she did not provide the wound care for Resident #1, but that she observed the Family Member completing it when the resident first got to the facility. ADON B stated the nurses were responsible for ensuring all orders were in place when Resident #1 was admitted to the facility. She stated the staff should not have performed wound care without physician orders. ADON B stated if Hospice did not provide a wound care order, the Facility MD or Wound Dr. should have provided a temporary order. ADON B stated the risk of completing wound care without an order was injuring the resident. During an interview on [DATE] at 6:06 PM, the DON revealed she worked at the facility for 2 months. The DON stated dressing changes were completed a couple times a day on Resident #1 due to his large cancer tumor. The DON stated she was aware they had to contact Hospice about updating the orders due to Resident #1's family requests. The DON stated she was not aware that no wound care orders were put in place when he admitted to the facility. She stated if hospice did not provide an order, she expected the nursing staff to notify the facility's MD to get wound care orders until hospice provided them. The DON stated the risk of not having wound care orders was infection. She stated it was the whole nursing team's responsibility to ensure the orders were completed. During an attempted telephone interview on [DATE] at 1:45 PM, the Facility Physician did not answer and no phone call was returned during the investigation. During an interview on [DATE] at 6:39 PM, the Administrator revealed he had worked at the facility since [DATE]. He stated Resident #1 admitted to the facility with the tumor. The Administrator stated he expected there to be wound care orders for any wound care. He stated the risk of not having those orders was it affected the plan of care and that Resident #1 required frequent wound dressing changes. The Administrator stated dressing changes needed to be completed based on physician orders. Record review of the facility's policy titled, Physician Orders, revised [DATE], revealed the following: .2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to complete a baseline care plan that addressed hospice services for Resident #1. This failure could place residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs.Findings included :Record review of Resident #1's face sheet, dated [DATE], revealed he was an [AGE] year-old male who admitted on [DATE] with a diagnosis of Malignant Neoplasm of thyroid gland (thyroid cancer). Record review of Resident #1's discharge MDS, dated [DATE], revealed that he expired in the facility on [DATE]. Record review of Resident #1's care plan, dated [DATE], revealed that he required a 1-2-person assistance with ADLs, and a 2-person assistance transfer with a mechanical lift due to his malignant neoplasm of thyroid gland. Resident #1's care plan further revealed that he was at risk of pain related to cancer and was a DNR. Record review revealed no care plan for hospice services. Record review of Resident #1's progress note, completed on [DATE] at 6:12 PM from ADON B revealed the following, Resident arrived via [Transport company]. Residet vitals are stable. Resident DX thyroid cancer.Resident is a hospice pt. [Hospice Company]Record review of Resident #1's physician orders, dated [DATE], revealed the following order effective [DATE], Admit to Skilled Care.for Malignant neoplasm of thyroid gland. Record review revealed no physician order for hospice care services. Interview on [DATE] at 12:50 PM with the Hospice Nurse revealed she was Resident #1's case manager. She stated she was unable to recall how long he was on hospice services due to him having a different nurse while he lived at home. The Hospice Nurse stated he was admitted to the facility on hospice services, and she provided the facility with written orders, but that his records were also faxed over before he admitted . Interview on [DATE] at 4:22 PM with ADON B revealed she had worked at the facility for 4 months. ADON B stated she was working the floor when Resident #1 was admitted to the facility on hospice services on [DATE]. She stated Resident #1's care plan should have included hospice services with the company name. She stated it was the nurse's responsibility to include that as part of the care plan. She stated the risk of not having hospice on the care plan was it could cause harm to the resident.Interview on [DATE] at 6:06 PM with the DON revealed she had worked at the facility for 2 months. The DON stated Resident #1 should have had a care plan for hospice. She stated it was the whole nursing team's responsibility to review and complete the care plans. The DON stated the risk of not having hospice on the care plan was it could affect Resident #1's quality of care. Record review of the facility's policy titled, Hospice Program revised [DATE], revealed the following: .2. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/family will be developed and shall include but not limited to directives for managing pain and other uncomfortable symptoms. The care plan shall be revised by the Interdisciplinary Team, as necessary to reflect the resident's current status.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to order and administer Levothyroxine (Levothyroxine Sodium) for Resident #1 while at the facility from 05/01-[DATE]. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included:Record review of Resident #1's face sheet, dated [DATE], revealed he was an [AGE] year-old male who admitted on [DATE] with a diagnosis of Malignant Neoplasm of thyroid gland (thyroid cancer). Record review of Resident #1's discharge MDS, dated [DATE], revealed that he expired in the facility on [DATE]. Record review of Resident #1's care plan, dated [DATE], revealed that he required a 1-2-person assistance with ADLs, and a 2-person assistance transfer with a mechanical lift due to his malignant neoplasm of thyroid gland. Resident #1's care plan further revealed that he was at risk of pain related to cancer.Record review of Resident #1's medication list, faxed to the facility from the hospice company on [DATE] at 2:51 PM revealed the following order: Levothyroxine 112 mcg (medication to treat underactive thyroid) oral tablet every day with a start date of [DATE]. Record review of Resident #1 facility physician orders, undated, revealed the following order: LEVOTHYROXINE 112 MCG TABLET (Levothyroxine Sodium) Malignant neoplasm of thyroid gland for Diagnostic ([START [DATE] 13:31] 1 tab by mouth One time daily [Time: 08:00 AM])Record review of Resident #1's May MAR, undated, revealed no doses of the levothyroxine were administered while at the facility . During an interview on [DATE] at 2:21 PM with Resident #1's Family Member revealed she took Resident #1's thyroid medication to the facility with the rest of his medications when he arrived on [DATE]. She stated Resident #1 never received his thyroid medication while he was there because she asked a nurse about it before he died and she was not aware of it. The Family Member stated she confirmed when she received the medications back after he passed that the levothyroxine was never given to him. The Family Member stated he was taking it at home on hospice, and it was present on his medication list. During an interview on [DATE] at 12:50 PM, the Hospice Nurse revealed she was the nurse who admitted Resident #1 to the facility on [DATE]. She stated he was admitted on a Friday ([DATE]) then passed away the following Tuesday ([DATE]). The Hospice Nurse stated she provided the facility with written orders on [DATE]. She stated she recalled writing an order for the Levothyroxine since it was on his medication list. During an interview on [DATE] at 3:52 PM, RN C stated she recalled the Family Member asking her about his levothyroxine. She stated she contacted the MD and got an order for it. RN C stated she saw it was on his previous medication list and Resident #1 should have received it while at the facility. She stated she did not give him the levothyroxine and was unable to recall if it was in the medication cart. RN C stated the risk of residents not receiving their medications was they would not get the medication benefits. RN C stated it was the nurse who admitted Resident #1's responsibility to put the orders in, but all nurses could review and check. During an interview on [DATE] at 4:22 PM, ADON B revealed she had worked at the facility for 4 months. ADON B stated when hospice provided a medication list or written orders, it should get uploaded into the MAR by the facility nurse. ADON B stated there should have been an order for Levothyroxine if it was on Resident #1's medication list. ADON B stated she was the one who uploaded his medications into the MAR when he admitted but could not recall any of the medications or orders. She stated all the nurses were responsible for ensuring the orders were updated and accurate. The ADON stated the risk of not having all the medications put in the MAR, was it would not be administered, and could cause harm to the resident. During an interview on [DATE] at 6:06 PM, the DON revealed she had worked at the facility for 2 months. The DON stated Resident #1's levothyroxine should have been ordered on admission if it was on his medication list. The DON was unable to confirm why the medication was not added until [DATE]. The DON stated the risk of not having the medication ordered was it affected the residents' quality of care and disease management. She stated it was the whole nursing team's responsibility to ensure the orders were completed.During an attempted telephone interview on [DATE] at 1:45 PM, the Facility Physician did not answer and no phone call was returned during the investigation. Record review of the facility's Physician Orders, revised [DATE], revealed the following: .2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.Record review of the facility's Hospice Program policy, revised [DATE], revealed the following: .6. The Hospice Agency will provide the following documentation:.g. Hospice physician and attending physician (if any) orders specific to the resident.

Based on interview, observation and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care for 1 of 4 residents (Resident #1) reviewed for hospice services. The facility failed to ensure Resident #1 had a physician order for hospice care. This failure could place residents at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs. Findings included : Record review of Resident #1's face sheet, dated [DATE], revealed he was an [AGE] year-old male who admitted on [DATE] with a diagnosis of Malignant Neoplasm of thyroid gland (thyroid cancer). Record review of Resident #1's discharge MDS, dated [DATE], revealed that he expired in the facility on [DATE]. Record review of Resident #1's care plan, dated [DATE], revealed that he required a 1-2-person assistance with ADLs, and a 2-person assistance transfer with a mechanical lift due to his malignant neoplasm of thyroid gland. Resident #1's care plan further revealed that he was at risk of pain related to cancer and was a DNR. Record review revealed no care plan for hospice services. Record review of Resident #1's progress note, completed on [DATE] at 6:12 PM from ADON B revealed the following, Resident arrived via [Transport company]. Residet vitals are stable. Resident DX thyroid cancer.Resident is a hospice pt. [Hospice Company]Record review of Resident #1's physician orders, dated [DATE], revealed the following order effective [DATE], Admit to Skilled Care.for Malignant neoplasm of thyroid gland. Record review of Resident #1's physician orders, dated [DATE], revealed no physician order for hospice care services. During an interview on [DATE] at 2:21 PM, Resident #1's Family Member revealed she brought Resident #1 to the facility because he was getting closer to the end, was on hospice services, and required full time care. The Family Member stated Resident #1 was on hospice services when he lived at home and it was continued once at the facility. During an interview on [DATE] at 12:50 PM, the Hospice Nurse revealed she was Resident #1's case manager. She stated she was unable to recall how long he was on hospice services due to him having a different nurse while he lived at home. The Hospice Nurse stated he was admitted to the facility on hospice services, and she provided the facility with written orders, but that his records were also faxed over before he admitted . During an interview and observation on [DATE] at 4:22 PM, ADON B revealed she had worked at the facility for 4 months. ADON B stated she was working the floor when Resident #1 admitted to the facility on [DATE]. ADON B stated Resident #1 was admitted to the facility on hospice services. She stated there should have been an admit to hospice order in Resident #1 physician orders. During the interview, ADON B reviewed the physician orders and stated there was no admit to hospice order. ADON B stated she recalled putting in a progress note that Resident #1 was on hospice services, but could not recall why the order was not put in. ADON B stated the risk of not having a hospice order was harm to the patient . ADON B stated it was all the nurse's responsibility to ensure the hospice order was put in. During an interview on [DATE] at 6:06 PM, the DON revealed she had worked at the facility for 2 months. The DON stated Resident #1 should have had an admit to hospice order since he admitted to the facility on hospice services. The DON stated the hospice order was to notify staff and assist with Resident #1's quality of care. The DON stated the order also reminded staff to review the hospice binder for continuity of care. The DON stated it was the whole nursing team's responsibility to ensure the orders were complete. She stated the risk of not having a hospice order affected the quality of care. Record review of the facility's policy titled, Hospice Program revised [DATE], revealed the following: .2. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/family will be developed and shall include but not limited to directives for managing pain and other uncomfortable symptoms. The care plan shall be revised by the Interdisciplinary Team, as necessary to reflect the resident's current status.7. Documentation will be housed in the electronic health record (EHR) under the Hospice tab If the hospice agency has their own proprietary EHR, the facility will scan and upload documentation into the communities' EHR.

Based on observation, interviews and record review the facility failed to maintain medical records that were complete and accurately documented for 2 (Resident #50 and Resident #9) of 16 residents reviewed for resident records.1. The facility failed to accurately document Resident #50's use of a hand splint on 04/07/26 and 04/08/26 when the splint was not applied.2. The facility failed to ensure Resident #9's physician orders had the correct medication administration route for eight medications, which were orders to give medications by mouth, when the resident had a nothing by mouth status. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.Findings included: Record review of Resident #50's quarterly MDS Assessment, dated 02/06/26, reflected an [AGE] year-old female admitted [DATE]. Resident #50 had diagnoses which included Diabetes Mellitus (high blood sugar resulting from the body inability to properly use insulin), Hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting left non-dominant side and cerebral infarction (loss of blood flow to part of the brain). Resident #50's BIMS score was 15, which indicated his cognition was intact. The MDS Section O – Special Treatments, Procedures, and Programs – Restorative Nursing Programs resident was provided with the use of a splint. Record review of Resident #50's care plan, dated 03/12/26, reflected the following: Problem/Strengths: Pain. Interventions: Use non-pharmacological pain interventions to assist with pain management (splint left hand, warm blankets for joint pain, reposition). Problem/Strengths: Limited range of motion upper extremity left hand related to contracture. Goals: Will maintain range of motion of as evidenced by place splint. Will improve range of motion. Interventions: Range of motion by staff. Observe for pain or increased stiffness. Problem/Strengths: Needs assistance with splint to left hand. Goals: Splint will be correctly applied per MD order. Apply splint on day shift for 6 hours per day. Remove splint on second shift. Record review of Resident #50's physician order, dated 09/10/25, reflected the following: SPLINT On Day Shift [Time: Shift 1] LEFT HAND SPLINT ON 6 HOURS PER DAY for Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage . Monitor skin around splint for redness or skin breakdown. Start Date 09/10/25. Record review of Resident #50's April 2026 MAR revealed the splint was in place during the first shift on 04/07/26 and 04/08/26. Observation and interview on 04/07/26 at 10:47 AM revealed Resident #50 in her room sitting in her wheelchair. Observed Resident #50's left hand to be contracted and she was not wearing her splint. Resident #50 was able to partially open her hand, no observation of skin issues. Resident was able to gesture her response. Resident #50 gestured she had a splint but had not been asked to wear it. Hand splint was not observed in the room. Observation on 04/07/26 at 12:40 PM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 8:55 AM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 10:05 AM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 12:55 PM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 2:15 PM revealed Resident #50 did not have a splint on her left hand. Interview on 04/08/26 at 2:18 PM, RN D revealed Resident #50 had orders for the use of a splint. She stated it was the responsibility of the nurses or therapy to put on the splint on Resident #50. RN D stated she had not attempted to put on the splint on Resident #50 today (04/08/26) or yesterday (04/07/26). She stated Resident #50 goes to therapy at around 10AM and therapy also puts on the splint. Observed RN D entered Resident #50 room and was searching for the resident splint but was unable to locate it. RN D reviewed the Resident #50's MAR and stated she documented at 12:38 PM that resident had the splint on; however, she did not ask or attempted to place the splint on resident. RN D stated she documented incorrectly and should had documented No to show that the splint was not put on. She stated it was not good care if documentation was incorrect. Interview on 04/08/26 at 2:29 PM, Director of Rehab revealed Resident #50 was not receiving services from therapy. She stated Resident #50 was receiving services from Physical Therapy from 03/01/26 to 04/01/26 due to a fall. She stated Resident #50 had not been seen since 04/01/26. Director of Rehab stated Resident #50 had an order for the use of splint and it was the responsibility of Restorative Aide to put it on. Interview on 04/08/26 at 2:32 PM, Restorative Aide revealed she had not applied any hand splint to Resident #50 in months. She stated she was aware Resident #50 used to wear a splint, but she was not responsible for putting it on. She stated the last time she put on the splint was sometime last year 2025. Follow up interview 04/08/26 at 3:16 PM, Director of Rehab revealed she was not aware Restorative Aide was not putting on the splint on Resident #50. She stated if there was an order then it was the responsibility of the nurses to put on the splint on Resident #50. Interview on 04/09/26 at 3:28 PM, ADON A revealed if there was an order for the use of a splint it was the responsibility of the nurses to put on the splint on the resident. She stated it was a daily check off for the nurses on the MAR and should be applying the splint or attempting too. ADON A stated her expectation was for documentation to be accurate. She stated if the documentation was not accurate then it would be an issue. Interview on 04/09/26 at 4:39 PM, the DON revealed the nurses and CNAs were responsible for putting on hand splints. She stated her expectation was for the nurses to follow physician orders and apply the use of the hand splint. She stated she expected the documentation to be correct and if not documented it did not happen. She stated if documentation was not accurate it would interfere with the patient care. 2. Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included aphasia (language disorder resulting from damage to the brain), paraplegia (paralysis affecting the lower half of the body), malnutrition (when the body does not get enough nutrients), and respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body). Further review of the MDS revealed Resident #9 had unclear speech, was usually understood, and usually understood others, was dependent for ADLs, and required a feeding tube, oxygen therapy, suctioning and tracheostomy care. Record review of Resident #9's Care Plan dated 08/28/25 reflected the following:- hydration – gtube with goal of improve or maintain hydration and an intervention that included Gtube for all nutrition- enteral feeding with goal of nutritional needs will be met with no S/SX of aspiration with intervention that included administer feeding tube as ordered Record review of Resident #9's Physician orders revealed the following orders:- order date 06/27/2025 GABAPENTIN 300 MG CAPSULE 1 by mouth Every 8 hours 07:00 AM, 03:00 PM, 11:00 PM - order date 06/27/2025 HYOSCYAMINE SULF 0.125 MG TAB 1 by mouth Every 8 Hours as needed - order date 07/01/2025 DIET: Order – NPO - order date 07/01/2025 MIRALAX 17 GM/1 Dose POWDER FOR SOLUTION by mouth On Day Shift [Time: Shift 1] - order date 07/01/2025 SENNA-LAX 8.6 MG TABLET 1 by mouth One time daily [Time: 8:00 AM] - order date 07/01/2025 ASPIRIN 81 MG TABLET, CHEWABLE 1 by mouth One time daily [Time: 08:00 AM] - order date 08/27/2025 CYMBALTA 60 MG CAPSULE, DELAYED RELEASE for Depression, ([START 08/27/25 16:39] 60 MG by mouth Twice a day [Time: 08:00 AM, 09:00 PM]) - order date 10/16/2025 Buspirone 5 MG TABLET for Depression, unspecified for Anxiety ([START 10/16/25 09:46] 1 tab by mouth Twice a day [Time 08:00 AM, 09:00 PM]) - order date 10/28/2025 METHOCARBAMOL 500 MG TABLET for Pain, unspecified for Pain - Generalized 1 by mouth Three times a day [Time: 10:00 AM, 04:00 PM, 11:00 PM] give at 10AM, 4PM, 11PM Interview and record review on 04/09/26 at 9:22 AM, RN G stated she had never given Resident #9 anything by mouth and had not noticed the orders that said by mouth. RN G pulled up Resident #9's chart and showed surveyor where it said NPO. RN G stated she knew Resident #9 was NPO from report and only the nurse would give meds. She stated if the MA looked, they would see the resident was NPO. She stated it could be a risk if an agency nurse or a new nurse was reading the orders and they did not get report. She said it was probably entered wrong and she would fix it or call her manager. Interview on 04/09/26 at 12:28 PM, NP E stated all g-tube were nothing by mouth and if orders were incorrect and medications were given by mouth the resident could aspirate. Interview on 04/09/26 at 3:19 PM, ADON A stated she had worked there for about 2.5 weeks. She stated she was now aware that Resident #9's orders had several medication orders that said g-tube and by mouth, and she had made the nurses and DON aware. ADON A stated the nurse, who received the admission orders, would have entered the orders. She stated the ADON was responsible for clarifying the orders the following day. She stated she expected nurses to verify physician orders. She said the risk to the resident could be medication errors. Interview on 04/09/26 at 4:26 PM, the DON stated the admission nurse entered orders when a resident admits and the next nurse on shift and the ADON were supposed to verify them on the next shift and the next day. The DON stated if somebody tried to give Resident #9 anything by mouth she could choke or aspirate. She said in the clinical meeting the previous day's admissions should be reviewed and she did not know why the orders were not reviewed before. Record review of the facility policy titled Physician orders – electronic revised 01/12/2020 revealed Policy 1. The licensed nurse will receive and transcribe the physician's orders according to Practice Guidelines. 2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.Procedure.2. The licensed nurse clarifies and reconciles all orders that may lead to an administration error. 3. The electronically entered order will be automatically transcribed onto the Medication admission Record (MAR) or Treatment Record. Date and initials of the transcriber will be automatically recorded. Record review of facility policy titled Medication Administration Enteral Tubes dated 2007, revealed the following:2. The physician's order must specify the route of administration of any medication via feeding tube. This should be stated in the directions at a minimum as 'per tube' or 'via tube', but certainly the type of tube may be specified.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 2 residents (Resident #2) reviewed for PASARR.The facility failed to refer Resident #2 for a PASRR Level II assessment when the facility failed to correct his PASRR level I assessment. This failure could place residents at risk of not receiving specialized services to meet their needs. Findings included:Record review of Resident #2's most recent MDS assessment dated [DATE], revealed at [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of Post-Traumatic Stress Disorder, or PTSD (a mental health condition that's caused by witnessing or being part of an extremely stressful or terrifying event). Further review of the MDS revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #2's PASRR Level 1 Screening form (used to determine whether a resident may have serious mental illness or intellectual disability), dated 03/20/26, revealed no was answered for the following screening question:-Is there evidence or an indicator that the individual has a Mental Illness? Record review of Resident #2's clinical hospital paperwork dated 03/08/26 through 03/16/26 revealed Resident #2 had a diagnosis of post-traumatic stress disorder. Interview on 04/08/26 at 11:20 AM, MDS nurse B stated she only entered PASRR information if a resident was admitted from home. She stated the Admissions Coordinator uploaded the screening forms for other residents. Interview and record review on 04/08/26 at 11:25 AM, the Admissions Coordinator stated he entered PASRR information into Simple (software used by nursing facilities) for residents upon admission. He stated he gets the information when the hospital faxed or emailed it to him. He showed surveyor Resident #2's PASRR screening form from the hospital with no Mental Illness noted on the form. He stated he entered the information exactly as it was on the hospital form into Simple. He said the nurses had access to Simple and could go in and edit if they found an error. Interview on 04/09/26 at 11:50 AM, the DON stated the Admissions Coordinator entered the information from the hospital and he should try to facilitate corrections. She stated if there were corrections, usually MDS or the SW were to go back in and enter the correct information. The DON stated if a resident admitted with a qualifying condition and it was in the paperwork from the hospital and the facility did not get the hospital to change it, then they would have to correct it. She stated if not done it could affect the quality of care and how they approached the resident's care. She stated she was responsible for overseeing PASRR was completed correctly. She said moving forward it would be discussed in the morning clinical meeting and MDS would complete at that time. Interview on 04/09/26 at 5:01 PM, the Administrator stated the facility did not have a policy on PASRR and they followed Texas PASRR guidelines.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 18 residents (Resident #102) reviewed for baseline care plans. The facility failed to ensure Resident #102 had a baseline care plan, or conversely a comprehensive care plan, within 48 hours of admission. These failures could place the residents at risk of not having their needs and preferences met. Findings included:Record review of Resident #102's 5-day MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included cancer, hypertension (high blood pressure), diabetes, respiratory failure, septic pulmonary embolism (infected blood clots that travel to the lungs causing fever, cough, chest pain, and respiratory distress), and polyneuropathy (damage to multiple peripheral nerves causing numbness, burning pain, and muscle weakness). Resident had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected the resident required supervision for ADLs and was on pain regimen. Record review of Resident #102's progress notes dated 02/06/26 reflected he had discharged home with stable vitals and discharge instructions. Record review of Resident #102's clinical record revealed the resident did not have a care plan completed which included a baseline care plan. Interview on 04/09/26 at 3:39 PM with ADON A revealed she had only been working at the facility since February 2026 before Resident #102 was admitted and it appeared the baseline care plans were not being completed correctly. ADON A said she was told the ADONs were responsible for filling them out, but she said that would not be possible as the ADONs were not always at the facility when new residents were admitted . ADON A said when new residents were admitted the admitting nurse was responsible for opening the baseline care plans and completing as much as they could from the hospital orders and documentation. ADON A further stated baseline care plans should be completed timely because it gave the staff information on the admitting resident and how to care for them and they would implement that soon. Interview on 04/09/26 at 3:53 PM, MDS Nurse B revealed baseline care plans were a group effort between nursing management such as ADONs and the DON. MDS Nurse B said she did not know why Resident #102's baseline care plan was not completed, and she said it was important for the care plans to be completed timely, so the nurses had the resident orders match their plan of care. Interview on 04/09/26 at 4:29 PM, the DON revealed she had recently been hired and been at the facility for a few days. The DON said the baseline care plans should be completed by the nurse that admitted the resident and the ADONs were to overlook them for accuracy. The DON further stated baseline care plans were important to establish a resident's plan of care. Record review of the facility's policy titled Care Plan-Process reviewed 03/2023 reflected the following: .1. Initiate a Baseline Care Plan and complete within forty-eight (48) hours of admission based on the physician's orders and nursing evaluation.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #56) reviewed for care plans.The facility failed to ensure Resident #56 had a care plan that addressed the residents' need for oxygen use.This failure could place residents at risk for incomplete assessments which could cause incorrect care and services in oxygen support and could result in a decline in health.Findings included:Record review of Resident #56's quarterly MDS Assessment, dated 02/09/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Type 2 diabetes mellitus without complications (high blood sugar resulting from the body's inability to properly use insulin), Non-Alzheimer's Dementia (problems with memory and thinking), heart failure, hypertension (high blood pressure) and cancer. Resident #56's BIMS score was 09, which indicated moderate cognitive impairment. The MDS Section J - Health Condition reflected resident had shortness of breath or trouble breathing when lying flat. The MDS Section O - Special Treatments, Procedures, and Programs reflected the resident received oxygen therapy. Record review of Resident #56's care plan dated 03/17/26, revealed the care plan did not address the resident's oxygen use.Record review of Resident #56's physician orders, dated 01/28/26, reflected O2 SAT Check Every Shift [Time: Shift 1, Shift 2, Shift 3] Monitor resident for signs and symptoms of shortness of breath for Essential (primary) hypertension, Paroxysmal atrial fibrillation (a fast, irregular heartbeat), Heart failure, Need HOB elevated to avoid SOB while lying flat.Record review of Resident #56's physician orders, dated 04/05/26, reflected Oxygen Every Shift [Time: Shift 1, Shift 2, Shift 3] for Shortness of breath oxygen via nasal canula.Record review of Resident #56's physician orders, dated 04/06/26, reflected Oxygen wean off oxygen slowly for Shortness of breath. Maintain o2 > 90%. Physician orders did not address how much oxygen Resident #56 should be administered. Record review of Resident #56's April 2026 MAR revealed Resident #56's O2 sats were within normal limits.Observation and interview on 04/07/26 at 10:36 AM, revealed Resident #56 sitting in her room sitting in her wheelchair. Resident #56 was observed to have her oxygen on via nasal cannula. The oxygen concentrator was set at 1.5L. Resident #56 stated she was having a hard time breathing but that the nurse had just checked her oxygen levels and they were normal. Observation and interview on 04/07/26 at 1:03 PM, revealed Resident #56 in the hallway ambulating in her wheelchair. Resident #56 did not have her oxygen on. Resident #56 stated she was feeling better. She stated she used to always receive oxygen but recently oxygen was only provided as needed. Resident #56 stated she could not recall how much oxygen she should be receiving.Observation on 04/08/26 at 10:04 AM, revealed Resident #56 in bed sleeping. She was observed to be receiving oxygen, and it was set at 1.5L. No distress was noted.Interview on 04/09/26 at 1:10 PM, RN D revealed Resident #56 was receiving oxygen and it should be care planned. She stated she was not aware it was not care planned. RN D stated it was the responsibility of MDS Coordinators to update care plans. Interview on 04/09/26 at 2:57 PM, MDS Nurse B revealed the MDS Coordinators were responsible for care plans. She stated residents receiving oxygen should be care planned. MDS Nurse B reviewed Resident #56's care plan and stated she was not aware oxygen was not care planned. MDS Nurse B stated Resident #56's care plan from July 2025 addressed oxygen use; however, when the facility changed systems the care plan was not transferred over. She stated the last care plan meeting was on 02/11/26 and oxygen should have been addressed. MDS Nurse B stated oxygen should be care planned so that the nurses know the reason why it was being used. Interview on 04/09/26 at 3:32 PM, ADON A revealed the charge nurses were responsible for putting orders in the system and the ADONs were to follow up to ensure the orders were correct. She stated for residents receiving oxygen the order should specify how many liters to provide. ADON A stated multiple people were responsible for care plans. She stated she would have to review the facility's policy to ensure if the use of oxygen should be care planned. Interview on 04/09/26 at 4:31 PM, the DON revealed Resident #56 was receiving oxygen but only as needed and not continuous. She stated Resident #56 was being weaned off the oxygen; however, due to her age and diagnosis it would be best for the resident to be placed back on continuous. The DON stated her expectation was for Resident #56's oxygen orders to specify how many liters to administer even if resident was being weaned off from it. The DON stated she did not know the previous oxygen orders or the liters being administered to Resident #56 prior to being weaned off. The DON stated oxygen should be care planned. She stated she was not aware Resident #56 was not care planned for the use of oxygen. She stated anything being provided to a resident should be care planned. The DON stated any licensed nurse, MDS, ADON and herself were responsible for updating care plans. She stated the potential risk of not care planning oxygen could lead to poor care. Record review of the facility Comprehensive Care Plans policy, revised 02/12/2020, reflected the following: It is the policy of this facility to develop and implementation a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #28) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #28's fingernails were kept clean.This failure had the potential to affect residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included:Record review of Resident #28's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. Record review of Resident #28's care plan dated 02/10/26 reflected the resident required assistance with personal hygiene related to weakness. Interventions included providing extensive assistance with personal hygiene. During an observation and interview on 04/07/26 at 2:08 PM, Resident #28 was in her bed. The resident's fingernails had a black substance underneath each one. When asked if staff cleaned her nails, she looked at them, smiled, and said, Yes. When asked if she would like to have her fingernails cleaned, she replied, Yes. Observation on 04/09/26 at 10:44 AM revealed Resident #28's fingernails continued to have black substance underneath each one. Interview on 04/09/26 at 1:26 PM, CNA C revealed aides were responsible for cleaning resident fingernails. CNA C said she worked with Resident #28 about two times a week, but she had not noticed the resident's fingernails had been dirty. CNA C said it was important for the residents to have clean fingernails to prevent infections and said she would go in there and clean them.Interview on 04/09/26 at 1:44 PM with the Restorative Aide revealed she had been providing care for Resident #28 that day, 04/09/26, and noticed the day prior the resident's fingernails were dirty but said the resident had refused to have them cleaned as she sometimes did. The Restorative Aide said the aides were responsible for cleaning the resident's fingernails for infection control purposes. Interview on 04/09/26 at 1:46 PM with CNA C revealed she had just left Resident #28's room and the resident had allowed her to clean her fingernails. Interview on 04/09/26 at 1:47 PM with RN D revealed she had only worked with Resident #28 that day and she had not noticed Resident #28's dirty fingernails and no one had reported them to her. Interview on 04/09/26 at 3:36 PM with ADON A revealed nail care should be done by the aides during shower and as needed. ADON A said if the residents refused multiple times, then it should be documented. ADON A further stated the charge nurses should also keep up with resident hygiene and ensure it was being done. ADON A said fingernails should be clean because they contain a lot of bacteria. Interview on 04/09/26 at 4:25 PM with the DON revealed nail care should be done by the aides or the nurses during showers or as needed. The DON said it was important for the residents to have clean fingernails for infection control purposes. Record review of the facility's policy titled Bathing revised on 02/2020 reflected the following: Standard of Practice: Staff will provide bathing services for residents within standard practice guidelines.Procedure:.Perform hand hygiene and perform nail care.

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 residents (Resident #50) reviewed for range of motion. The facility failed to ensure Resident #50 had her hand splint applied to her left hand per physician orders for contracture management. The failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included:Record review of Resident #50's quarterly MDS Assessment, dated 02/06/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included Diabetes Mellitus (high blood sugar resulting from the body's inability to properly use insulin), Hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting left non-dominant side and cerebral infarction (loss of blood flow to part of the brain). Resident #50's BIMS score was 15, which indicated her cognition was intact. The MDS Section O - Special Treatments, Procedures, and Programs - Restorative Nursing Programs reflected resident was provided with the use of a splint. Record review of Resident #50's care plan dated 03/12/26, reflected the following: Problem/Strengths: Pain. Interventions: Use non-pharmacological pain interventions to assist with pain management (splint left hand, warm blankets for joint pain, reposition). Problem/Strengths: Limited range of motion upper extremity left hand related to contracture. Goals: Will maintain range of motion of as evidenced by place splint. Will improve range of motion. Interventions: Range of motion by staff. Observe for pain or increased stiffness. Problem/Strengths: Needs assistance with splint to left hand. Goals: Splint will be correctly applied per MD order. Apply splint on day shift for 6 hours per day. Remove splint on second shift. Record review of Resident #50's physician order, dated 09/10/25, reflected the following: Splint on Day Shift [Time: Shift 1] Left Hand Splint On 6 Hours Per Day for Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage . Monitor Skin Around Splint for Redness or Skin Breakdown. Start Date 09/10/25. Record review of Resident #50's April 2026 MAR revealed the splint was in place during the first shift on 04/07/26 and 04/08/26. Observation and interview on 04/07/26 at 10:47 AM, revealed Resident #50 in her room sitting in her wheelchair. Observed Resident #50's left hand to be contracted and she was not wearing her splint. Resident #50 was able to partially open her hand, with no observation of skin issues. Resident #50 gestured she had a splint but had not been asked to wear it. A hand splint was not observed in the room. Observation on 04/07/26 at 12:40 PM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 8:55 AM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 10:05 AM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 12:55 PM revealed Resident #50 did not have a splint on her left hand. Observation on 04/08/26 at 2:15 PM revealed Resident #50 did not have a splint on her left hand. Interview on 04/08/26 at 2:18 PM, RN D revealed Resident #50 had orders for the use of a splint. She stated it was the responsibility of the nurses or therapy to put the splint on Resident #50. RN D stated she had not attempted to put on the splint on Resident #50 today (04/08/26) or yesterday (04/07/26). She stated Resident #50 goes to therapy at around 10AM and therapy also puts on the splint. Observed RN D entered Resident #50's room and was searching for the resident's splint but was unable to locate it. RN D reviewed Resident #50's MAR and stated she documented at 12:38PM that resident had the splint on; however, she did not ask or attempt to place the splint on resident. She stated the potential risk of not putting on the hand splint would be resident having pain. Interview on 04/08/26 at 2:29 PM, Director of Rehab revealed Resident #50 was not receiving services from therapy. She stated Resident #50 was receiving services from Physical Therapy from 03/01/26 to 04/01/26 due to a fall. She stated Resident #50 had not been seen since 04/01/26. Director of Rehab stated Resident #50 had an order for the use of splint and it was the responsibility of Restorative Aide to put it on. Interview on 04/08/26 at 2:32 PM, Restorative Aide revealed she had not applied any hand splint to Resident #50 in months. She stated she was aware Resident #50 used to wear a splint, but she was not responsible for putting it on. She stated the last time she put on the splint was sometime last year 2025. Follow up interview on 04/08/26 at 3:16 PM, Director of Rehab revealed she was not aware Restorative Aide was not putting the splint on Resident #50. She stated if there was an order then it was the responsibility of the nurses to put the splint on Resident #50. Interview on 04/09/26 at 3:28 PM, ADON A revealed if there was an order for the use of a splint it was the responsibility of the nurses to put the splint on the resident. She stated it was a daily check off for the nurses on the MAR and should be applying the splint or attempting to. She stated the potential risk of not applying the splint could cause contractures to get worse. Interview on 04/09/26 at 4:39 PM, the DON revealed the nurses and CNAs were responsible for putting on hand splints. She stated her expectation was for the nurses to follow physician orders and apply the hand splint. She stated the potential risk of not applying the splint could cause contractures to get worse. Record review of the facility's Joint Mobility/Range of Motion Program and Splitting - Initiating of the Program policy, dated April 2012, reflected the following: Patients/residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes throughout the comprehensive nursing assessment. A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy.Appropriate candidates for the Nursing Restorative Splinting Program may include but are not limited to: Patients/Residents who require a progressive splint or brace wearing schedule in order to build up wearing tolerance. Patients/Residents requiring frequent checks for skin integrity.

Based on observation, interview, and record review, the facility failed to ensure, based on a resident's comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or the resident preferences indicated otherwise for of 1 of 6 residents (Resident #53) reviewed for nutrition. The facility failed to monitor Resident #53's weight when she gained 16 pounds in 20 days, while receiving all her nutrition via a feeding tube. This failure could place the residents at risk of weight loss/gain, and a decline in their physical condition. Findings included:Record review of Resident #53's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included diabetes, stroke (when blood flow to part of the brain is blocked or a blood vessel bursts, depriving brain tissue of oxygen) aphasia (language disorder caused by brain damage usually from a stroke or injury), hemiplegia (paralysis of one side of the body), and seizure disorder. The MDS reflected Resident #53's cognitive skills for daily decision making were severely impaired and had no speech. The MDS reflected the resident's weight at the time of the MDS was 144lbs and required a feeding tube due to coughing/choking during meals or when swallowing medications. Record review of Resident #53's care plan, dated 02/10/26, reflected the resident required total assistance with tube feeding. Interventions included to weigh per facility protocol with follow-up as indicated. Observation 04/7/26 at 11:43 AM of Resident #53 she was sitting in her geri-chair in the TV room. The resident was connected to a g-tube that was running at 82ml an hour. The resident was spoken to, and only made short eye contact but was not able to speak. The resident did not appear to be in any discomfort or distress. Record review of Resident #53's monthly physician orders for April 2026, revealed she was on Glucerna 1.2 Cal @ 82ml/hr enteral feeding (delivers liquid nutrition directly into the stomach) with a start date of 07/15/26. Record review of Resident #53's weights for the following dates reflected the following:03/03/26 - 146.4 pounds03/19/26 - 148 pounds03/25/26 - 152.6 pounds04/02/26 - 157.8 poundsObservation on 04/09/26 at 11:17 AM revealed Resident #52 was weighed via hoyer lift and the scale showed 164.6 poundsInterview on 04/09/26 at 11:19 AM, the RD revealed if the weights were correct then Resident #53 had a significant weight gain. The RD said Resident #53 had been stable the previous months and the last time she was the resident was on 03/22/26 but she did not pull the resident's weights. Interview on 04/09/26 at 12:45 PM, RN D revealed she cared for Resident #53, and no one had reported any weight gain to her nor had she noticed any weight gain on the resident. RN D said the Restorative Aide would obtain resident weights and then report inconsistencies to the ADONs or the DON. Interview on 04/09/26 at 12:49 PM, the Restorative Aide revealed she was responsible for getting resident weights and she said Resident #53 had been stable but noticed her weight increase in about the last month. The Restorative Aide said if she noticed weight variances she would report to the charge nurse. The Restorative Aide said she told the resident's previous nurse, but she did not recall the nurse's name, and she no longer worked at the facility. The Restorative Aide further stated she had not noticed any physical changes in the resident because of her weight gain. Interview on 04/09/26 at 2:05 PM, the RD revealed Resident #53 appeared to have a significant weight gain and did not know what caused it. The RD said she tried to make weekly visits to the facility, but no one reported weight concerns with Resident #53. The RD said that if weight concerns were noted they were to let the ADON know or she, the RD, could be contacted via email so she could assess and give recommendations. The RD further stated Resident #53 admitted with a weight of around 160lbs and did not think there were any risks with the resident's current weight. The RD said the resident's ideal weight according to her BMI would be around 130lbs plus or minus 10% . Interview on 04/09/26 at 3:42 PM, ADON A revealed the Restorative Aide got resident weights and if she were to notice a trend of loss or gain, she was to notify the charge nurse and the ADONs so they could notify the RD. ADON A said she was not over Resident #53's care and the other ADON was out of the state at the time. DON A said it was important to report any inconsistent weight changes so they could assess the cause of the loss or the gain of the resident. Interview on 04/09/26 at 3:54 PM, Resident #53's Family Member revealed they visited often. The Family Member stated they had not noticed any weight gain for Resident #53, and the resident had not appeared to be in any distress during their visits. Interview on 04/09/26 at 4:27 PM, the DON revealed she had only worked at the facility for a few days. She stated the Restorative Aide was responsible for resident weights, and if there was weight gain or loss, the Unit Managers needed to be notified. She stated the Uniter Managers could have the resident weighed again or the resident could be assessed for disease processes. She stated they would then make any necessary nutritional adjustments. The DON stated she was not aware of Resident #53's significant weight gain. Record review of the facility's Weight Monitoring policy, dated May 2023, reflected the following: PolicyResident weights will be recorded and monitored at a minimum frequency of monthly.c) If the weekly weights shows more than a two percent (2%) gain or loss, the resident is reweighed within (24) hours.f) If there is an actual weekly gain or loss of 2%, the resident/family, physician and the Registered Dietitian are notified but the Nursing Department.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 3 residents (Resident #9) reviewed for enteral feeding. 1. The facility failed to ensure RN G mixed each crushed medication with water and administered one medication at a time through Resident #9's g-tube.2. The facility failed to ensure RN G administered Resident #9's g-tube medication by gravity. These failures could place residents at increased risk of aspiration, bloating discomfort, and not receiving the full benefit of the medications administered.Findings included:Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female admitted [DATE] with diagnoses that included aphasia (language disorder resulting from damage to the brain), paraplegia (paralysis affecting the lower half of the body), malnutrition (when the body does not get enough nutrients), and respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body). Further review of the MDS revealed Resident #9 had unclear speech, was usually understood and usually understood others, was dependent for ADLs, and required a feeding tube, oxygen therapy, suctioning and tracheostomy care. Record review of Resident #9's Care Plan, dated 08/28/25, reflected the following:- hydration - gtube with goal of improve or maintain hydration and an intervention that included Gtube for all nutrition- enteral feeding with goal of nutritional needs will be met with no S/SX of aspiration with intervention that included administer feeding tube as orderedRecord review of Resident #9's physician orders reflected the following orders:- order date 07/01/2025 DIET: Order - NPO - order date 07/01/2025 Tube - Flush Order Every Shift [Time: Shift 1, Shift 2, Shift 3] Flush tube with min 30cc before and after feeding administration.- order date 06/27/2025 BACLOFEN 10 MG TABLET Gastrostomy Tube Three times a day 08:00 AM, 12:00 PM, 09:00 PM- order date 07/10/2025 OXYCODONE HCL 5 MG TABLET Pain, unspecified for Pain - Moderate Gastrostomy Tube Three times a day [Time: 08:00 AM, 12:00 PM, 09:00 PM]Observation and interview on 04/08/26 at 12:15 PM revealed RN G had just finished crushing medications at the cart and said she was going to administer baclofen and a pain pill to Resident #9. RN G donned a gown and mask and performed hand hygiene. RN G entered Resident #9's room, provided privacy, donned gloves and stated the baclofen and pain pill were due at 12:00 PM and she would change Resident #9's feed after giving the meds. RN G had placed 3 cups on the bedside table and said she mixed both crushed pills in 20 cc of water, and one cup had 30 cc and one had 45 cc of water to flush. RN G drew up water with the syringe and flushed Resident #9's tube with 30 cc of water, then used the syringe to draw up the medication mixture, connected the syringe and used the plunger to push the mixture down into the tube. RN G then removed the syringe, drew up some water from the other cup and put it in the cup that had the medication mixture, drew that up in the syringe, then connected the syringe back to the tubing and used the plunger to push the fluid down. RN G drew up the remaining water with the syringe, connected it back to the tube and pushed the plunger to flush, then removed the syringe. RN G stated with the last flush she used half of the water and put it back in the med cup to get all the medicine and then used the other half to flush afterwards. Interview on 04/09/26 at 9:22 AM, RN G stated she was trained on the floor to administer g-tube meds and had trained with Resident #9. She stated that Resident #9's meds and food was thick. She said knowing her particular patient, it would not have flowed with gravity and that was why she knew to push the medications with the syringe. She stated if she had not trained with Resident #9, she would have started with gravity. RN G stated if she were to administer by gravity, she would pour each med and flush with 10 cc of water and pour another, but since she was drawing up, she crushed the medications and mixed them with water, then combined them to get enough pressure to push through the tube. She stated there was no physician order to mix or push the meds and she used her nursing judgment. RN G said normally, if there was an issue it would specify not to mix them together. She stated there was no risk of mixing Oxycodone and baclofen together and there were no interactions between them. She said the most risk would be not giving all of the medication. She said since they were crushing them, it goes from the crush bag and to the cup and whatever was left in the crush bag and the cup was wasted. When asked if there was any risk of pushing the meds instead of using gravity, RN G stated only by pushing anything too fast. She said she mixed water and for example if it was 60mL she would put 10-15 mL at a time then take a break, that way it goes in slower. She said if the Resident was on the feeding pump at 60mL, the pump would be doing the same thing and she would not push a lot of fluid at one time because it could make the resident throw up, or cough. Interview on 04/09/26 at 12:28 PM, NP E stated when administering medications though g-tube it should be done by gravity. Interview on 04/09/26 at 3:19 PM, ADON A stated administering two medications at the same time was inappropriate and she started an in-service on the correct way to administer those medications. She said each pill should be separated and mixed, typically, with 30 mL of water and administered. ADON A stated g-tube medications should be administered by gravity. She said she would not push multiple medications through a syringe because it could get clogged, lessen the effect of the pain meds or there could be a reaction.Interview on 04/09/26 at 4:26 PM, the DON stated her expectation for staff administering medication through a g-tube was that no medications be mixed together and each medication should have their own cup. She stated staff were to flush the tube with water prior to giving the medication, with the syringe connected to the resident, put one medication in at a time and go with gravity and flush with water after the medication. She stated the medications should not be pushed with the syringe because it could irritate the gut and force air in. Record review of facility policy titled Medication Administration Enteral Tubes dated 2007, revealed the following: .10. Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose. The standard of practice is that crushed medications should not be combined and given all at once via feeding tube.12. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications.Procedures.2. Prepare medications for administration.b. Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in water.12. Remove plunger from syringe and insert syringe into tubing.14.c. Allow medication to flow down tube via gravity or per manufacturer's specifications.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 (Resident #56) of 6 residents reviewed for respiratory care, in that: The facility failed to obtain a physician order for Resident #56's use of supplemental oxygen.This deficient practice could affect residents who received oxygen therapy continuously placed residents at-risk for respiratory infection, and ineffective treatment.Findings included:Record review of Resident #56's quarterly MDS Assessment, dated 02/09/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Type 2 diabetes mellitus without complications (high blood sugar resulting from the body's inability to properly use insulin), Non-Alzheimer's Dementia (problems with memory and thinking), heart failure, hypertension (high blood pressure) and cancer. Resident #56's BIMS score was 09, which indicated moderate cognitive impairment. The MDS Section J - Health Condition reflected resident had shortness of breath or trouble breathing when lying flat. The MDS Section O - Special Treatments, Procedures, and Programs reflected the resident received oxygen therapy. Record review of Resident #56's care plan dated 03/17/26, revealed the care plan did not address the resident's oxygen use.Record review of Resident #56's physician orders, dated 01/28/26, reflected O2 SAT Check Every Shift [Time: Shift 1, Shift 2, Shift 3] Monitor resident for signs and symptoms of shortness of breath for Essential (primary) hypertension, Paroxysmal atrial fibrillation (a fast, irregular heartbeat), Heart failure, Need HOB elevated to avoid SOB while lying flat.Record review of Resident #56's physician orders, dated 04/05/26, reflected Oxygen Every Shift [Time: Shift 1, Shift 2, Shift 3] for Shortness of breath oxygen via nasal canula.Record review of Resident #56's physician orders, dated 04/06/26, reflected Oxygen wean off oxygen slowly for Shortness of breath. Maintain o2 > 90%. Physician orders did not address how much oxygen Resident #56 should be administered. Record review of Resident #56's April 2026 MAR revealed Resident #56's O2 sats were within normal limits.Observation and interview on 04/07/26 at 10:36 AM, revealed Resident #56 sitting in her room sitting in her wheelchair. Resident #56 was observed to have her oxygen on via nasal cannula. The oxygen concentrator was set at 1.5L. Resident #56 stated she was having a hard time breathing but that the nurse had just checked her oxygen levels and they were normal. Observation and interview on 04/07/26 at 1:03 PM, revealed Resident #56 in the hallway ambulating in her wheelchair. Resident #56 did not have her oxygen on. Resident #56 stated she was feeling better. She stated she used to always receive oxygen but recently oxygen was only provided as needed. Resident #56 stated she could not recall how much oxygen she should be receiving.Observation on 04/08/26 at 10:04 AM, revealed Resident #56 in bed sleeping. She was observed to be receiving oxygen, and it was set at 1.5L. No distress was noted. During an observation and interview on 04/08/26 at 10:20 AM, RN D revealed she was Resident #56's assigned nurse. She stated Resident #56 was receiving oxygen; however, the resident had been weaning off the oxygen. She stated Resident #56 was receiving 2 liters of oxygen per minute. RN D reviewed Resident #56's physician orders and stated the resident had orders for weaning off and to keep the resident's oxygen saturation levels above 90%. RN D stated Resident #56's physician orders did not indicate how much oxygen to administer. RN D stated when she reviewed the order to provide the oxygen to Resident #56, she had mistaken the Shift 2 on the order as to give 2 liters. RN D proceeded to enter Resident #56's room, and she looked at Resident #56's oxygen concentrator. She then adjusted oxygen concentrator to deliver 2 liters per minute. RN D stated it was set between 1.5 liters-2 liters. She stated she was not aware that the physician orders did not indicate how much oxygen to give. She stated it was the responsibility of the nurses to put in orders, and the ADON was responsible for reviewing the orders. She stated the potential risk of not having an order specifying how much oxygen to provide would be the resident not receiving the correct amount and could lead to death.Interview on 04/09/26 at 3:32 PM, ADON A revealed the charge nurses were responsible for putting orders in the system and the ADONs were to follow up to ensure the orders were correct. She stated for residents receiving oxygen the order should specify how many liters to provide. ADON A stated the potential risk of not having orders specifying the amount of oxygen to provide could lead to sats levels being off or poisoning if given too much. Interview on 04/09/26 at 4:31 PM, the DON revealed Resident #56 was receiving oxygen but only as needed and not continuous. She stated Resident #56 was being weaned off the oxygen; however, due to her age and diagnosis it would be best for the resident to be placed back on continuous. The DON stated her expectation was for Resident #56's oxygen orders to specify how many liters to administer even if resident was being weaned off from it. The DON stated she did not know the previous oxygen orders or the liters being administered to Resident #56 prior to being weaned off. The DON stated the potential risk of not having a physician order for administering oxygen could lead to death or if given too much could cause other adverse effects. Record review of the facility Applying an Oxygen Delivery Device policy, revised 01/12/2020, reflected the following: Staff will apply oxygen delivery devices in accordance with standard practice guidelines. Procedure: Validate physician orders.

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 #58) reviewed for dialysis.The facility failed to ensure post-dialysis assessments were completed for Resident #58. This failure could place residents at risk of inadequate post-dialysis care.Findings included:Record review of Resident #58's admission MDS Assessment, dated 01/01/26, reflected a [AGE] year-old male admitted [DATE]. Resident #58 had diagnoses which End-Stage Renal Disease, hypertension, heart failure, Diabetes Mellitus and hyperlipidemia. Resident #58's BIMS score was 15, which indicated his cognition was intact. The MDS Section O - Special Treatments, Procedures, and Programs reflected the resident received dialysis. Record review of Resident #58's care plan dated 03/19/26 reflected the following: Problem/Strengths: Dialysis. Goal: Improve or maintain current kidney function. Interventions: Dialysis as ordered [Name, address and number]. Check weight frequently and as ordered. Check shunt or access port for dialysis as ordered. Check my vital signs as ordered and as needed.Record review of Resident #58's physician order dated 8/21/25 reflected an order for Resident #58 to Dialysis Every Shift [Time: Shift 1, Shift 2, Shift 3] Monitor shunt/graft/fistula for S/X of infection and adequate circulation Dialysis on Monday and Fridays for Chronic kidney disease, unspecified.Record review of Resident #58's Dialysis Communication (Pre/Post) Dialysis forms dated 01/09/26, 01/16/26, 01/30/26, 02/09/26, 02/20/26, 03/06/26, 03/20/26, 03/23/26, 03/27/26 reflected there was no information documented on the resident assessment and observation post-dialysis sections.Interview on 04/07/26 at 11:02 AM, Resident #58 revealed he was a dialysis patient and would go to dialysis twice a week on Monday and Fridays. He stated his chair time was after lunch. Resident #58 stated he had not missed treatment. He stated he was provided with a form when he went to dialysis, and the dialysis staff documented his chair time. He stated staff would check his vitals before leaving for dialysis treatment but could not recall vitals checks upon return to the facility. Interview on 04/09/26 at 1:04 PM, RN D stated she was the nurse assigned to Resident #58. She stated Resident #58 was a dialysis resident and would go to dialysis twice a week on Mondays and Fridays. She stated Resident #58 left the facility for dialysis after lunch between 12:00 PM and 12:30PM. RN D stated she was not sure what time Resident #58 returned from dialysis. She stated when a resident went to dialysis it was the responsibility of the assigned nurse to provide the resident with a dialysis communication form and complete the pre-assessment prior to the resident going to dialysis. She stated she was responsible for completing the pre-dialysis assessment and the 2:00 PM-10:00 PM nurse was responsible for completing the post dialysis assessment. RN D stated the pre and post dialysis assessment were completed on the dialysis communication forms. RN D reviewed the dialysis communication forms and stated the post dialysis assessments were not completed. She stated monitoring vital signs were important. RN D stated the potential risk of not monitoring or documenting post-dialysis vitals was that it could lead resident to be unconscious or change in his well-being. Interview on 04/09/26 at 3:08 PM with LVN H revealed she was the nurse assigned to Resident #58; however, it was her first time working with him. She stated she had not admitted Resident #58 from dialysis. LVN H stated LVN I was his usual 2-10PM assigned nurse. Interview on 04/09/26 at 3:24 PM with ADON A revealed nursing staff were expected to complete pre- and post-vitals on residents who received dialysis. She stated Resident #58 was not her assigned resident. She stated it was the responsibility of the assigned nurse to complete the pre and post assessments and the responsibility of ADON J to ensure it was being completed. She stated ADON J was out on leave. She stated it was important to monitor vitals because the amount of liquid taken out during the dialysis process could affect the resident health. Interview on 04/09/26 at 4:36 PM with the DON revealed the assigned nurse was responsible for assessing vitals prior to resident going to dialysis and document in the system. She stated the assigned nurse should send the communication form with the resident, obtain the form upon return and complete the post vitals. She stated she was not aware Resident #58's dialysis communication forms were not being completed. She stated it was the responsibility of the nurses for completing the pre and post dialysis and the ADONs were responsible for reviewing the documentation thought audits. She stated the potential risk of not completing the post-assessments could lead to residual bleeding.An attempt was made to contact LVN I by phone on 04/09/26 at 4:44PM; however, there was no answer.Record review of the facility's Dialysis - Hemodialysis policy reviewed 04/14/23, reflected the following: Policy: Staff will ensure that residents who require dialysis receive such services consistent with standards of practice. 3. The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection forms as follows: a. EHR>Resident Data Collection>Dialysis b. Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center. c. Post Dialysis: Community nurse to complete Section B with dialysis center information. Community nurse to assess and complete Section C. d. Place document in the appropriate section of the medical record.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 medication carts (Hall 100 and 200 carts) reviewed for pharmacy services. The facility failed to ensure two boxes of fast acting 40% glucose gel, with an expiration date of April 2025, had been removed from the Hall 100 and 200 medication carts. This failure could place residents at risk of receiving medications that were ineffective. Findings included: Observation on 04/08/26 at 10:14 a.m., of the 100-hall medication cart with RN F revealed 1 unopened box of Fast Acting 40% Glucose Gel (concentrated, rapid absorption treatment for low blood sugar) with an expiration date of 04/2025. Observation on 04/08/26 at 10:26 a.m., of the 200-hall medication cart with RN G revealed 1 unopened box of Fast Acting 40% Glucose Gel, with an expiration date of 04/2025. Interview on 04/08/26 at 10:22 a.m., with RN F revealed it was her first day back after being on vacation. RN F stated the 40% Glucose Gel expired in 04/2025. She stated she was not sure where the Glucose Gel came from, but it was used to treat low blood sugar. RN F stated she checked her cart every shift for expired medications but had not done it yet that shift. She stated she did not recall previously seeing the glucose gel in her cart and had not used it. RN F stated it was all nurses' responsibility to check for expired medications. RN F stated the risk of having expired medications in the cart was it could be given to the resident and not function. RN F stated she had done training on checking for expired medications and reviewed the medications expiration date before they were administered to residents. During an interview on 04/08/26 at 10:31 a.m., with RN G, she opened the box of 40% Glucose Gel and stated the expiration date on both the box and bottle was April 2025. RN G stated she was not sure where the Glucose Gel came from or what it was. RN G stated the emergent diabetic medications were typically kept in their emergency kit, not in the carts. RN G stated her medication cart was checked throughout her shift, but she must have missed the expired Glucose Gel. She stated it was nurses' responsibility to ensure there were no expired medications in the carts. RN G stated the risk of having an expired medication on the cart was that it could be used and not work effectively. Interview on 04/09/26 at 11:56 a.m., with ADON A revealed the ADONs were responsible for ensuring there were no expired medications in the carts. ADON A stated she had worked at the facility for 4 weeks and had checked the cart once prior to this week. She stated the medication carts should be reviewed weekly by the ADONs. ADON A stated she did observe the glucose gel in the carts but did not see the expiration date. ADON A stated the medication aides and nurses should be reviewing the carts on their shifts. ADON A stated she had been getting everything more organized and educating the nurses. ADON A stated the risk of having an expired medication on the cart was it could be given and be ineffective. She stated the glucose gel was used to increase blood sugar and it could not function properly. ADON A stated the emergency blood sugar medications were not usually found in the medication carts. ADON A stated she was working on in-services and education to prevent expired medications from remaining in the medication carts. Interview on 04/09/26 at 12:05 p.m., with DON revealed she had worked at the facility for 4 full days. She stated the ADONs were overall responsible to ensure there were no expired medications, but the nurses and medication aides should also be reviewing the expiration dates on all their medications. The DON stated the pharmacist also came at least once a month to review and complete spot checks on the medication carts. The DON stated she was planning a thorough training with the ADONs because everyone was new to the facility. The DON stated the risk of having expired medications was that they could be given and cause a reaction or have no potency. The DON stated she would be putting audits in place, monitoring, and completing in-services for the staff to prevent further issues with expired medications. Interview on 04/09/26 at 12:11 p.m., the Regional Nurse Consultant revealed the Glucose gel was typically found in the emergency kit, so it must have been missed when medication carts were reviewed. The Regional Nurse Consultant stated the nurses were responsible for ensuring there were no expired medications in the medication carts and the ADONs oversee that. She also stated the pharmacist came monthly and did spot checks on the medication carts. The Regional Nurse Consultant stated the risk of having expired medications was that they could be given to the residents and not work to the full potential. She stated the Glucose Gel was used in emergency low blood sugar situations. Interview on 04/09/26 at 12:40 p.m., NP E revealed that no residents should be given any expired medications, and they should be removed from the medication carts. NP E stated the Glucose Gel was typically a standing order for all diabetic residents and used in situations where blood sugar was very low. She stated the glucose gel would not work properly if it expired in April of 2025. Record review of the facility's Medication Storage policy, revised January 2026, reflected the following: .14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #1 and Resident#2) of 4 residents reviewed for quality of care.1. The facility failed to ensure Residents #1 was being provided with oxygen on 03/05/26 at 02:02PM as per physician's orders. 2.The facility failed to ensure Resident #2 had physician's order in her chart for oxygen that was observed being provided on 03/05/26. This failure could place residents at risk of illness and respiratory complications.Findings included:1.Record review of Resident #1's entry MDS Assessment, dated 02/02/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4, and his diagnoses included Shortness of breath, and he was on continuous oxygen therapy.Record review of Resident #1's care plan dated 01/31/2026 reflected: Problem [Resident#1] Respiratory Diagnosis. Goals: Improve or maintain respiratory status. Interventions: Administer Oxygen as orderedRecord review of Resident #1's active physician's orders dated 02/01/20256 revealed oxygen at 2 LPM by NC every Shift for shortness of breath.Observation on 03/05/26 at 02:02PM revealed Resident #1 was lying in bed and not receiving oxygen. The tubing was observed covered with bedsheets and the oxygen concentrator was marked at 2 liters per minute and was actively running. The only staff that was near the resident was CNA B who was being observed for incontinent care.Observation and interview on 03/05/26 at 02:24PM with CNA B inside Resident#1 room revealed the tubing was covered with his bedsheets. CNA B stated she had not noticed he was not on oxygen, and Resident #1 was known for removing his canula from his nose, but she had not reported that to the nurse. She stated she knew he was supposed to be on continuous oxygen at 2 liters (of supplemental oxygen every minute.Interview on 03/05/26 at 03:31 PM with RN C revealed she was the nurse assigned to Resident #1. She stated Resident #1 had oxygen orders for continuous oxygen. She stated she was not aware he was not on oxygen, and she had not been to his room for hours. She stated it was nurses' responsibility to be checking on residents on oxygen to ensure they were getting oxygen. She stated the possible negative outcome for not receiving oxygen could be difficulty breathing.2. Record review of Resident #2's admission MDS assessment, dated 02/10/2026, indicated Resident #2 was an [AGE] year-old female, who originally admitted to the facility on [DATE] and readmitted on [DATE]. The assessment indicated Resident #2's BIMS score was 10, which indicated her cognition was moderately impaired. The assessment indicated Resident #2 had chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) and acute respiratory failure with hypoxia (condition where the body's tissues don't get enough oxygen to function properly) Record review of Resident #2 care plan, dated,1/22/26 indicated Problem: - Respiratory Diagnosis. Goal: Improve or maintain respiratory status. Interventions Administer Oxygen as ordered.Record review of Resident #88's physician order summary report, dated 03/05/26, did not indicate an active physician's order for oxygen use. Observation and interview on 03/05/26 at 12:30 PM revealed, Resident #2 was with a family member in the dining room with portable oxygen tank at zero liters per minute and the tubing was not connected on her. Interview with Resident#2 revealed she was on oxygen, and she received oxygen when provided by nurses. The family member stated she could not recall her mother on oxygen, and she came to visit her almost every day during lunch time.Observation on 03/05/26 at 01:43 PM revealed Resident#2 was on oxygen at 2 liters per minute.Interview and observation on 03/05/26 at 01:45PM PM with RN C revealed Resident #2 was on oxygen at 2 liters per minute, and she could not recall whether there was an order in her chart. She stated she did not see an order for Resident #2's oxygen use. RN C stated, there should be an order for oxygen, and Resident #2 should not be given oxygen without one. RN C stated nurses were responsible for ensuring resident orders were in chart and should match care provided. RN C stated she was the one that put residents on portable oxygen before leaving the room for therapy in the morning. RN C stated not having an order for oxygen placed Resident #2 at risk of further respiratory concerns and shortness of breath. Interview on 03/05/26 at 04:40PM with the [NAME] Nurse Coordinator revealed residents who received oxygen should have oxygen orders. She stated it was the responsibility of the charge nurse, or whoever applied oxygen, to ensure physician orders were obtained and put in the resident's chart. She stated the risk of administering oxygen without orders would be very low risk depending on resident status. The Regional Nurse Coordinator stated that all nurses were responsible for monitoring and evaluating residents on oxygen and administer oxygen. She stated the risk of not administering oxygen would be oxygen levels could drop, altered mental status, heart attacks, and a resident could go into distress.Record review of the facility's policy titled Oxygen Administration and dated October 2010 revealed the following: . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident.Record review of the facility's policy titled OXYGEN THERAPY, CONCENTRATOR - INITIATION revised January 12,2020 revealed the following: The licensed staff will provide the prescribed amount of oxygen therapy to the residents as prescribed by physician and according to practice guidelines.1. Review physicians' order for oxygen.13. Document in the eMAR/eTAR ordered oxygen therapy administration.

Based on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Residents #1) of 1 resident reviewed for quality of care.The facility failed to ensure Resident #1's Stage 4 pressure ulcer on his sacrum was covered with a dressing on 03/05/26.This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.Findings included:1.Record review of Resident #1's entry MDS Assessment, dated 02/02/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4, and his diagnoses included diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (hyperglycemia) due to insufficient insulin production (Type 1) or ineffective insulin use (Type 2 and the MDS reflected he had a Stage 4 pressure ulcers that was present upon admission/entry.Record review of Resident #1's care plan, dated 02/23/26, reflected: Problem: [Resident #1] has Stage 4 pressure ulcer of sacral. Goals: Pressure ulcers will show signs of healing and be free from infection. Interventions: - Treatment as ordered, monitor and report if ineffective.Record review of Resident #1's Physician orders, dated 02/20/26, reflected: - Cleanse sacrum and bilateral buttock stage 4 with wound cleanser, pat dry, apply Santyl and calcium alginate cover with dry dressing dailyRecord review of Resident #1's Progress Notes for March 2026 reflected there was no information related to his wound dressing not being there on 03/05/26.Review of treatment administration record on 03/05/26 revealed treatment was last administered on 03/03/26 before treatment was changed to Tuesday, Thursday and Saturday on 03/04/26. Observation and interview on 03/05/26 at 01:55PM revealed Resident #1 was lying in bed. Resident#1 stated he was doing well. Resident#1 stated he admitted to the facility with wounds on his sacrum. Observation on 03/05/26 at 02:02PM revealed CNA B was providing Resident #1 with incontinence care. She sanitized and put on Personal protective equipment (PPE) and explained the procedure to resident. She put all supplies together, washed her hands, and put on gloves. CNA B cleansed the resident's abdominal folds and the perineal using one wet wipe. She helped the resident to turn using the draw sheet. She cleansed the resident's buttocks. Resident was observed to have an open wound on his sacrum that was not covered and draining on the brief. She removed gloves washed hands, put on clean gloves, applied a clean brief, and left resident comfortable. She removed the PPE and washed her hands.Interview on 03/05/26 at 02:10 PM with CNA B revealed she was the CNA assigned to Resident #1. She stated she had provided incontinence care to Resident #1. She stated she noticed the resident's dressing was peeling off, and it had fecal matter on it, so she removed the dressing at 09 :30 AM. She stated she knew she was supposed to notify the nurse or the treatment nurse about the soiled dressing, which fell off, but she did not. She stated it slipped her mind, and she forgot to notify the nurse. She stated she was aware she was not allowed to remove dressings, and she knew she was supposed to call the nurse to come and replace the soiled and peeling dressing with clean dressing, but not for her to remove it. She stated Resident #1 did not complain of pain. She stated the risk of not having a dressing on would be infection and the wound getting bigger. She stated she had done training on calling the nurse if a dressing had become soiled and not to remove the dressing, but she could not recall when. Interview on 03/05/26 at 03:31PM with RN C, who was the charge nurse assigned to Resident#1, revealed she was not made aware that Resident #1's dressing had come off by CAN B while she provided incontinent care earlier that morning. She stated her expectation was for CNA B to report to her so that she could replace the soiled dressing with a clean dressing when she was performing incontinent care on Resident #1. She stated the risk of removing a dressing and not replacing it with a clean one, was infection. She stated she had done training on dressing changes, if soiled or dislodged but she could not tell when it was.Interview on 03/05/26 at 04:23PM with the Wound Care Nurse revealed Resident #1 had a physician's order to cleanse and cover the wound daily and an order for as needed in case the dressing got soiled or dislodged. She stated she was not made aware that Resident #1's dressing had come off. She stated when she completed wound care (03/03/26) on Resident #1, she had applied a dressing over it. She stated her expectations were for the nurses to monitor the dressing every shift and if the dressing came off, the resident had as needed treatment orders to follow. She stated her expectation was for CNA B to call her or the nurse to replace the soiled or dislodged dressing. She stated the potential risk of dressing falling off would be wound decline and infections. She stated she preferred the CNAs to notify the nurses, because if the wound was left open, the resident could have a bowel movement and that also would predispose Resident#1 to the risk of infection. She stated she had not provided staff with training since she was newly employed.Interview on 03/05/26 at 04:40 PM with the Regional Nurse Coordinator revealed Resident #1 should have had a dressing on his sacrum wound. The Regional Nurse Coordinator said all wound dressing orders was scheduled and PRN orders so that if the dressing were soiled during incontinent care, it could be replaced by the nurse on duty. The Regional Nurse Coordinator said the nurse on duty would have been responsible for replacing the dressing when CNA B noticed it was missing or soiled. The Regional Nurse Coordinator said the facility had trained staff on wound care and dressing changes, but no training records were provided as requested during the interview. Record review of the facility's treatment of wounds: dressing changes- performing (general information policy, dated July 2018, reflected: 8. Change the wound dressing if feces seep beneath the dressing

Based on interviews, and record review, the facility failed to inform the resident's physician, responsible party, and notify, consistent with his or her authority, when there was a change in condition for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in blood pressure was discovered for Resident #1. The physician was not made aware of the continuous low blood pressure vital checks until Resident #1 was being evaluated to be transferred to the hospital for an unrelated treatment. This deficient practice could place residents at risk of not having their physicians informed when there was a change in condition resulting in a delay in medical intervention and decline in health.Findings included: Record review of Resident #1's Care Plan, dated 12/01/25, revealed a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses of hypertension (high blood pressure), Arteriovenous fistula (abnormal connection between an artery and a vein), Benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous growth of the prostate gland, which can lead to urinary symptoms due to the pressure it exerts on the urethra), age related physical debility, and immune thrombocytopenic purpura (auto-immune disorder of low platelet counts). 11/22/2025 documented staff will notify physicians of any changes in condition. 11/24/2025 documented monitor vital signs as ordered and as needed. 11/24/2025 documented provide medications and treatments ordered for current cardiac status. Report results to doctor. Record review of Resident #1's Annual MDS Assessment, dated 11/25/2025, reflected Resident #1 had a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognitive function. Resident #1 had diagnosis of Anemia (Low level of red blood cells), Coronary Artery Disease (Narrowing of coronary arteries), Heart Failure, Hypertension (High blood pressure). Record review of Resident #1's Admissions Assessment, dated 11/23/2025, reflected diagnosis of history of pulmonary embolism (Stroke), and hypotension (Low blood pressure). Record review of Progress Note, dated 11/29/2025 at 11:22 AM reflected Resident #1's blood pressure was 85/59. Documented by Medication Aide E. Medications were held because Resident #1's blood pressure was too low to give medication. Record review of Progress Note, dated 11/29/2025 at 8:54 PM reflected Resident #1's blood pressure was 73/55. Documented by Medication Aide E. Medications were held because Resident #1's blood pressure was too low to give medication. Record review of Change in Condition inservice, dated 12/01/2025, reflected 31 care staff received training for a change in condition. Record review of Resident #1's electronic medical records dated 12/03/2025 reflected the following blood pressure vitals: 85/59 on 11/29/2025 at 11:22 AM, 85/59 on 11/29/2025 at 11:25 AM, 70/53 on 11/29/2025 at 1:40 PM, 73/55 on 11/29/2025 at 8:54 PM, 85/60 on 11/29/2025 at 8:57 PM, 86/60 on 11/29/2025 at 8:58 PM, 88/60 on 11/30/2025 at 1:59 AM, 62/50 on 11/30/2025 at 11:59 AM. Record review of Resident #1's electronic medical records dated 12/03/2025 reflected the following blood pressure vitals: 69/47 on 11/25/2025 at 8:35 PM, 69/47 on 11/25/2025 at 8:44 PM. Record review of Resident #1's electronic medical records dated 12/03/2025 reflected the following blood pressure vitals: 66/45 on 11/24/2025 at 8:07 PM, 66/45 on 11/24/2025 at 8:16 PM. Interview on 12/03/2025 at 12:30 PM with Physician C revealed that the facility did not notify the physician of the low blood pressure for Resident # that was discovered on 11/29/2025. The physician stated that blood pressure can affect internal organs if it stays low long enough. She stated it can cause chronic kidney failure. She stated that the low blood pressure could have been a sign of an underlying infection. She stated had she of known that his blood pressure was low on 11/29/2025 she would have informed the facility to send Resident #1 to the hospital for further evaluation. She stated it might not have been severe, but it would have been out of caution until. She stated that no matter what they should have informed the physician or nurse practitioner of consecutive low blood pressure readings that require the facility staff to withhold the low blood pressure medications. She stated that the facility should have notified her even with Resident #1's history of low blood pressure. She stated that the risk would be low, but necessary to consider so that residents can receive the proper care and monitoring earlier to prevent a more serious outcome. While discussing the change in conditions that occurred on 11/29/2025 and 11/30/2025 it was discovered that Resident #1 had other instances of low blood pressure readings that Physician C was not notified of. She stated that she also should have been notified of the low blood pressure readings on 11/24/2025 and 22/25/2025. Interview on 12/03/2025 at 1:00 PM with Director of Nursing B revealed that Resident #1 was taking midodrine 5mg tablets for low blood pressure. He had a history of low blood pressure and was to receive the low blood pressure medication every day to raise his blood pressure. If his blood pressure is low at the time of medication pass, he will not receive his blood pressure medication at that time. Director of Nursing G stated that Medication Aide E and RN F would have been the staff members that took vitals for Resident #1 on 11/29/2025 an 11/30/2025. She stated that she did not think this was a failure of them failing to follow their notification policy because Resident #1 had a history of low blood pressure and that the low blood pressure readings on 11/29/2025 to 11/30/2025 was his normal. Director of Nursing B was informed via telephone on 12/03/2025 at 1:10 PM by Nurse Practitioner G that the staff failed to notify Nurse Practitioner G or Physician C of the low blood pressure readings that began on 11/29/2025 and continued until 11/30/2025. Director of Nursing G stated that she would train the staff to make physician notifications for a resident change in vital conditions. Interview on 12/03/2025 at 1:10 PM with Nurse Practitioner G revealed that the facility staff did not notify her of Resident #1's low blood pressure readings on 11/29/2025. She stated that the facility staff should have contacted the physician's office to let them know that Resident #1 was having continuous low blood pressure readings and that his low blood pressure medication was being withheld. She stated that when she reviewed Resident #1's chart to determine whether or not he needed to be sent to the hospital for an unrelated event she discovered that his blood pressure had been consistently low for more than 24 hours. In an interview on 12/03/2025 at 2:00 PM, Administrator A stated that he understood that Medication Aide E and RN F should have notified Physician C of Resident #1's low blood pressure on 11/29/2025 prior to when Physician C discovered that Resident #1 had low blood pressure on 11/30/2025. Interview on 12/03/2025 at 2:30 PM with RN F was attempted. Voice Messages were left requesting a call back. Interview on 12/03/2025 at 2:44 PM with RN F was attempted. Voice Messages were left requesting a call back. Record review of the facility Change in Condition policy reflected The practitioner needs a detailed description of the patient's condition to determine whether a symptom is problematic or simply a normal or expected variant. 1.Changes in condition of the patient are determined by current and past medical conditions, medical orders, patient safety factors and/or by assessments. 1. Vital Signs As part of the interdisciplinary team, Certified Nursing Assistants (CNAs) and Certified Medication Technician (CMTs) are expected to report findings that might represent an acute change in condition. An acute change in condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Resident #1) of five residents reviewed for abuse. The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from sexual abuse. CNA A was observed, on a camera video footage, engaging in an inappropriate, sexual oriented activity with Resident #1 on 02/02/24. The noncompliance was identified as PNC. The IJ began on 02/02/24 and ended on 02/04/24. The facility had corrected the noncompliance before the survey began on 02/05/24. This failure placed residents at risk for serious injuries, abuse, and serious psychosocial harm. Findings included: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life], elevated blood pressure, and muscle weakness. Her BIMS score not assessed related to Resident #1 never understood. Functional status reflected Resident #1 was totally dependent and required assistance of 1 to 2 staff for toileting hygiene, shower, and personal hygiene. Bladder and bowel assessment reflected Resident #1 was always incontinent of bladder and bowel. Record review of Resident #1's Care Plan reflected the following: -Resident #1 had dementia evidenced by severe cognitive impairment and inability to communicate. Interventions: Offer resident two simple choices to reduce the stress of decision making and increase resident's sense of autonomy. Initiated on 08/17/21 and last revised on 02/05/24. -Resident #1 at risk for problems with elimination (bladder and bowel). Interventions: check resident every 2 hours and assist with toileting as needed, provide peri-care after each incontinent episode. Initiated on 8/17/21 and last revised on 02/05/24. Record review of Resident #1's Order Summary for February 2024 revealed: -Transfer to the hospital for evaluation and SANE exam with an order date of 02/03/2024. -Memantine tablet 5 mg, give 1 tablet by mouth two times a day for dementia with an order date of 08/17/2021. Review of the facility's Provider Investigation Report involving Resident #1 dated 02/04/24 reflected, .Incident date 02/02/24 at 6:50 PM revealed local PD reported that family member of roommate to Resident #1 had made an allegation of possible sexual abuse to resident #1 based on camera footage. Local PD came to the facility. Investigation initiated by PD and facility. Employee suspended. MD notified, Resident #1's family notified and came to the facility. DON assessed Resident #1 with RP present at the bedside. No destress or change in behavior noted upon assessment. Resident #1 was sent to the hospital for SANE exam, and she returned back to the facility with no new orders. Every shift observation put in place to monitor for any behavioral, cognitive changes. Resident #1 was seen by MD and Psychiatric with no new orders. Police initial request was to hold off on staff interviews until further directive. On 2/5/24 detectives arrived in the facility to continue investigation. At this time, permission was given to interview staff but advised we could not contact the accused. On 2/6/24, the PD disclosed to the Administrator that the Alleged Perpetrator had been arrested in connection with this allegation. Provider response included in-service on abuse/neglect completed, QAPI was held on 2/6/24, and resident safe survey was completed. The Investigation Summary revealed after reviewing the findings, it is summarized that the facility has confirmed that abuse occurred. Record review of a camera video footage, dated 02/02/2024 not timed, reflected CNA A removed Resident #1 brief. He moved Resident #1 to the edge of the middle of the bed. Resident #1 was lying on her back with legs extended in an upright position. CNA A was facing the resident in a standing position between the legs. CNA A was observed putting his hands on the shoulders of the resident to pull her closer to him. CNA A moved in a repetitive forward motion and the resident moving with the motion. The resident was heard making unintelligible sounds on the video. CNA A then placed the brief on the resident, repositioned her in the bed and left the room. Record review of Resident #1's nurses note dated 02/04/24 electronically signed at 08:52 AM revealed on 02/03/24 at 11:20 PM DON went to Resident #1 room with RP at the bed side. The DON did head to toe skin assessment with no open areas or concerns noted. Record review of Resident #1's pain risk assessment dated [DATE] reflected pain intensity of 0 Record review of Resident #1 medical record reflected Resident #1 was sent to the hospital on 02/03/24 at 11:45 PM Record review of Resident #1's emergency room Hospital Records, dated 02/04/24, reflected the following: [AGE] year-old female with past medical history of dementia presented to the emergency department for SANE exam. Visit Diagnosis: Abrasion of labia. Record review of Resident #1's hospital records dated 02/04/24 reflected the following: RN assisted SANE nursing in cleaning and changing Resident #1, rash visible around groin and genital area. Resident #1 seen scratching multiple times throughout process. Record review of Resident #1's hospital records dated 02/04/24 reflected Resident #1 was discharged from the hospital, on 02/04/24, back to the facility. In an interview on 02/05/24 at 10:15 AM, the Administrator stated the DON got the call from RN E on 02/03/24 at 9:50 PM, police officer in the facility. Around 9:30 to 10 PM he was in the building. The officer told him on the phone he had evidence of sexual potential assault. By the time Administrator got to the facility CNA A had already left. The officer would not share the video with the facility. The facility requested the video from Resident #1's roommate's family member. The facility notified Resident #1's RP. They were in the facility 15 - 20 min later. The DON went with the RP to Resident#1's room. Assessment reflected redness could be from the brief. Resident#1 transferred to Baylor [NAME] & with Medical Center. The facility talked to the RP on Sunday 02/03/24, she said at the hospital they did the exam at 4:00 AM on Sunday. Resident came back the same morning. The facility received the video on 02/04/24 at 12:56 PM In an interview on 02/05/24 at 11:21 AM, Resident #1's roommate's family member stated Resident #2 called her on the phone on 02/03/24 and told her she heard, last evening, sexual comments between Resident #1 and a CNA. The family member stated she looked at the camera, she observed inappropriate act from the CNA. She stated she took the camera footage to the police station. The officer watched the camera footage with other officers, and they went to the facility. In an interview on 02/05/24 at 12:46 PM, Detective C assigned to the case requested to hold off on staff interviews until further directive. On 2/5/24 at 2:35 PM, Detective C arrived in the facility to continue investigation. At this time, permission was given to interview staff, but he advised not to contact CNA A. On 02/05/24 at 2:40 PM, attempted to interview Resident #1, she responded illogically to most questions asked of her or did not respond at all. When attempted to discuss the recent sexual abuse allegation Resident #1 responded with unmeaningful words. On 02/05/24 at 2:45 PM, RN E stated he worked on 02/03/24 from 2 PM to 10 PM. RN E stated around 9:50 PM a police officer approached him and asked him about the manager. RN E called the DON. RN E did not know why the police where in the facility, he stated couple minutes later the DON, and the Administrator came to the facility. RN E stated he was not assigned to Resident #1. In an interview on 02/07/24 at 9:00 AM, Administrator stated, on an interview on 02/06/24, Detective C told him CNA A admitted he attempted to sexually assault Resident #1. He told him CNA A was arrested on 02/05/24. On 02/07/24 at 11:06 AM attempted to call Detective C; left message. Observation on 02/07/24 at 11:25 AM with CNA F who performed incontinent care for Resident #1 revealed redness to the left inner thigh at brief lining area. In an interview on 02/07/24 at 1:12 PM, Resident #1' RP stated the police department called her and informed her CNA A was arrested on 02/05/24 because he confessed to the sexual act. Review of CNA A's timesheets reflected he worked on 02/02/24 from 1:54 PM to 10:09 PM. Record review of Resident #1 psychiatric services note dated 02/06/24 revealed Resident #1 was seen for trauma/stressor related disorders, issues with trauma. The report stated Resident #1 was the recent victim of possible sexual assault. The report indicated Resident #1 was very confused with severe cognitive impairment. The document was signed by PA B Review CNA A's personal file reflected no barrier for employment: - Criminal history conviction name search on 12/19/22 - No search results found. - Nurse aide: NA certification status: Active. Certification number: NA0008319536. Issue date: 4/27/2005. Expiration: 6/12/2025 - Texas HHS Employability status check search results date 12/19/2022: Unemployable? NO. NAR status: Active. NAR active unemployable: NO. MAR status: Active. Incident on the EMR: NO - No result found for CNA A. Annual checklist: - Office of inspector general: 11/22/23 - DADS Employability status: 11/22/23 - DPS CCH Verification: 11/22/23 - Performance Evaluation: 11/20/23 - Compliance Code of Conduct Certification: 11/20/23 In-Services: Abuse - 10/13/23, Abuse - 12/20/22, Abuse - 12/1/23, Abuse - 1/26/24. In an interview on 02/07/24 at 1:17 PM, the Administrator revealed CNA A was suspended on 02/03/24 and terminated on 02/04/24. In an Interview on 02/07/24 at 1:25 PM, the DON stated she never got any complaint about CNA A. She stated some family members requested him to assist there loved one. She stated she watched the video, and it was disturbing. She stated all staff had been in serviced on abuse neglect before they start their shift. Review grievance log for last 3 months reflected no grievance about CNA A. An impromptu Quality Assurance and Performance Improvement was completed on 02/06/24 with the MD, Psych, Psychology, Administrator, DON, and Social Worker. Review of facility's in-services to nursing staff dated 02/03/24 to 02/05/24 reflected eleven nurses and twelve CNAs were in-serviced on Abuse and neglect reporting and prevention. Individual interviews with LVNs, RNs, CNAs, and MA from different shifts (LVN G, LVNH, LVN I, RN J, RN E, RN K, CNA L, CNA F, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, and MA S) on 02/05/24 and 02/07/24 revealed they had received in-service training on abuse and neglect. All staff were able to verbalize understanding of in-service training regarding abuse and sexual abuse. Review of the facility's policy titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property, dated 06/23/2017 and reviewed 02/12/2020 reflected, .1. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members Definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. On 02/07/24 at 4:40 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 02/02/24 to 02/04/24. The IJ was determined to have been removed on 02/04/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/05/24. On 02/08/24 at 2:30 PM, Detective D stated she was calling from Detective C's office. She stated they arrested CNA A on 02/25/24, and he was in jail. She stated, he admitted it. The detective was very short on the information she provided.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 24 residents (Residents #63 and #188) reviewed for pain management. 1. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #63 when she showed signs and symptoms of significant pain which was unrelieved by ordered Tylenol during wound care for her Stage 4 pressure wounds on 10/05/22. 2. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #188 when she complained of significant pain that woke her from sleep on 10/05/22. An immediate Jeopardy (IJ) situation was identified on 10/05/22. While the IJ was removed on 10/07/22 at 6:19 PM, the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures led to two residents experiencing significant pain and placed resident who require pain management at risk for significant pain. Findings include: 1. Record review of Resident #63's quarterly MDS, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. Section B reflected she had minimal difficulty hearing, unclear speech, rarely made herself understood, rarely understood others, and had moderately impaired vision. Her BIMS score was 0, which indicated a severe cognitive impairment. Her behavior assessment reflected she did not have hallucinations, delusions, or any other behavioral symptoms. The assessment of her functional status reflected she was totally dependent on one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #63 had an indwelling catheter and was always incontinent of bowel. Review of the pain management assessment reflected Resident #63 was unable to answer questions and in the previous 5 days the staff had not observed nor documented indicators of pain or possible pain. Review of Section M reflected Resident #62 was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. Further review reflected Resident #63 had five stage 4 pressure ulcers and three were present on admission or re-entry. Record review of the facility's wound report, dated 10/05/22, reflected Resident #63 had Stage 4 pressure wounds to her back, sacrum, and right toe. She had an unstageable pressure wound to her left toe, and trauma from a medical device to her right elbow and her left toe. Record review of Resident #63's order report, dated 10/05/22, reflected the following orders: 1. 03/09/22- Pain scale every shift. 2. 08/04/22- Tylenol 650 mg every 4 hours PRN for pain/temperature. 3. 10/05/22- Norco 5 mg/325 mg 1 tablet 1 time per day. 4. 10/05/22- Norco 5 mg/325 mg 1 tablet every 8 hours PRN for pain. Her diagnosis listed on the order report were metabolic encephalopathy (impaired brain function), Stage 4 sacral pressure ulcer (area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage), dehydration, dementia, legal blindness, restlessness, insomnia, depressive episodes, pain, generalized anxiety disorder, and schizophrenia. Record review of Resident #63's care plans, dated 10/05/22, reflected Resident #63 had a severe cognitive impairment related to dementia, a hearing deficit, a speech deficit, and a visual impairment. A care plan for pain with onset date of 03/09/22 was updated on 10/05/22 at 1:22 PM and reflected Resident #63 had chronic pain and the PAINAD scale would be used due to the resident's cognitive impairment. Interventions included: 1. Administer pain medications as ordered. 2. Analyze and document factors that precipitate pain and what may reduce it. 3. Non-pharmacological comfort measures: relaxation and repositioning. 4. Notify the physician of any changes in level or frequency of pain, any increase in use of PRN pain medications, and any noted side effects of pain medications. 5. Observe resident for signs of pain with care and interactions. 6. Provide rest periods to facilitate comfort, sleep, and relaxation. 7. Re-assess interventions with any changes in response to pain or pain medications and with every assessment. A care plan for behavioral changes was updated on 10/05/22 at 12:53 PM by RN F due the resident's previous living situation of known elderly abuse and the following goals and interventions were added on 10/05/22: 1. Receive culturally competent trauma-informed care to reduce triggers that may re-traumatize. 2. Analyze key times, places, circumstances, triggers, and was de-escalates behavior. 3. Complete residence life story in order to know the resident. 4. Cue the resident prior to care delivery. Use one step directions and a slow pace. 5. Decreased stimulation. 6. Remain non-judgmental. Be alert to changes in behavior. 7. Be aware of your proximity, ask before touching or hugging. 8. Focus on creating an atmosphere of trust. 9. Maintain respectful physical and emotional boundaries. Prior to 10/05/22, the interventions for trauma-informed care were promoting independence and personal choices and providing a pleasant and home-like environment. Record review of Resident #63's MARs from 06/01/22 to 10/05/22 reflected the following: 1. Order for Norco 5 mg/325 mg 1 tablet PRN every 6 hours of pain was ordered from 03/09/22 to 09/03/22 and administered for generalized pain on: 06/01/22, 06/03/22, 06/04/22, 06/07/22, 06/09/22, 06/13/22, 06/14/22, 06/15/22, 06/16/22, 06/17/22, 06/21/22, 06/22/22, 06/23/22, 06/24/22, 06/27/22, 06/28/22, 06/29/22, 06/30/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/12/22, 07/17/22, 07/19/22, 07/20/22, and 07/21/22. 2. Order for Tylenol 650 mg every 4 hours PRN Pain was started on 08/04/22 and administered on: 08/04/22, 08/08/22, 08/09/22, 09/25/22, 09/27/22, and 10/05/22. Record review of Resident #63's pain assessments from 06/01/22 to 10/05/22 reflected 4 pain assessments were documented during that time frame: 1. On 06/07/22 at 11:15 AM, LVN D documented Resident #63 had pain 6 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, tense body language, and was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with positioning and movement. LVN C documented she administered PRN Norco for pain. The pain was affective the resident's quality of life with ADLs, activities, ambulation and mobility. 2. On 09/05/22 at 1:05 PM, LVN C documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, relaxed body language, and there was no need to console. Activities and movement made the pain worse. LVN C documented she administered PRN Tylenol for pain. LVN C documented the pain was not affecting the resident's quality of life. 3. On 10/07/22 at 10:15 AM, the Wound Care Nurse documented a late entry from 10/05/22. He documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with movement. The Wound Care Nurse documented the pain was affecting the resident's quality of life with depression. 4. On 10/05/22 at 8:34 PM, LVN E documented Resident #63 had pain 4 of 10 using the PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain. LVN E documented the pain was not affecting the resident's quality of life. Record review of Resident #63 Daily Wound TARs from 06/01/22 to 10/04/22 documented signs of pain during wound care on 06/06/22 (4 of 10), 06/11/22 (5 of 10), and 06/12/22 (6 of 10) (interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain). An observation and interview on 10/05/22 at 9:45 AM revealed the Wound Care Nurse and the Staffing Nurse completed wound care on a Resident #63. Prior to the wound care, Resident #63 was smiling and said, Good morning. Resident #63 had four pressure wounds which required a wound treatment, three of which were stage 4 wounds and one which was an unstageable deep tissue injury (DTI). The Staffing Nurse and the Wound Care Nurse turned the resident onto her right side and the resident cried out, That hurts! The Wound Care Nurse proceeded to complete the wound care to the resident's sacrum and during the wound care the resident cried out twice, saying That hurts! That hurts! Both times, the Wound Care Nurse told her he was sorry and would try to be gentle but continued with the wound care. In addition to her verbal communication of pain, Resident #63 also displayed facial grimacing, intermittent rapid breathing when the Wound Care Nurse touched the wound to her sacrum and was tense and rigid. The Wound Care Nurse also asked Resident #63 if she was OK twice during the sacral wound care, and she did not give a verbal response. Once the Wound Care Nurse completed the wound care to Resident #63's sacrum, the Staffing Nurse turned the resident onto her back and the resident cried out, Oh no! Oh no! That hurts! The Wound Care Nurse told the Staffing Nurse he would need to turn Resident #63 onto her back to complete the wound care to her lower back. The State Surveyor intervened and asked the Wound Care Nurse if Resident #63 had been medicated for pain prior to wound care. The Wound Care Nurse stated he had assessed Resident #63 for pain prior to the wound care and the resident had complained of pain at a level of 4 out of 10. He said he notified Resident #63's nurse, LVN D, and asked her to give Resident #63 a medication for pain. The Wound Care Nurse stated he believed LVN D gave Resident #63 Tylenol 10 to 15 minutes ago (10/05/22 at 9:30 AM). The Staffing Nurse said Resident #63 would cry out every time she was turned. The State Surveyor asked the Staffing Nurse to check what Resident #63 had received for pain. The Staffing Nurse left the room. In an interview on 10/05/22 at 10:00 AM, the Staffing Nurse stated Resident #63 received Tylenol for pain 30 minutes ago, 10/05/22 at 9:30 AM. The Staffing Nurse said Resident #63 did not have anything else ordered for pain, and the State Surveyor intervened and asked if the doctor could be notified since it appeared the Tylenol was not effective in managing Resident #63's pain. The Staffing Nurse stated he would have LVN D call Resident #63's doctor. In an interview on 10/05/22 at 10:15 AM, Resident #63 was notified by the State Surveyor the nurse would call the doctor since she was still experiencing pain. Resident #63 stated, Please do. It's hurting. Resident #63 indicated she experienced pain to her back but was unable to provide a numerical level of pain on a scale of 1 to 10. In an interview with the DON on 10/05/22 at 1:00 PM, the DON said Resident #63 had a history of abuse and when touched she would moan. The DON said nurses were expected to differentiate between Resident #63's trauma response and pain by assessing their vital signs and body language. The DON stated signs of pain could include facial grimacing. The DON said if Resident #63 said That hurts, she would expect the nurse to give a medication for pain and if a pain medication was already given, the nurse should call the doctor. The DON said if Resident #63 said That hurt, during wound care, the nurse should have stopped and that was what the Wound Care Nurse told her he did that day (10/05/22). In a telephone interview with MD G on 10/05/22 at 1:10 PM, MD G said she was Resident #63's attending physician. MD G said she was not aware of Resident #63 experiencing pain that was not relieved by the ordered Tylenol. MD G said if she was notified of pain for a resident, she would typically order a consult for pain management with MD H. MD G said at times, the nurses would contact MD H directly to get a medication for pain ordered. MD G said because the wound care was important for Resident #63, it would be important that Resident #63 had a PRN medication for pain ordered so the wound care could be completed, and nurses were expected to call her or MD H to ask for a stronger pain medication if the ordered medication was not affective. In a telephone interview on 10/05/22 at 1:23 PM, MD H stated she was a physiatrist (medical doctor that specializes in the field of physical medicine and rehabilitation), and she also handled the pain management at the facility. MD H said she received a call on 10/05/22 from a facility nurse and stated she was told Resident #63's wound care could not proceed due to her pain. MD H said she re-ordered the Norco routinely to be given prior to wound care and told the nurse they needed to coordinate with the Wound Care Nurse to ensure the Norco was given in the morning prior to wound care. MD H said prior to 10/05/22 she had not been contacted about Resident #63's pain. MD H said when she visited Resident #63 in the past, she never complained of pain, was pleasantly confused, and would hold her hand and smile. MD H said she was also unaware of Resident #63 displaying signs of pain with movement. MD H said as Resident #63's wounds began to heal, the nerves could start to regenerate, and she could experience more pain and if she had been notified of the pain with wound care, she would have ordered Norco with wound care like she did when she was notified on 10/05/22. MD H said she had not followed Resident #63 since May 2022. In a telephone interview on 10/05/22 at 1:38 PM, MD I said she was the facility's wound physician. MD I said he observed Resident #63's wounds weekly and would perform wound care for Resident #63 with the Wound Care Nurse. MD I said the last time he observed Resident #63 was on 10/03/22. MD I said, one out of every few times, Resident #63 would moan during wound care, and said she was largely non-verbal. MD I said rarely would he need to take a break during the wound care for Resident #63 due to her signs of pain, and one or two times he had to stop wound care for Resident #63 due to her pain. MD I said the Wound Care Nurse was present when he stopped the wound care for Resident #63 due to her pain. MD I said aside from stopping the wound care, he would defer to the pain management physician as to what a nurse should do if a resident displayed signs of pain during wound care. In an interview on 10/05/22 at 4:10 PM, the Wound Care Nurse said he heard Resident #63 say Oh! Oh! I hurt! when he touched her backside during her sacral wound care on 10/05/22. He said his plan was to finish up the wound care. The Wound Care Nurse said Resident #63 hardly ever displayed signs of pain during wound care and she was, totally fine the majority of the time. The Wound Care Nurse said today, 10/05/22 was the first time in a while, Resident #63 displayed signs of pain during wound care. He said the last time Resident #63 displayed signs of pain during wound care was maybe in the summertime when her wounds were bad (Summer 2022). The Wound Care Nurse said Resident #63's wounds had started healing and were starting to granulate so her nerve endings may be starting to come back, and she may be in more pain than normal. The Wound Care Nurse said the signs of pain Resident #63 displayed while he was performing her sacral wound care on 10/05/22 he would not necessarily say were signs she was in pain, rather her displaying signs of past trauma. The Wound Care Nurse said he last received training on pain management, which included the different types of pain assessments, in August 2022. The Wound Care Nurse said he would have rated Resident #63's pain during the sacral wound care at a level 3 or 4 out of 10. The Wound Care Nurse said if Resident #63 had kept hollering, he would have rated her pain at maybe a 6 or 7 out of 10. The Wound Care Nurse said if Resident #63 would have screamed the roof off he would rate her pain at a level of 10 out of 10. The Wound Care Nurse said indicators of pain included yelling, grimacing, clutching, grabbing, holding, not wanting to turn, rubbing a specific area, or crying out. The Wound Care Nurse said if a resident displayed these signs of pain, he would assess the pain by asking the resident questions such as if the pain was sharp or how long they had it. The Wound Care Nurse said he would then tell the resident's nurse about the pain. The Wound Care Nurse said if a resident displayed signs of pain during wound care, he would not want to leave the wound open, so he would first finish the wound care. The Wound Care Nurse said he should not continue wound care, until the resident received pain medication and the resident was re-assessed for pain. The Wound Care Nurse said the signs Resident #63 displayed during the sacral wound care he performed on 10/05/22 were not signs of pain, he said they were signs of trauma from her past. The Wound Care Nurse said he could differentiate between Resident #63's pain and trauma symptoms because when it was trauma, she would say things like, I'm scared, or, daddy. The Wound Care Nurse said if given a chance to repeat the wound care he performed for Resident #63's sacral wound on 10/05/22 he would give her more time for the pain medication to kick in. The Wound Care Nurse said he should have waited and hour or so for the Tylenol to take effect. The Wound Care Nurse said MD I worked at the facility for 2 months and he was present when MD I assessed Resident #63's wounds. The Wound Care Nurse denied being present when the wound care for Resident #63 was stopped by MD I due to her pain. In an interview on 10/05/22 at 4:31 PM, the Staffing Nurse said he did not know what happened in Resident #63's past life because when she was turning onto her side she would cry out Oh, you're hurting me. The Staffing Nurse said he would be able to know if Resident #63 had pain based on her facial expressions and if she continued to cry out. The Staffing Nurse said Resident #63's pain should be assessed using the PAINAD scale. The Staffing Nurse said Resident #63 had pain during wound care on 10/05/22 and she said she was hurting. The Staffing Nurse said he would have rated her pain a 5 of 10 during sacral wound care on 10/05/22. The Staffing Nurse said if a resident showed signs of pain during care, staff should stop what they were doing and check orders for pain medications. The Staffing Nurse said if the resident was medicated for pain prior to care, that meant the medication was not working and the nurse needed to call the doctor. In a follow-up interview on 10/07/22 at 12:06 PM, the Staffing Nurse said Resident #63 would always cry out saying Ouch, don't hurt me. The Staffing Nurse said he did not work with Resident #63 often but noted, on at least 3 occasions, her crying when she was repositioned and she said, Don't hurt me. I'm hurting. The Staffing Nurse could not provide dates of the incidents and stated based on his nursing judgement he determined Resident #63 was not in pain. The Staffing Nurse said he never completed a PAINAD or any pain assessment for Resident #63, but he should have completed and documented a pain assessment if Resident #63 complained of hurting. In an interview and observation on 10/07/22 at 8:53 AM, LVN D said on 10/05/22, after her morning medication pass, the Wound Care Nurse asked her if she had already given Resident #63 pain medication and she told him, No. She said the Wound Care Nurse told her Resident #63 had complained of pain and she told him she would give Resident #63 Tylenol. LVN D said she had never been asked to give Resident #63 pain medications before wound care. LVN D said she had never observed wound care or incontinent care for Resident #63. LVN D said, in the past, Resident #63 had PRN Norco ordered and she would receive it every morning for pain. LVN D said she would assess Resident #63 for pain using the PAINAD scale when Resident #63 was moaning/groaning and had facial grimacing. LVN D said recently, Resident #63 complained of a headache, and she had given her Tylenol. LVN D said she did not know when or why the order for Resident #63's PRN Norco for pain was discontinued. LVN D said she had never been notified by the aides that Resident #63 had signs of pain. In an interview on 10/05/22 at 4:37 PM, CNA J said she regularly worked with Resident #63. She said Resident #63 would cry, but she did not think Resident #63 was in pain. CNA J said she believe crying was a reaction to someone touching her or being moved. CNA J said she thought Resident #63 had some discomfort with her contractures, and, normally cries out when she's being moved. 2. Record review of Resident #188's Admission Assessment, dated 09/27/22, reflected a female resident who was admitted to the facility on [DATE] at 6:20 PM from an acute care hospital. Resident #188 was alert and oriented to person, place, time, year, and month. She had a diagnosis which included acute and chronic pain. She wore hearing aids, her speech was clear, and she made herself understood. Resident #188's had diagnoses which included a history of falling, edema (swelling) , diabetes, and chronic kidney disease. The resident was able to report pain and denied pain. Resident #188's tolerable/acceptable pain level was 0 (0-10 scale). Record review of Resident #188's orders, dated 10/07/22, reflected she was an [AGE] year-old female. Her orders included: 1. 09/27/22- Pain scale every shift. 2. 10/05/22- Tylenol 650 mg every 6 hours PRN for moderate pain (4-6). 3. 10/06/22- Voltren Arthritis Pain gel 1%, 1 gel topically 3 times per day. Record review of Resident #188's MARs from 09/27/22 through 10/06/22, reflected she received PRN Tylenol for pain on: 09/29/22, 09/30/33, 10/01/22, 10/05/22, and 10/06/22. Record review of Resident #188's care plan, dated 10/07/22, reflected a care plan for pain initiated on 09/27/22. Interventions included: administering pain medications as ordered, analyzing and reducing factors that precipitated pain, assessing characteristics of pain, encouraging the resident to attend activities and exercise, giving pain medications before the pain became severe, non-pharmacological pain measures of relaxation/rest, notifying the physician of any changes in level or frequency of pain or any increase in use of PRN pain medications, observing the resident for signs of pain with care and interactions. Record review of Resident #188's PT evaluation on 09/28/22 reflected she was assessed for pain and verbalized a pain level of 8/10 (severe pain) to her left lower extremity at rest and with movement. Her pain caused a decrease in activity tolerance and participation. Prolonged activity worsened the pain and remaining still relieved the pain. Record review of Resident #188's PT notes from 09/28/22 to 10/06/22 reflected on 09/28/22 and 10/04/22 Resident #188 had pain. A numerical pain level was not documented. In an interview and observation on 10/05/22 at 6:52 AM, revealed Resident #188 told LVN A she had pain in her right shoulder. She stated she told the overnight nurse at 3:30 AM but the night nurse had not done anything and walked out of her room. Resident #188 rated her pain an 8 to 9 out of 10. LVN A gave Resident #188 Tylenol 650 mg for her pain. In interview and observation on 10/05/22 at 2:50 PM, revealed Resident #188 was lying in bed, awake and alert. She said she had pain which woke her up on 10/05/22 at 3:30 AM, pressed her call light, and told the nurse about her pain. She said the nurse did not do anything and walked out of the room. The resident could not identify the nurse. Resident #188 said the Tylenol she received from LVN A that morning (10/05/22 at 6:52 AM) was somewhat effective and rated the pain to her shoulder a 5 or 6 out of 10. Resident #188 said LVN A did not re-assess her pain after he administered the Tylenol. Resident #188 said she had bursitis (painful condition that affects the small, fluid-filled sacs - called bursae (bur-SEE) - that cushion the bones, tendons and muscles near your joints. Bursitis occurs when bursae become inflamed) to her right shoulder which caused her pain. She said it made working with therapy at the facility difficult. A telephone interview with LVN R who worked overnight on 10/04/22 into 10/05/22 was attempted on 10/07/22 1:04 PM and 3:21 PM, but contact was unsuccessful. A telephone interview with LVN S who worked overnight on 10/04/22 into 10/05/22 was attempted on 10/07/22 at 1:11 PM and 3:24 PM, but contact was unsuccessful. Record review of the facility's policy titled Treatment of Wounds: Dressing Changes, dated 07/2018, reflected the policy did not address pain management during wound dressing changes. Record review of the facility's policy titled Pain Management and Basic Comfort Measures, dated 01/12/20, reflected, . Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines . Procedure: Identify the resident. Ask the resident if he or she is in pain. Perform hand hygiene if appropriate. Examine the site of the patient's pain, which may include subjective and objective data collection measures. Evaluate the resident's medical history . Provide pain medication as prescribed . Evaluate for analgesic [pain medication] side effects and pharmacological/ non-pharmacological effectiveness . Observe for unresolved pain and address per physician's orders. Record pain management techniques in the record . The policy did not address pain assessments in residents who were non-verbal or had a cognitive impairment. Record review of the Pain Assessment in Advanced Dementia (PAINAD) pain scale on 10/12/22 at https://geriatricpain.org/sites/geriatricpain.org/files/2020-06/PAINAD.pdf reflected the assessment for pain was based on the following factors: breathing, negative vocalizations (moan, groaning, calling out, crying), facial expressions (smiling, inexpressive, sad, frowning, facial grimacing), body language (relaxed, tense, rigid, pulling or pushing away), and consolability (no need to console, distracted or reassured by voice or touch, or unable to console, distract or reassure). The total scores ranged from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain. Instructions included: Observe the older person both at rest and during activity/with movement. For each of the items included in the PAINAD, select the score (0, 1, or 2) that reflects the current state of the person's behavior. Add the score for each item to achieve a total score. Monitor changes in the total score over time and in response to treatment to determine changes in pain. Higher scores suggest greater pain severity. Note: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and report from an individual knowledgeable of the person and their pain behaviors. Remember that some individuals may not demonstrate obvious pain behaviors or cues. This was determined to be an Immediate Jeopardy (IJ) on 10/05/22 at 5:40 PM. The ADM and the DON were notified. The ADM and the DON were provided with the IJ template on 10/05/22 at 5:40 PM. The following Plan of Removal submitted by the facility was accepted on 10/06/22 at 4:40 PM and reflected: Date: 10/05/2022 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY For F697 To Whom it may concern, Summary of Details which lead to outcomes On 10/5/2022, during annual survey initiated at [Facility Name/Address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F697 The notification of the alleged immediate jeopardy states as follows: The facility failed to assess, provide effective pain treatment, and address pain promptly for two residents with significant pain, Resident #63 and Resident #188. What corrective action will be taken for those residents found to have been affected by the deficient practice: [Resident #63] was immediately assessed by 6-2 LVN charge nurse for any concerns of unrelieved pain or distress following wound care. Clinical staff were educated regarding pain at 6:30 PM. Follow up pain assessment in advanced dementia (PAINAD) was conducted at 8 PM by MDS Nurse Manager. Tylenol 325 mg tablets, 2 tablets by mouth every 4 hours as needed prn for pain or [temperature) Original order date 8/4/22 and remains a current order An additional order for hydrocodone 5/325 was received and given to the resident prior to completion of remainder of her wound care. Pain Management MD notified at 10:08 AM of potential pain during wound care for [Resident #63] with new order received for hydrocodone 5/325mg given on 10/5/2022. Pain was reassessed as being effective on 10/5/22 at 11:10 AM by 6-2 LVN. 'Resident sleeping with eyes closed. No signs of distress noted.' [Resident #63] showed no further signs of pain post wound care upon assessment by ADON on 10/5/2022. [Resident # 188] was immediately assessed for any unrelieved pain with no further complaints upon assessment by ADON on 10/5/2022. Physician notified of residents 5/10 pain after Tylenol administered. Voltren Gel 1% three times a day (T.I.D.) to right shoulder. was ordered 10/6/22, and a telemedicine visit was conducted by primary physician to discuss residents' treatment plan. How other residents with the potential to be affected by the same deficient practice will be identified; Residents experiencing pain have the potential to be affected What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; The Administrator/Director of Nursing/Assistant Director of Nursing have received Training by the Regional Nurse Consultant on 10/5/2022 on: Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Change of Condition (acute) InterAct 4.5 Stop and Watch Early Warning System, Policy on how to review pain management and physician notification in Facility Daily Clinical Morning meeting. Policy on how to review pain management and physician notification in the Weekly Interdisciplinary Team Meeting Wound Care nurse and LVN A In-service was conducted by DON/Designee on 10/05/2022 on Integrative Approaches for pain management with post-test to include proper notifications to MD with documentation including any follow up post medication administration. Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Stop and Watch Early Warning System InterAct 4.5 Change of Condition (acute) To include signs and symptoms of pain. Subjectivity of pain for residents able to verbalize pain. Objectivity of pain for residents who are unable to verbalize pain by use of Pain in Advanced Dementia patients (PAINAD). Residents tolerable pain level Assure pain medication, if ordered, has been administered prior to treatment Immediately stop if resident has any complaint of pain. Notification to physician if additional pain medication is needed. Participation and Policy on how to review pain management and physician notification in Facility Da [TRUNCATED]

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representatives when there was a significant change in the resident's physical, mental, or psychosocial status and a need for 1 (Resident #63) of 5 residents reviewed for physician notification. The facility failed to immediately notify Resident #63's attending physician when she had significant pain which was unrelieved by ordered Tylenol. An immediate Jeopardy (IJ) situation was identified on 10/05/22 at 5:40 PM. The DON and the ADM were notified, the IJ template was provided, and a POR was requested. While the IJ was removed on 10/07/22 at 6:19 PM, the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure led to one resident experiencing significant pain and placed residents who had a significant change and a need to alter treatment significantly at risk for not receiving appropriate, timely treatment. Findings include: Record review of Resident #63's quarterly MDS, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. Section B reflected she had minimal difficulty hearing, unclear speech, rarely made herself understood, rarely understood others, and had moderately impaired vision. Her BIMS score was 0, which indicated a severe cognitive impairment. Her behavior assessment reflected she did not have hallucinations, delusions, or any other behavioral symptoms. The assessment of her functional status reflected she was totally dependent on one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #63 had an indwelling catheter and was always incontinent of bowel. Review of the pain management assessment reflected Resident #63 was unable to answer questions and in the previous 5 days the staff had not observed nor documented indicators of pain or possible pain. Review of Section M reflected Resident #62 was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. Further review reflected Resident #63 had five stage 4 pressure ulcers and three were present on admission or re-entry. Record review of the facility's wound report, dated 10/05/22, reflected Resident #63 had Stage 4 pressure wounds to her back, sacrum, and right toe. She had an unstageable pressure wound to her left toe, and trauma from a medical device to her right elbow and her left toe. Record review of Resident #63's order report, dated 10/05/22, reflected the following orders: 1. 03/09/22- Pain scale every shift. 2. 08/04/22- Tylenol 650 mg every 4 hours PRN for pain/temperature. 3. 10/05/22- Norco 5 mg/325 mg 1 tablet 1 time per day. 4. 10/05/22- Norco 5 mg/325 mg 1 tablet every 8 hours PRN for pain. Her diagnosis listed on the order report were metabolic encephalopathy (impaired brain function), Stage 4 sacral pressure ulcer (area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage), dehydration, dementia, legal blindness, restlessness, insomnia, depressive episodes, pain, generalized anxiety disorder, and schizophrenia. Record review of Resident #63's care plans, dated 10/05/22, reflected Resident #63 had a severe cognitive impairment related to dementia, a hearing deficit, a speech deficit, and a visual impairment. A care plan for pain with onset date of 03/09/22 was updated on 10/05/22 at 1:22 PM and reflected Resident #63 had chronic pain and the PAINAD scale would be used due to the resident's cognitive impairment. Interventions included: 1. Administer pain medications as ordered. 2. Analyze and document factors that precipitate pain and what may reduce it. 3. Non-pharmacological comfort measures: relaxation and repositioning. 4. Notify the physician of any changes in level or frequency of pain, any increase in use of PRN pain medications, and any noted side effects of pain medications. 5. Observe resident for signs of pain with care and interactions. 6. Provide rest periods to facilitate comfort, sleep, and relaxation. 7. Re-assess interventions with any changes in response to pain or pain medications and with every assessment. A care plan for behavioral changes was updated on 10/05/22 at 12:53 PM by RN F due the resident's previous living situation of known elderly abuse and the following goals and interventions were added on 10/05/22: 1. Receive culturally competent trauma-informed care to reduce triggers that may re-traumatize. 2. Analyze key times, places, circumstances, triggers, and was de-escalates behavior. 3. Complete residence life story in order to know the resident. 4. Cue the resident prior to care delivery. Use one step directions and a slow pace. 5. Decreased stimulation. 6. Remain non-judgmental. Be alert to changes in behavior. 7. Be aware of your proximity, ask before touching or hugging. 8. Focus on creating an atmosphere of trust. 9. Maintain respectful physical and emotional boundaries. Prior to 10/05/22, the interventions for trauma-informed care were promoting independence and personal choices and providing a pleasant and home-like environment. Record review of Resident #63's MARs from 06/01/22 to 10/05/22 reflected the following: 1. Order for Norco 5 mg/325 mg 1 tablet PRN every 6 hours of pain was ordered from 03/09/22 to 09/03/22 and administered for generalized pain on: 06/01/22, 06/03/22, 06/04/22, 06/07/22, 06/09/22, 06/13/22, 06/14/22, 06/15/22, 06/16/22, 06/17/22, 06/21/22, 06/22/22, 06/23/22, 06/24/22, 06/27/22, 06/28/22, 06/29/22, 06/30/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/12/22, 07/17/22, 07/19/22, 07/20/22, and 07/21/22. 2. Order for Tylenol 650 mg every 4 hours PRN Pain was started on 08/04/22 and administered on: 08/04/22, 08/08/22, 08/09/22, 09/25/22, 09/27/22, and 10/05/22. Record review of Resident #63's pain assessments from 06/01/22 to 10/05/22 reflected 4 pain assessments were documented during that time frame: 1. On 06/07/22 at 11:15 AM, LVN D documented Resident #63 had pain 6 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, tense body language, and was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with positioning and movement. LVN C documented she administered PRN Norco for pain. The pain was affective the resident's quality of life with ADLs, activities, ambulation and mobility. 2. On 09/05/22 at 1:05 PM, LVN C documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, relaxed body language, and there was no need to console. Activities and movement made the pain worse. LVN C documented she administered PRN Tylenol for pain. LVN C documented the pain was not affecting the resident's quality of life. 3. On 10/07/22 at 10:15 AM, the Wound Care Nurse documented a late entry from 10/05/22. He documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with movement. The Wound Care Nurse documented the pain was affecting the resident's quality of life with depression. 4. On 10/05/22 at 8:34 PM, LVN E documented Resident #63 had pain 4 of 10 using the PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain. LVN E documented the pain was not affecting the resident's quality of life. Record review of Resident #63 Daily Wound TARs from 06/01/22 to 10/04/22 documented signs of pain during wound care on 06/06/22 (4 of 10), 06/11/22 (5 of 10), and 06/12/22 (6 of 10) (interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain). An observation and interview on 10/05/22 at 9:45 AM revealed the Wound Care Nurse and the Staffing Nurse completed wound care on a Resident #63. Prior to the wound care, Resident #63 was smiling and said, Good morning. Resident #63 had four pressure wounds which required a wound treatment, three of which were stage 4 wounds and one which was an unstageable deep tissue injury (DTI). The Staffing Nurse and the Wound Care Nurse turned the resident onto her right side and the resident cried out, That hurts! The Wound Care Nurse proceeded to complete the wound care to the resident's sacrum and during the wound care the resident cried out twice, saying That hurts! That hurts! Both times, the Wound Care Nurse told her he was sorry and would try to be gentle but continued with the wound care. In addition to her verbal communication of pain, Resident #63 also displayed facial grimacing, intermittent rapid breathing when the Wound Care Nurse touched the wound to her sacrum and was tense and rigid. The Wound Care Nurse also asked Resident #63 if she was OK twice during the sacral wound care, and she did not give a verbal response. Once the Wound Care Nurse completed the wound care to Resident #63's sacrum, the Staffing Nurse turned the resident onto her back and the resident cried out, Oh no! Oh no! That hurts! The Wound Care Nurse told the Staffing Nurse he would need to turn Resident #63 onto her back to complete the wound care to her lower back. The State Surveyor intervened and asked the Wound Care Nurse if Resident #63 had been medicated for pain prior to wound care. The Wound Care Nurse stated he had assessed Resident #63 for pain prior to the wound care and the resident had complained of pain at a level of 4 out of 10. He said he notified Resident #63's nurse, LVN D, and asked her to give Resident #63 a medication for pain. The Wound Care Nurse stated he believed LVN D gave Resident #63 Tylenol 10 to 15 minutes ago (10/05/22 at 9:30 AM). The Staffing Nurse said Resident #63 would cry out every time she was turned. The State Surveyor asked the Staffing Nurse to check what Resident #63 had received for pain. The Staffing Nurse left the room. In an interview on 10/05/22 at 10:00 AM, the Staffing Nurse stated Resident #63 received Tylenol for pain 30 minutes ago, 10/05/22 at 9:30 AM. The Staffing Nurse said Resident #63 did not have anything else ordered for pain, and the State Surveyor intervened and asked if the doctor could be notified since it appeared the Tylenol was not effective in managing Resident #63's pain. The Staffing Nurse stated he would have LVN D call Resident #63's doctor. In an interview on 10/05/22 at 10:15 AM, Resident #63 was notified by the State Surveyor the nurse would call the doctor since she was still experiencing pain. Resident #63 stated, Please do. It's hurting. Resident #63 indicated she experienced pain to her back but was unable to provide a numerical level of pain on a scale of 1 to 10. In an interview with the DON on 10/05/22 at 1:00 PM, the DON said Resident #63 had a history of abuse and when touched she would moan. The DON said nurses were expected to differentiate between Resident #63's trauma response and pain by assessing their vital signs and body language. The DON stated signs of pain could include facial grimacing. The DON said if Resident #63 said That hurts, she would expect the nurse to give a medication for pain and if a pain medication was already given, the nurse should call the doctor. The DON said if Resident #63 said That hurt, during wound care, the nurse should have stopped and that was what the Wound Care Nurse told her he did that day (10/05/22). In a telephone interview with MD G on 10/05/22 at 1:10 PM, MD G said she was Resident #63's attending physician. MD G said she was not aware of Resident #63 experiencing pain that was not relieved by the ordered Tylenol. MD G said if she was notified of pain for a resident, she would typically order a consult for pain management with MD H. MD G said at times, the nurses would contact MD H directly to get a medication for pain ordered. MD G said because the wound care was important for Resident #63, it would be important that Resident #63 had a PRN medication for pain ordered so the wound care could be completed, and nurses were expected to call her or MD H to ask for a stronger pain medication if the ordered medication was not affective. In a telephone interview on 10/05/22 at 1:23 PM, MD H stated she was a physiatrist (medical doctor that specializes in the field of physical medicine and rehabilitation), and she also handled the pain management at the facility. MD H said she received a call on 10/05/22 from a facility nurse and stated she was told Resident #63's wound care could not proceed due to her pain. MD H said she re-ordered the Norco routinely to be given prior to wound care and told the nurse they needed to coordinate with the Wound Care Nurse to ensure the Norco was given in the morning prior to wound care. MD H said prior to 10/05/22 she had not been contacted about Resident #63's pain. MD H said when she visited Resident #63 in the past, she never complained of pain, was pleasantly confused, and would hold her hand and smile. MD H said she was also unaware of Resident #63 displaying signs of pain with movement. MD H said as Resident #63's wounds began to heal, the nerves could start to regenerate, and she could experience more pain and if she had been notified of the pain with wound care, she would have ordered Norco with wound care like she did when she was notified on 10/05/22. MD H said she had not followed Resident #63 since May 2022. In a telephone interview on 10/05/22 at 1:38 PM, MD I said she was the facility's wound physician. MD I said he observed Resident #63's wounds weekly and would perform wound care for Resident #63 with the Wound Care Nurse. MD I said the last time he observed Resident #63 was on 10/03/22. MD I said, one out of every few times, Resident #63 would moan during wound care, and said she was largely non-verbal. MD I said rarely would he need to take a break during the wound care for Resident #63 due to her signs of pain, and one or two times he had to stop wound care for Resident #63 due to her pain. MD I said the Wound Care Nurse was present when he stopped the wound care for Resident #63 due to her pain. MD I said aside from stopping the wound care, he would defer to the pain management physician as to what a nurse should do if a resident displayed signs of pain during wound care. In an interview on 10/05/22 at 4:10 PM, the Wound Care Nurse said he heard Resident #63 say Oh! Oh! I hurt! when he touched her backside during her sacral wound care on 10/05/22. He said his plan was to finish up the wound care. The Wound Care Nurse said Resident #63 hardly ever displayed signs of pain during wound care and she was, totally fine the majority of the time. The Wound Care Nurse said today, 10/05/22 was the first time in a while, Resident #63 displayed signs of pain during wound care. He said the last time Resident #63 displayed signs of pain during wound care was maybe in the summertime when her wounds were bad (Summer 2022). The Wound Care Nurse said Resident #63's wounds had started healing and were starting to granulate so her nerve endings may be starting to come back, and she may be in more pain than normal. The Wound Care Nurse said the signs of pain Resident #63 displayed while he was performing her sacral wound care on 10/05/22 he would not necessarily say were signs she was in pain, rather her displaying signs of past trauma. The Wound Care Nurse said he last received training on pain management, which included the different types of pain assessments, in August 2022. The Wound Care Nurse said he would have rated Resident #63's pain during the sacral wound care at a level 3 or 4 out of 10. The Wound Care Nurse said if Resident #63 had kept hollering, he would have rated her pain at maybe a 6 or 7 out of 10. The Wound Care Nurse said if Resident #63 would have screamed the roof off he would rate her pain at a level of 10 out of 10. The Wound Care Nurse said indicators of pain included yelling, grimacing, clutching, grabbing, holding, not wanting to turn, rubbing a specific area, or crying out. The Wound Care Nurse said if a resident displayed these signs of pain, he would assess the pain by asking the resident questions such as if the pain was sharp or how long they had it. The Wound Care Nurse said he would then tell the resident's nurse about the pain. The Wound Care Nurse said if a resident displayed signs of pain during wound care, he would not want to leave the wound open, so he would first finish the wound care. The Wound Care Nurse said he should not continue wound care, until the resident received pain medication and the resident was re-assessed for pain. The Wound Care Nurse said the signs Resident #63 displayed during the sacral wound care he performed on 10/05/22 were not signs of pain, he said they were signs of trauma from her past. The Wound Care Nurse said he could differentiate between Resident #63's pain and trauma symptoms because when it was trauma, she would say things like, I'm scared, or, daddy. The Wound Care Nurse said if given a chance to repeat the wound care he performed for Resident #63's sacral wound on 10/05/22 he would give her more time for the pain medication to kick in. The Wound Care Nurse said he should have waited and hour or so for the Tylenol to take effect. The Wound Care Nurse said MD I worked at the facility for 2 months and he was present when MD I assessed Resident #63's wounds. The Wound Care Nurse denied being present when the wound care for Resident #63 was stopped by MD I due to her pain. In an interview on 10/05/22 at 4:31 PM, the Staffing Nurse said he did not know what happened in Resident #63's past life because when she was turning onto her side she would cry out Oh, you're hurting me. The Staffing Nurse said he would be able to know if Resident #63 had pain based on her facial expressions and if she continued to cry out. The Staffing Nurse said Resident #63's pain should be assessed using the PAINAD scale. The Staffing Nurse said Resident #63 had pain during wound care on 10/05/22 and she said she was hurting. The Staffing Nurse said he would have rated her pain a 5 of 10 during sacral wound care on 10/05/22. The Staffing Nurse said if a resident showed signs of pain during care, staff should stop what they were doing and check orders for pain medications. The Staffing Nurse said if the resident was medicated for pain prior to care, that meant the medication was not working and the nurse needed to call the doctor. In a follow-up interview on 10/07/22 at 12:06 PM, the Staffing Nurse said Resident #63 would always cry out saying Ouch, don't hurt me. The Staffing Nurse said he did not work with Resident #63 often but noted, on at least 3 occasions, her crying when she was repositioned and she said, Don't hurt me. I'm hurting. The Staffing Nurse could not provide dates of the incidents and stated based on his nursing judgement he determined Resident #63 was not in pain. The Staffing Nurse said he never completed a PAINAD or any pain assessment for Resident #63, but he should have completed and documented a pain assessment if Resident #63 complained of hurting. In an interview on 10/05/22 at 4:37 PM, CNA J said she regularly worked with Resident #63. She said Resident #63 would cry, but she did not think Resident #63 was in pain. CNA J said she believe crying was a reaction to someone touching her or being moved. CNA J said she thought Resident #63 had some discomfort with her contractures, and, normally cries out when she's being moved. Record review of the facility's policy titled, Change if Condition (Acute), dated 02/12/20, reflected: The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication with the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is a physician response. The practitioner needs a detailed description of the patient's condition to determine whether a symptom is problematic or simply a normal or expected variant . Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help practitioners their potential causes and consequences . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms or signs, or unrelieved by measures already prescribed . As part of the interdisciplinary team, Certified Nursing Assistants (C.N.A.'s) . are expected to report findings that might represent ACOC's . The nurse notifies the responsible physician utilizing the appropriate channels and chain of command. Notify the physicians in the following order unless otherwise indicated by physician order, by routine service, or as indicated by patient condition: a) Attending Physician b) Advanced Practice Registered Nurse (APRN) or c) As necessary, notify the nursing supervisor . d) The nursing supervisor (in hours) and nursing administrator (on call) will determine the need to initiate the following steps: a. Notification of the Medical Director . Document in the medical record the date, time and name of each physician notified, actions taken and/or patient's response to treatment . Review of the facility's policy titled Pain Management and Basic Comfort Measures, dated 01/12/20, reflected, . Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines . Procedure: Identify the resident. Ask the resident if he or she is in pain. Perform hand hygiene if appropriate. Examine the site of the patient's pain, which may include subjective and objective data collection measures. Evaluate the resident's medical history . Provide pain medication as prescribed . Evaluate for analgesic [pain medication] side effects and pharmacological/ non-pharmacological effectiveness . Observe for unresolved pain and address per physician's orders. Record pain management techniques in the record . The policy did not address pain assessments in residents who were non-verbal or had a cognitive impairment. This was determined to be an Immediate Jeopardy (IJ) on 10/05/22 at 5:40 PM. The ADM and the DON were notified. The ADM and the DON were provided with the IJ template on 10/05/22 at 5:40 PM. The following Plan of Removal submitted by the facility was accepted on 10/06/22 at 4:40 PM and reflected: Date: 10/05/2022 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY For F697 To Whom it may concern, Summary of Details which lead to outcomes On 10/5/2022, during annual survey initiated at [Facility Name/Address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F697 The notification of the alleged immediate jeopardy states as follows: The facility failed to assess, provide effective pain treatment, and address pain promptly for two residents with significant pain, Resident #63 and Resident #188. What corrective action will be taken for those residents found to have been affected by the deficient practice: [Resident #63] was immediately assessed by 6-2 LVN charge nurse for any concerns of unrelieved pain or distress following wound care. Clinical staff were educated regarding pain at 6:30 PM. Follow up pain assessment in advanced dementia (PAINAD) was conducted at 8 PM by MDS Nurse Manager. Tylenol 325 mg tablets, 2 tablets by mouth every 4 hours as needed prn for pain or [temperature) Original order date 8/4/22 and remains a current order An additional order for hydrocodone 5/325 was received and given to the resident prior to completion of remainder of her wound care. Pain Management MD notified at 10:08 AM of potential pain during wound care for [Resident #63] with new order received for hydrocodone 5/325mg given on 10/5/2022. Pain was reassessed as being effective on 10/5/22 at 11:10 AM by 6-2 LVN. 'Resident sleeping with eyes closed. No signs of distress noted.' [Resident #63] showed no further signs of pain post wound care upon assessment by ADON on 10/5/2022. [Resident # 188] was immediately assessed for any unrelieved pain with no further complaints upon assessment by ADON on 10/5/2022. Physician notified of residents 5/10 pain after Tylenol administered. Voltren Gel 1% three times a day (T.I.D.) to right shoulder. was ordered 10/6/22, and a telemedicine visit was conducted by primary physician to discuss residents' treatment plan. How other residents with the potential to be affected by the same deficient practice will be identified; Residents experiencing pain have the potential to be affected What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; The Administrator/Director of Nursing/Assistant Director of Nursing have received Training by the Regional Nurse Consultant on 10/5/2022 on: Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Change of Condition (acute) InterAct 4.5 Stop and Watch Early Warning System, Policy on how to review pain management and physician notification in Facility Daily Clinical Morning meeting. Policy on how to review pain management and physician notification in the Weekly Interdisciplinary Team Meeting Wound Care nurse and LVN A In-service was conducted by DON/Designee on 10/05/2022 on Integrative Approaches for pain management with post-test to include proper notifications to MD with documentation including any follow up post medication administration. Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Stop and Watch Early Warning System InterAct 4.5 Change of Condition (acute) To include signs and symptoms of pain. Subjectivity of pain for residents able to verbalize pain. Objectivity of pain for residents who are unable to verbalize pain by use of Pain in Advanced Dementia patients (PAINAD). Residents tolerable pain level Assure pain medication, if ordered, has been administered prior to treatment Immediately stop if resident has any complaint of pain. Notification to physician if additional pain medication is needed. Participation and Policy on how to review pain management and physician notification in Facility Daily Clinical Morning meeting. Participation and Policy on how to review pain management and physician notification in the Weekly Interdisciplinary Team Meeting Wound Nurse will be educated on documenting pain level pre-procedure, during procedure, and post procedure to assure pain is being assessed and managed. Wound nurse will monitor subjective and objective signs and symptoms of pain during wound dressing changes and if objective or subjective pain identified will assess patient using P.A.I.N.D. scale of pain for cognitively impaired, and pain scale of 1-10 for alert residents. Results will be documented in resident Medical Record. Wound nurse will note residents tolerable pain level per most recent pain assessment for those residents who are able to verbalize pain level. The PAINAD will be utilized for those residents not able to verbalize pain. The PAINAD assess breathing, negative vocalization, facial expression, body language, and consolability, providing an objective level of pain by score system. Wound Nurse and nurses' notes will be reviewed daily Monday-Friday for any indication of pain to assure pain was managed and physician notified if needed. Nursing staff (full time, PRN, and those who are on vacation/leave) are being in-serviced by DON/Designee on proper notifications to MD with documentation including follow up assessment for pain. This in-service was started on 10/05/2022 by the DON/designee. PRN staff and those staff on PTO will be identified and staffing coordinator will flag to assure in-service is completed prior to working. This in-service was started on 10/5/2022 by the DON/designee and will continue until all staff has been in serviced. If staff was not present at the in-service, they will not be able to work until in-service has been completed. PRN staff and those staff on PTO will be identified and staffing coordinator will flag to assure in-service is completed prior to working. All new licensed clinical nursing staff will receive education on All clinical nursing staff including PRN staff and those staff on PTO or leave will receive education on Pain assessment for all residents in facility completed on 10/5/2022 with no significant findings. All new licensed clinical nursing staff including PRN staff and those staff on PTO or leave will be identified and staffing coordinator will flag to assure in-service is completed prior to working. Review of pain assessment scores were reviewed and follow up of unrelieved pain. Physician will be notified for alternate treatment plans. The Interdisciplinary team will monitor effectiveness of pain management weekly in Standards of Care Committee to assure current treatment plans are adequate and covering pain. Physician will be notified if treatment plan found not to be effective per Interdisciplinary Team review for any new orders to treatment plan. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and DON or designee will audit proper notifications for complaints of pain per review of TAR and nurses' notes M-F in clinical morning meetings. Administrator will be responsible for ensuring audit completion DON or designee will audit pain medication administration for completion of follow-up and effectiveness of pain medication in daily clinical meeting (M-F). Administrator will be responsible for ensuring audit completion during clinical meeting. Random audits by DON/designee via resident interview will be conducted three times per week on those residents who have been identified as having pain to assure their pain has been addressed, physician notified as needed, and care planned. Administrator will be responsible for ensuring audit completion. Results of interviews will be entered into patient's medical record and results of said interviews will be documented on a separate audit form to assure interviews were conducted and documented. Random audits by DON/designee and competency evaluation of wound care treatments will be conducted three times per week to assure residents are comfortable and within tolerable pain levels. Pain levels are identified by residents as to what is tolerable on each pain assessment. Administrator will be responsible for ensuring audit completion. Administrator will forward results of both morning meeting audits and Standards of Care audits monthly to the QAPI Committee for review and/or action. Involvement of Medical Director The Medical Director, [MD G] was notified about the immediate Jeopardy on 10/05/2022. The Medical Director will be meeting with the Interdisciplinary team on 10/06/022 to discuss more about the immediate Jeopardy and ways to address the alleged

Based on observation, interview and record review, and review of facility policies, the facility failed to provide supervision and/or assistive devices to prevent accidents for four residents (Resident # 6, R20, R23, and R24) of 14 residents reviewed for accidents out of 31 sampled residents. 1. R#23 and R#6 both sustained nasal fractures after multiple falls, 2. R#20 sustained a fall in which he incurred lacerations to the forehead which required hospital treatment. 3. In addition, R#24 left the facility without staff supervision. These failures could affect residents by placing them at risk of elopement and sustaining falls, with severe injuries. Findings include: 1. Review of R#23's closed record revealed he was admitted to the facility from the hospital on 02/01/21. Per the undated Face Sheet, the resident's diagnoses included repeated falls, laceration to the head, [CONDITION(S)] with loss of consciousness and [CONDITION(S)] disorder. The Admission Data sheet, dated 02/01/21, located in the Electronic Medical Record (EMR) under the Admission tab, identified the resident at high risk for falls due to his mild/moderately impaired cognition, diagnoses, need for assistance with balance, total dependence on others for transfers, use of a wheelchair, incontinence, and multiple medications. Interventions to prevent falls on admission included keeping needed items in reach/easy access, therapy evaluation, a low bed, reminders to use the call light and bedrails for positioning and safety. Review of R#23's admission Minimum Data Set (MDS), dated [DATE], revealed it also triggered falls as a care concern. The MDS noted the resident had a fall in the last month prior to admission, was severely cognitively impaired, was totally dependent on staff for transfers, did not walk during the assessment period, and the resident's balance could not be assessed. Review of the comprehensive care plan, derived from the MDS information, revealed that R#23 was at risk for falls. Review of the care plan, due date 02/08/21, revealed that the approaches to prevent falls included anticipating the resident's needs and checking frequently, and keeping the call light and personal items in reach. Review of the care plan revealed it did not include the need for a low bed, which was first identified in the Admission Data form. Review of the Incident tab in the EMR revealed that R#23 sustained four falls prior to his discharge from the facility on 03/15/21. a. On 02/09/21 at 3:00 PM, an Incident/Accident Report documented that the resident had an unwitnessed fall at 3:00 PM and sustained a skin tear to the right side of the forehead. Per the report, the resident was observed lying face down in floor in front of opened closet door with wheelchair and feeding pump/pole near by . It appears resident fell to the floor while attempting to grab clothing items out of closet without assistance. An x-ray of the skull was ordered and found no fractures. In response, the resident, who was assessed as severely cognitively impaired, was instructed to always call for assistance with ambulating. Resident does not verbalize understating or intent to comply. In response to this fall, the Incident/Accident Report, noted that the resident's bed was placed in the lowest position with fall mats on both sides of bed. Review of the comprehensive care plan revealed that this fall was noted on the care plan; however, the care plan was not updated to include the interventions of the bed in the lowest position or fall mats on both side of the bed. b. Per an Incident/Accident Report, indicated that the resident's next unwitnessed fall was at 3:30 AM on 02/18/21. The report stated that the resident crawled out of bed and no injuries were noted. The Therapy Screen portion of the Incident/Accident Report noted that adaptive equipment needs included keeping the bed in the low position and the placement of fall mats on bilateral sides of the bed. Review of the report revealed no evidence as to whether the bed in low position and falls mats, which were recommended after the first fall, were in place at the time of this fall. Although this was the second time that the need for the bed in the lowest position and fall mats was recommended, review of the comprehensive care plan revealed that it was not updated with these assistive devices. c. On 02/22/21 at 5:50 AM, R23 had a third unwitnessed fall. Per the Incident/Accident Report, the resident was found laying on his back .lacerations observed on the forehead with bleeding. Help call and 911 initiated pressure on the forehead before the resident was transferred to the hospital. The Incident/Accident Report noted that the resident returned to the facility at 8:45 AM with a fractured nose, bleeding from the nose, four stitches on the left side top of the right eye, and two stitches on the bridge of the nose. Review of the Incident/Accident Report revealed no description of how this fall occurred. However, a Post Fall Huddle form dated 02/22/21 revealed the fall occurred when the resident was transferring out of bed unassisted. Resident did not use call light to call for help. The form noted that the resident did not remember to use call light. Although staff had identified that the fall occurred because the resident, who was severely cognitively impaired, did not remember to use the call light, the Follow Up plan to prevent a repeat fall based on the same root cause was Reeducation with resident on using the call light. Further review of both the 02/22/21 Incident/Accident Report and 02/22/21 Post Fall Huddle form revealed that it could not be determined if previously recommended interventions of a low bed and fall mats were in place at the time of the resident's fall with fracture. The comprehensive care plan listed the 02/22/21 fall; however, the care plan was still not revised to include either the bed in the lowest position or the use of fall mats. d. Per the 02/25/21 Incident/Accident Report, at 1:50 PM, R#23 had a fourth unwitnessed fall, and was found between the wheelchair and bed, trying to put himself to bed. According to this report, Instead of sitting on the bed he missed it and sat down beside the bed. No injury was sustained in this fall. The Therapy Screen documented on this report included the approach of a wheelchair sitting schedule. Review of the comprehensive care plan revealed that it was updated on 02/22/21 to include the use of a wheelchair; however, there was no specific sitting schedule developed. Review of the ADL [Activities of Daily Living] Plan of Care electronic care plan system used by direct staff revealed that it did not notify the aides that the resident was at high risk for falls until 02/22/21, after the resident fell and sustained the fractured nose. The electronic Plan of Care system was updated on 02/22/21 to show the resident was at high risk; however, it did not include any approaches which staff were supposed to use to help prevent falls. Interview with MDS Licensed Practical Nurse (LPN) #20 on 05/08/21 at 9:40 AM revealed the MDS team completed the comprehensive care plan. After that, nurses on the floor could revise/update the care plan whenever the need for a new intervention was identified. She stated that if the nurse identified the need for fall mats or a low bed, they had the ability to add it to the care plan. MDS LPN #20 stated that in addition, falls were discussed in morning meetings, and new interventions could be added to the care plan at that time. Further interview with MDS LPN #20 on 05/08/20 at 10:00 AM revealed that the nurses were also able to update the electronic Plan of Care system used by direct care staff and add new approaches when the need for them was identified. Interview with the Director of Nursing (DON) on 05/07/21 at 2:55 PM revealed that by the time of the second fall (02/18/21), fall mats and the bed in the lowest position should have been included on the care plan and in use by staff. She reviewed the Accident/Incident Report forms for the 02/18/21 and 02/22/21 falls and confirmed that, based on the facility's documentation it was not possible to determine if the fall mats and low bed were in place at the time of each fall. The DON stated that in addition to the Incident/Accident Report, the facility also completed a Fall Huddle form on each fall which included more detail and will tell us what happened - what was in place. The DON stated that Fall Huddle reports were kept by the Assistant Director of Nursing (ADON) on the unit, and she would obtain copies for review. During an additional interview with the DON on 05/07/21 at 4:10 PM, she stated she could not locate any other Post Fall Huddle reports. She stated that one of these reports should have been completed for each fall; however, there was no evidence this occurred except after the 02/22/21 fall with fracture. The DON reviewed the 02/22/21 Post Fall Huddle with the survey team and confirmed that it did not document whether mats at bedside and a low bed were in use at the time of the fall with fracture. The DON stated that, without this information, she could not tell if all interventions needed to prevent falls had been in place to prevent each accident. She continued, that, without the Post Fall Huddle forms, there was no way to determine if the facility had identified a possible root cause and contributing falls of the fall. During this interview, the DON also noted that the intervention of reinforcing use of the call light with the resident was not an effective approach, as the resident was severely cognitively impaired and had already demonstrated that he did not remember to use the call light. Additional interview with the DON on 05/08/21 at 9:00 AM revealed the nurse on the unit and aides responsible for the resident were to complete the Post Fall Huddle form the next day, giving specific details and reviewing the circumstances of the fall. The form would then be given to the ADON #23 for review and action. Interview with the ADON#23 on 05/08/21 at 11;25 AM revealed that R#23's fall with fracture occurred when he got out of bed unassisted. She stated that she did not know the resident or his cognitive status well enough to know if he could remember to use the call light. The ADON#23 stated that the resident's bed was in the lowest position when the fall occurred; however, she could not remember if there were fall mats on the floor. Further interview with the ADON#23 revealed that if the fall mats had been in place, she would have included them in her documentation. Review of R#6's closed record revealed she was admitted to the facility on [DATE]. A Nurses Note dated 06/30/20 revealed the resident had a fall at home prior to admission, generalized weakness, was a high falls risk, and had diagnoses of hypertension, cancer of the brain with a craniotomy, [CONDITION(S)] disorder, and dementia. The Nurses Note completed at the time of the resident's 06/30/20 admission stated the resident could walk with a walker with guidance, needed assistance of one staff, and was placed in a bed in the low position with the call light in reach. Review of R#6's admission MDS, dated [DATE], revealed it triggered falls as a care concern. The MDS noted the resident had a fall with fracture in the six months prior to admission, was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 9/15, and needed extensive assistance from staff for bed mobility, transfers, ambulation, locomotion, and toilet use. The resident's balance was not steady and she was only able to stabilize with staff assistance. Review of the comprehensive care plan revealed that the resident was identified as at risk for falls from admission on 06/30/20, based on her generalized weakness, as well as diagnoses of heart failure and hypertension. Review of the electronic ADL Plan of Care used by direct care staff revealed that on 07/02/21, it identified the resident as at high risk for falls. However, further review revealed that this plan of care did not list any interventions which staff were to use to prevent falls. A Fall Risk evaluation completed 07/03/20 documented that the resident was at high risk for falls related to medication use, incontinence, use of a walker, cognitive status, diagnoses, and need for assistance with transfers. Additional Fall Risk evaluations conducted on 07/10/21 and 07/11/21 also documented that the resident remained at high risk for falls. Review of the Incident tab in the EMR revealed that the resident sustained at least nine falls prior to her discharge from the facility, which per a Nurses Note occurred on 07/31/21. a. Review of an Incident/Accident Report revealed that R#6 sustained her first fall in the facility on 07/03/21 at 4:46 PM. The fall, was unwitnessed, per this report, which stated, Charge nurse found resident lying on her back in bathroom .Resident stated she bumped into card board box kept inside bathroom. The fall occurred when, Resident was going to shower room unassisted before the aid came to help. Educated resident to call for help. Interventions taken after the incident included call light in reach, Bed in low position. The resident's care plan was updated to show that the resident was at high risk for falls due to her cognitive status and need for assistance with transfers. Interventions added included the use of a walker and keeping the call light available for use; however, the care plan was not revised to include the need for the bed to be kept in the low position, which was first identified at the time of the 06/30/20 admission to the facility. b. Review of an Incident/Accident Report revealed that R#6 had her second fall on 07/10/20. The unwitnessed fall occurred at 2:45 AM, and the resident was observed laying on the floor face down, in front of walker. Upon questioning, pt (patient) stated she was trying to go back to my room and I fell . Interventions listed on the Incident/Accident Report included, Reinforced importance to use call light for assistance .bed in lowest position, call light within reach. The use of a wheelchair was added to the care plan; however, the use of a low bed continued to not be included on the care plan. c. Review of an Incident/Accident report revealed that R#6 sustained her third fall on 07/11/20 at 2:41 AM. Per this report, During rounds, resident observed laying on the floor besides [sic] bed, pt. stated, I rolled out of bed .Reinforced use of call light for assistance, pt. verbalized understanding stated, 'It is difficult to accept I can't walk anymore.' Reassured pt. staff would assist with transfer- assisted pt. back to bed. Bed in lowest position .call light in reach. Review of the Incident/Accident report revealed that it could not be determined if the bed in the lowest position and call light in reach were in place at the time of the fall, or if these interventions were added when the resident was returned to her bed. Interventions noted in the Incident/Accident Report included the need for a well-lit/non-cluttered room, the call light in reach, and needed and desired items in reach/easy access. Review of the care plan revealed that the need for the well-lit/non cluttered room and low bed were not added to the care plan after this fall. The care plan continued to include the need for the call light and frequently used items to be kept within reach which had been listed since 07/03/21. There was no evidence of evaluation as to why these previously identified intervention were not successful in preventing the resident's falls. d. Review of an Incident/Accident Report revealed that R#6 sustained her fourth fall on 07/12/21 at 5:30 AM. Per this report the resident was observed laying on the floor besides bed and wheelchair. Per pt., I forgot to use call light, so I got up and fell . The Therapy Screen portion of the report noted that the resident was to continue therapy to improve stability in standing/gait and decrease fall risk. In addition, Therapy staff recommended frequent checks to decrease fall risk. Other interventions noted on the report included the need for the call light in reach (which had been care planned since 07/03/210), and bilateral mats at bedside. Review of the comprehensive care plan after this fall revealed that the care plan was not updated to include the mats at bedside, as well as the low bed and well-lit, non-cluttered room that were previously identified as approaches to prevent further falls. e. Review of an Incident/Accident Report revealed that R#6 sustained her fifth fall on 07/12/20at 4:30 PM. Per the report, the resident was found on the bathroom floor. Resident stated that she forgot to use the call light and used to [sic[ walker to go to the restroom by herself . Resident has fallen 4 times in the last 3 days. The report listed multiple interventions needed to prevent further falls, including, well-lit/non cluttered room, call light in reach, needed and desired items in reach/easy access, place resident in open area for maximum observation opportunities, bed in low position, reacher. Review of the care plan after this fall revealed it continued to not be updated with all needed interventions, and did not include the mats at bedside, the low bed or the well-lit, non-cluttered room that had previously been recommended. In addition, the care plan was not updated to include the new approaches of a reacher and keeping the resident in an open area for maximum observation. Although the care plan continued to include the need for the call light and frequently used items to be kept within reach, there was no evidence of evaluation as to why these previously identified intervention were not successful in preventing the ongoing falls and if they should be revised due to ineffectiveness. f. Review of Incident/Accident Report form revealed that R#6 sustained two falls on 07/16/21. At 2:30 PM, R#6's roommate reported that the resident slipped from her wheelchair. Per the second 07/16/21 report, at 6:43 PM, the CNA called the nurse into room. Nurse arrived and saw patient leaning over with her face on the window seal [sic] .Patient noted with bleeding from the nose. Nurse called for help and three staff assisted patient off the floor into her wheelchair. 911 was called and the resident was transported to the hospital. Per Nurses Note dated 07/17/20, the resident was readmitted to the facility at 2:15 AM on 07/17/21 with a fracture of the nose. The resident's room was changed, and per the Nurses Note, bed in lowest position, reinforced importance of using call light. However, no changes to the resident's care plan were noted after this fall with fracture. g. Review of an Incident/Accident report revealed that R#6 sustained her eighth fall on 07/19/20 at 5:00 AM. Per the report, resident call light came on .resident observed sitting on the floor, upon questioning, pt. stated, I got up to turn on the light and on my way I lost balance and sat on the floor. The intervention in response to this fall was reinforced importance of using call light. h. Review of an Incident/Accident Report revealed that R#6 sustained her ninth fall on 07/20/21 at 7:20 PM. Per the report the resident called out for help, nurse saw resident lying on floor. Resident walked into another resident's room to get diaper and fell . The intervention in response to this fall was educated resident about importance of call for help. On 07/21/21, the resident's care plan was updated to show that the resident's risk for falls was related to impulsive behavior. Review of the Incident tab in the EMR revealed no further falls prior to the resident's discharge from the facility on 07/31/21. Interview with the DON on 05/07/21 at 2:55 PM revealed that interventions identified to prevent falls should be included on the resident's care plan. The DON stated that for each fall, a Fall Huddle form should have been completed and would provide more detail and will tell us what happened - what was in place at the time of each fall. The DON stated that Fall Huddle reports, which included a root cause analysis of each fall, were kept by the ADON on the unit, and she would obtain copies for review. During an additional interview on 05/07/21 at 4:10 PM, the DON stated that the repeated intervention of reinforcing use of the call light was not an effective approach for residents with cognitive impairment who did not remember to use the call light. During an additional interview with the DON on 05/07/21 at 5:30 PM, she stated she could not locate any Post Fall Huddle reports for R#6. She confirmed that one of these reports should have been completed for each fall; however, there was no evidence this occurred. The DON stated that, without this information, she could not determine the root cause of each fall and was unable to determine if the identified interventions were in place or not at the time of each accident. Interview with MDS LPN #20 on 05/08/21 at 9:40 AM revealed that the resident's care plan should have been updated whenever new approaches to prevent falls were identified. She stated that these revisions could have occurred at the time the nurse responding to the fall identified their need, as well as during the morning meetings in which each fall was discussed. Final interview with the DON on 05/08/21 at 1:45 PM revealed she was unable to provide any additional information to show that each of the resident's falls were investigated to identify and act upon possible root causes. She confirmed that needed interventions were not put in place, stating, It should be done. 2. Review of a Face Sheet, found in R#20's EMR under the Resident file, indicated the resident was admitted on [DATE] with diagnoses that included fracture of left femur and unspecified dementia with behavioral disturbances. Review of Admission Data, found in R#20's EMR under Assessment tab indicated R#20 had a history of falls in the past 30 days and required extensive assistance with transfers. Under a category titled Fall Risk, on this same document noted the resident was considered high risk for falls. The identified interventions were to keep desire items close, low bed, and to remind the resident to use a call light. The document identified the resident with moderately impaired cognition. Review of ADL Plan of Care, dated 01/18/21 identified R#20 as being at high risk for falls. There were no interventions, such as a low bed, as previously identified from the Admission Data, record to reduce the opportunity of a fall. The ADL Plan of Care is a reference for the CNA to direct care for a resident. Review of R#20's MDS with an Assessment Reference Date (ARD) of 01/20/21, revealed the resident had a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. The assessment noted the resident was extensive assistance in bed and transfer and required the assistance of one staff member. Under the Care Area Assessment (CAA), indicated the resident was at risk for falls and directed staff to develop a care plan. Review of Care Plan, found in R#20's EMR under Care Plan, tab dated 01/18/21, indicated R#20 was at risk for falls. Under Interventions, of the care plan was noted to assess factors related to fall history. Review of Nurses Note, found in R#20's EMR under Nurses Note dated 01/24/21, indicated the resident was found on the floor next to his bed at 11:55 AM, and had a laceration on his forehead. The injury was approximately 1.5 inches. The noted indicated the resident was alert to himself only, there was no change in his level of consciousness, and noted the resident was waiting for his mother and father to take him home. The resident's family and Nurse Practitioner (NP) were notified of the fall with injury and the NP ordered the resident be sent to the local hospital for evaluation and treatment. Review of the hospital records dated 01/24/21 indicated R#20 sustained a fall while at the facility. The hospital records noted the resident had no intercranial abnormalities and no fractures because of the fall. The resident did receive sutures to his forehead and returned to the facility. Review of Care Plan, found in R#20's EMR under Care Plan, tab, revised on 01/24/21, indicated R#20 would be free from complications related to falling over the next three days and would verbalize understanding of the need for assistance over the next 90 days. Under Indications, of the care plan, revealed to place the resident's bed in the lowest position. Review of Incident/Accident Report, provided by the facility dated 01/25/21 indicated R#20 was found by staff and resident was on the floor near his bed and wheelchair. The report noted the resident fell from the wheelchair while attempting to transfer himself and without assistance. Under a section titled Recommendations, it directed staff to continue with the resident's physical and occupational therapy and to place resident in an open area close to the nursing station. There was no mention if the resident had his bed lowered at the time of his fall. Review of ADL Plan of Care, dated 02/01/21 identified R#20 as being at high risk for falls, had balance problems, had weakness on the resident's right side, and directed staff to place the bed in low position. During an interview on 05/06/21 at 3:40 PM, the Therapy Manager stated R#20 was toe touch only ( the foot or toes touch the floor, but do not bear any weight) and received therapy after his initial fall. The Therapy Manager said the resident was not ambulating at the time of his stay. During an interview on 05/08/21 at 10:20 AM, the DON said each resident was to be assessed, care planned, and then the development of the ADL care plan for the CNAs. The DON confirmed this was where CNAs would be aware of R#20's risk for falls and implement the interventions. The DON stated that the resident's cognition would vary throughout the day. The DON confirmed the resident was found next to his bed and the plan was to implement a lower bed and place a floor mat next to the bed for the resident. During a subsequent interview on 05/08/21 at 12:30 PM, the DON confirmed R20 was identified to be at high risk for falls upon admission and confirmed the resident was to have a lower bed implemented on 01/18/21. The DON printed up the ADL Plan of Care for the CNA staff during this interview and confirmed the lower bed was put on the CNA plan of care for the resident on 02/01/21. The DON said there was no other place in the clinical record to show the resident had a low bed implement prior to his 01/24/21 fall. The DON stated the admission assessment is completed by the admission nurse and when this happens the assessment triggers a general care plan in the EMR (baseline care plan), then the interventions were to be personalized in the comprehensive care plan and said this was not done for the resident. Review of a facility policy titled, Fall Management, dated 02/12/20 revealed, . The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards. 3. Review of R#24's undated Face Sheet in the EMR revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included end stage [CONDITION(S)], suicidal ideation, [CONDITION(S)], and dementia. Per the Admission Data report, dated 02/19/21, the resident was oriented to person and place, short term memory was OK, and the resident had no behavioral symptoms. An Elopement Risk was conducted as part of the Admission Data, and found the resident was at low risk for elopement. Review of a Daily Skilled Note dated 02/20/21 revealed that on the day following admission, the resident displayed behavioral symptoms and was exit seeking. Further review of the EMR, including Daily Skilled Notes, and Nurses Note entries revealed no further information about the exit seeking to provide specifics and describe the resident's new behavior. Review of a Daily Skilled Note for 02/22/21 also described the resident as exit seeking as well as rejecting care. Review of R#24's admission MDS revealed that the assessment date was 02/22/21. Per this MDS, the resident was severely cognitively impaired, wandered four - six days of the four-day assessment period since admission. Per the MDS, the resident's wandering placed the resident at significant risk of getting into dangerous places and significantly intruded on the privacy/activities of others. Review of the resident's baseline care plan revealed it was completed on 02/22/21. Although staff were aware that the resident was displaying exit seeking behaviors since 02/20/21, the Baseline Care Plan, documented that the resident was at low risk of elopement, and there were no interventions listed to prevent elopement. Review of an Incident/Accident Report, dated 02/22/21, revealed that at 2:50 PM, the resident ambulated out 100 Hall Side door without assistance and without supervision. At 3:00 PM, the resident was observed sitting upright on curb of therapy room parking lot. Resident stated several times, I want to go home and Take me to my house. The resident initially refused to be transferred back into the building, but in time, resident was successfully transferred back into building without injury. Further review of Nurses Note entries and the Incident tab in the EMR revealed the resident had no further elopements prior to her transfer to a hospital on 02/27/21 after a fall. Review of the electronic ADL Plan of Care used by direct care staff revealed that it was not updated to show the resident was at risk for elopement until 02/27/21 at 6:50 PM, after the resident was transferred out of the facility to the hospital. Interview with the DON on 05/05/21 at 12:30 PM revealed that the resident had a history or elopement prior to admission to the facility. The DON stated that, She didn't technically elope. She explained that Previous Administrator 38 told her that the resident was outside the building; however, it was not an elopement because the Administrator had interviewed staff and the resident, was visualized the whole time. During this interview, a request was made for the facility's investigation, including evidence of the staff interviews referenced by the DON. She stated that the facility had not been able to locate this information but was trying to contact Previous Administrator 38 to find where the documentation was kept. During this interview, the DON confirmed that staff should have immediately updated the resident's care plan when the resident first displayed exit-seeking behavior on 02/20/21. The DON stated that the nurse on the unit was supposed to initiate the baseline care plan on admission and should have added the problem of exit-seeking behavior when it was first identified. She reviewed the baseline and comprehensive care plans and confirmed that the resident's wandering behavior, which placed her at risk for elopement, was not added to the comprehensive care plan until 02/22/21, after the resident exited the building. Interview with Previous Administrator #15 on 05/05/21 at 11:55 AM revealed that although he was not the current Administrator of record, he was helping with administrative duties throughout the complaint survey. He stated that the facility was still looking for the investigation, adding that, Typically there should be one. He related that the investigation should include interviews with staff to see what happened, who witnessed the event, etc. Additional interview with the DON on 05/07/1 at 9:30 AM clarified that on the day that R#24 left the building, two staff were present in the front lobby when a visitor came in to the b [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident (Resident #394) of 14 residents reviewed for quality of care. The facility failed to provide Resident #394 with on-going thorough assessments, and effective interventions when she experienced significant amounts of pain and expressed the inability to urinate for over 24 hours. This failure could result in prolonged pain/discomfort and exacerbation of condition. Findings included: Review of Resident #394's admission assessment, dated 05/31/19, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The assessment included physician orders for [MEDICATION NAME] XL 10 milligrams, extended release daily (medication used to treat problems with bladder function), [MEDICATION NAME] 0.5 milligrams as needed for anxiety, and [MEDICATION NAME] one tablet every six hours as needed for pain. The resident was alert, orientated to person and year with mildly impaired decision-making skills, and no behaviors. Review of Resident #394's Care Plan, dated 05/31/19, reflected: At risk for problems with elimination. Facility interventions included assist to toilet as needed and provide peri-care after each incontinent episode. Review of Resident #394's Physician Orders, dated 05/31/19, reflected: [MEDICATION NAME] XL 10 milligrams daily (medication used to treat problems with bladder function) Review of Resident #394's Urine Analysis results, dated 06/03/19 at 1:18 p.m. reflected abnormal urine results including: Cloudy urine with protein (should be none), [MEDICATION NAME] (should be none), leukocytes (should be none), mucus (should be none), and bacteria (should be none.) Review of Resident #394's Urine Culture and Sensitivity results, dated 06/05/19 at 10:34 a.m., reflected the resident had a urinary tract infection sensitive to [MEDICATION NAME]. Review of Resident #394's Physician Notes revealed: 06/06/19: Resident, states she has urinary symptoms and believes she has a UTI . Foley catheter and dysuria (painful urination) . Assessment/Plan . 5. UTI- per nursing notes, patient had [MEDICAL CONDITION] and had Foley placed. Was started on [MEDICATION NAME]. An observation and interview with Resident #394 on 06/04/19 at 1:00 PM revealed she had been having trouble urinating. She could not remember how long she had been feeling like that. On 06/04/19 at 01:10 PM LVN A was asked about Resident #394's concerns to which the nurse responded, she always says that but when you check her brief, it will be wet. She is confused and has a history of dementia. She goes but she forgets. Review of Resident #394's daily skilled notes for 06/04/19 revealed: 06/04/19 at unknown time: Resident was alert and oriented with clear, yellow urine, and no pain. (Late entry note documented on 06/07/19.) 06/04/19 at unknown time: At shift change resident complained of fullness of bladder, assessed resident, no bladder distention. Urine Analysis positive for UTI, waiting on culture and sensitivity results. (Late entry note documented on 06/05/19) 06/04/19 at unknown time: Upon assessment, no complaint of bladder distention. (Late entry note documented on 06/06/19 at 12:08 a.m.) Observations and interviews on 06/05/19 at 10:30 a.m. revealed moaning was heard coming from the room of Resident #394. The resident was holding her abdomen with her left hand, crying, and moaning. The resident said she was having trouble pooing and peeing and she had pain to her lower abdomen. She rated her pain to the lower abdomen at a 12 on a scale of 1 (low pain) to 10 (high pain). Resident stated that she had already notified her nurse. The Resident pushed the call light for the nurse to come in again. At 10:35 a.m., CNA C came into the room. Resident #394 told CNA C that she was having trouble urinating and having a bowel movement. CNA C left the room and went to the nurse's station where she was observed talking to LVN A. At 10:38 a.m. LVN A entered the Resident's room and said to the Resident, You need to give the medicine time to work. I just gave it to you. LVN A left the room and was asked which medication she gave to the resident. LVN A said she gave the Resident [MEDICATION NAME] for pain in her legs. The LVN was asked about the Resident's concerns with trouble urinating and having a bowel movement. LVN A went back to the Resident's room and asked if she was having trouble urinating and having a bowel movement and the Resident responded yes. LVN A did not assess the Resident. LVN A said she was going to check the Resident's orders and see if she had any medications she could give the resident. At 10:45 a.m., LVN A said she called the Nurse Practitioner (NP) and received an order for [REDACTED]. LVN A told the DON she had received an order for [REDACTED]. DON said new orders were received for [MEDICATION NAME] for the Resident's UTI as well as Post Void Residual tests (tests used to check for urine retention in the bladder after urination). At 11:05 AM, Resident #394 was still complaining about having trouble urinating. The Resident's abdomen was exposed, and her abdomen looked distended. CNA [NAME] was in the room and said she had just changed the resident and her brief was moderately saturated with urine. At 11:11 AM, the Resident was given the first dose of [MEDICATION NAME] for urinary tract infection and the DON was at the bedside. At 11:30 a.m., LVN A returned to the resident's room and attempted an unsuccessful in and out catherization. At 11:44 a.m. the RN inserted an in and out cath and drained 700 mls of urine from the bladder. (A full bladder can hold approximately 500 mls to 530 mls of urine, if the bladder becomes too full, urine may back up into the kidneys.) An interview with LVN A on 06/05/19 at 12:35 p.m. revealed Resident #394 started complaining about having trouble urinating on 06/04/19 but the resident was having wet briefs. LVN A said she did not notify the physician about the Resident's complaints at that time, because the resident was having wet briefs. The nurse also said that the Urine Analysis (UA) test results came back on 06/03/19 showing the Resident had moderate bacteria in her urine. LVN A said the physician was not notified because it was the facility's policy to wait until they got the culture and sensitivity test results before notifying the physician. An interview on 06/05/19 at 1:45 p.m. with the DON revealed when she assessed Resident #394, her abdomen was distended. When asked about their policy regarding reporting urinalysis results to the physician, she said that some of the physicians wanted to wait until the culture and sensitivity test results were received before they were notified of the results. The DON said LVN A should have notified the physician about the urinalysis results since the resident was also complaining of trouble urinating. Review of Resident #394's daily skilled notes for 06/05/19 revealed: 06/05/19 at unknown time: Resident was alert and oriented to self with a non-distended bladder and clear, yellow urine, and no pain. (Late entry note documented on 06/06/19.) 06/05/19 at 2:39 a.m.: Resident medicated with [MEDICATION NAME] for complaint of pain. 06/05/19 at 10:22 a.m.: Resident medicated with [MEDICATION NAME] for complaint of anxiety. 06/05/19 at unknown time: Resident complaining of being unable to void, two heavy, wet briefs with no abdominal distention noted. DON entered the room, assessed, and noted distention. Physician called, and orders received for in and out catherization (cath) to assess for amount of urine left in bladder x two every six hours. Culture and sensitivity results of urine sample obtained, and the physician gave an order for [REDACTED]. 06/05/19 at 1:40 p.m.: Resident's bladder drained of 700 ml of urine using in and out cath procedure. An interview with the NP on 06/06/19 at 11:46 a.m. revealed she was notified about Resident #394 having trouble with urination on 06/05/19. She stated that if the resident had notified the nurse that she was having trouble urinating, she expected the nurse to call either herself or the physician about it. She also stated that she expected the facility to notify her of all lab results as soon as they received the results whether they were normal or abnormal. An interview with CNA C on 06/06/19 at 12:09 p.m. revealed on 06/05/19, she answered the call light, and Resident #394 told her she was in pain, having trouble urinating, and having trouble with having a bowel movement. CNA C said she notified LVN A about what the resident told her. An interview with the ADON on 06/06/19 at 1:45 p.m. revealed that if a resident complained about having trouble urinating, the nurse should first assess the resident, check with the CNA to see if the resident had been voiding and notify the physician if the resident continued to have pain or if the bladder was full. She stated that it was possible for a person to urinate and still have [MEDICAL CONDITION]. She said [MEDICAL CONDITION] could lead to complications like infections,[MEDICAL CONDITION], and pain. She said physicians needed to be notified about all lab results and urinalysis results should be reported to the physician or nurse practitioner as soon as possible whether positive or negative. Review of Resident #394's daily skilled notes for 06/06/19 revealed: 06/06/19 at 12:10 a.m. In and out cath completed with a return of 650 mls of urine. Order received to insert Foley catheter. 06/06/19 at 1:00 a.m. Resident agitated and confused and yelling, I want to pee! Foley catheter with output of 1200 mls in the bag. 06/06/19 at 5:00 a.m. Resident had an additional 500 mls of urine output. An interview with CNA F on 06/07/19 at 1:50 p.m. revealed Resident #394 started to complain about lower abdominal pain and having trouble urinating on 06/03/19 at around 7:00 a.m. The CNA stated that she notified LVN A about the resident's complaint. On 06/03/19 the Resident continued to complain about having trouble urinating during breakfast. After the resident was finished with breakfast, CNA F brought the Resident back to her room and notified LVN A that the resident was still complaining about having trouble voiding and lower abdominal pain. The resident complained about the symptoms four to five times on her shift and each time she notified LVN A. CNA F stated that the same thing happened on Tuesday (06/05/19) and Wednesday (06/06/19) morning. The resident complained four to five times about the problem on Tuesday and about two times on Wednesday before the Foley catheter was placed. An interview with the DON on 06/07/19 at 2:32 p.m. revealed after the Foley catheter was placed for Resident #394, she determined that Resident #394 was having an excessive amount of urine output. The physician was notified, and labs were ordered. The glucose level was tested and was (high) at 203. She said the Resident has been started on insulin for pre-diabetes. Review of the facility policy, dated 05/13/13, Change in Condition Reporting reflected: Purpose: The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is a physician response. Review of website lms.rn.com on 06/24/19 at 11:25 a.m. reflected: Your Assessment. Patients with renal or urinary problems will often complain about frequent, difficult, or painful urination, or blood in the urine . questions to ask: Any pain with urination? . Examination tips: palpate the abdomen for bladder distention . Possible cause: urinary tract infection . As the patient's nurse, you must critically analyze all of the data you are obtaining . and identify a plan of care for your patient .