Every finding on record at Beltline Healthcare Center

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags in the dry storage pantry and refrigerator areas.3. The facility failed to ensure that expired items in the dry storage pantry were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area were separated from the other canned food.5. The facility failed to ensure that foods brought into the facility by visitors was not stored in the facility's refrigerator. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 02/09/2026 at 9:40 AM, revealed the following: Dry Pantry area:* 6 packages of 8.6 oz. presweetened fruit punch flavored soft drink mix with an expiration date of 07/12/25.* 1 package of 106 oz. pasta noodles were unsealed and exposed to air.* 1 package of 106 oz. pasta noodles was labeled 11/25/25 use by 12/24/25.* 1 opened package of powdered dry milk was unsealed and exposed to air. * 1 opened bag 25 lb. bag labeled, Hotel & Restaurant flour was unsealed and exposed to air. * 1 plastic container labeled Pasta dated 01/01/25 use by 01-30-25 was unsealed and exposed to air. * 2 plastic containers labeled Rice dated 01/01/25 use by 01-30-25 was unsealed and exposed to air.* 1 plastic container labeled Yellow Corn Meal dated 01/01/25 use by 01-30-25 was unsealed and exposed to air.* 1 plastic container labeled Orzo was unsealed and exposed to air.* 1 package of 25 lb. traditional chicken breading was unsealed and exposed to air. * 1 dented can of 106 oz. sliced pears.* 1 dented can of 50 oz. tomato soup.* 1 dented can of 106 oz. spaghetti sauce.* 2 dented cans of 106 oz. grape jelly.* 1 dented 106 oz. can was unlabeled. Refrigerator area:* 1 metal container with clear saran wrap was labeled scrambled eggs was unsealed and exposed to air.* 1 metal container with clear saran wrap was labeled sausage was unsealed and exposed to air.* 1 metal container with clear saran wrap was labeled mech meat was unsealed and exposed to air.* 1 metal container with clear saran wrap was labeled puree meat was unsealed and exposed to air.* 1 metal container with clear saran wrap was labeled bacon was unsealed and exposed to air.* 1 clear plastic container labeled Chicken Salad was unsealed and exposed to air.* 1 clear plastic container labeled [Resident #21 - puree] was unsealed and exposed to air.* 5 cups labeled milk were unsealed and exposed to air. Freezer area:* I zip bag labeled Pot Roast was not labeled and was unsealed and exposed to air.* 1 plastic container of 11lbs. of chocolate Fudge Icing was unsealed and exposed to air.* 1 plastic bag labeled ham was dated 11/25/25 and did not have a shelf-life date.* 1 plastic bag labeled carrots was dated 02/06/26 and did not have a shelf-life date.* 1 plastic bag labeled chicken fried steak was dated 02/08/26 and did not have a shelf-life date.* 1 plastic bag labeled apple strudel was dated 01/12/25 did not have a shelf-life date and was unsealed and exposed to air. In an interview with the Interim Dietary Manager on 02/09/26 at 10:26 AM, he stated that he had been employed at the facility for 7 years. He stated that the Dietary Manager was currently out of the country and was not available. He was informed about the state surveyors findings during the initial brief tour of the kitchen, which included dented cans, labeling, expired and unsealed items in the dry storage, and refrigerator areas. He stated that all items that were unsealed in the kitchens dry pantry, refrigerator and freezer areas would be discarded and thrown in the trash. He reported that all staff were responsible for ensuring there were not any expired and unsealed items in the dry storage, refrigerator, and freezer areas. He stated that if dented cans were found, the dented cans were to be immediately removed from the shelf and placed in the designated area that is marked as Dented Cans. The Interim Dietary Manager stated he had a total of 3 staff members that he supervised, and they work various shifts. He stated all kitchen staff were reeducated and retrained on Food Storage via in-service training relating to the findings of the initial brief tour of the kitchen found by the state surveyor. He stated if staff were to find anything such as expired items, his expectation was they immediately throw away the item (s) and tell him about the item (s) that were thrown away. He stated if any item (s) were not labeled and/or dated, his expectation was for his staff to tell him and he would reeducate and retrain all kitchen staff through in-service training. He stated all kitchen staff were to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled and dated. He stated that the items found in the kitchen by the surveyor were a mistake and he would continue to provide education to his staff to ensure everyone knows his expectations and the facility's policy on Food Storage. He stated his expectation for his staff was they use the FIFO procedures to ensure there were not any expired food items throughout the facility's kitchen. He stated the kitchen staff were reeducated and retrained through in-service trainings regularly. He stated did not recall when the last in-service on Food Storage was taken. He stated if anyone ate food from the kitchen that was expired, dented cans andunsealed containers or bags, there was risk of becoming sick, which could cause them to have issues with their stomach. In an interview with [NAME] D on 02/09/26 at 10:46 AM, she stated that he had been employed as the cook at the facility for 7 years. [NAME] D stated that she was unaware there were expired and unsealed items in the dry storage and refrigerator areas. She stated all the staff were responsible for labeling and storing the items on the shelf and checking for dented cans and ensure the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. [NAME] D stated she had been in-serviced on food preparation and storage and she did not know when she received her last in-service training. She stated that her previous in-service trainings stated that all kitchen staff were responsible for everything in the kitchen, including the dry pantry, refrigerator and freezer areas were labeled (included the date it was placed in the refrigerator and a use by date), sealing of plastic containers and bags, and making sure that expired items are not in the kitchens dry storage, refrigerator and freezer areas. She stated that if a staff member sees any item(s) that were expired, the staff member was to immediately throw the item away in the trash can and then inform the Dietary Manager and other kitchen staff members about what they found and thrown away. [NAME] D stated all items in the kitchens dry storage, freezer and refrigerator areas were to be labeled and dated. [NAME] D stated that the clear plastic container in the facility's refrigerator labeled, [Resident #21] was brought to the facility by [Resident #21's] FM. [NAME] D stated sometimes [Resident #21] does not like the food that was served for the residents in the facility, therefore the FM will bring the food, such as mashed potatoes or pureed food in the container for [Resident #21] to eat. [NAME] D stated the staff kept the food in a clear plastic container and kitchen staff would warm the food up for [Resident #21] to eat. [NAME] D stated that she was unaware of the facility's food policy relating to Food Brought from outside of the facility. [NAME] D stated that she was unaware that storing [Resident #21's] food in the refrigerator with the food that was used for meals for the residents was considered cross-contamination. [NAME] D stated if someone ingested food from the facility's kitchen that was cross-contaminated, there was a risk that someone could become very ill. She stated that if anyone ate food that came from the kitchen's dry pantry, refrigerator and freezer areas that were unsealed, or expired items and dented cans there was potential of causing them to have stomachaches, headaches and diarrhea. On 02/09/2026 at 11:47 AM, an attempted telephone interview with the Dietary Manager was unsuccessful. In a telephone interview with the Interim Dietary Manager on 02/11/26 at 11:13 AM, he stated that he was aware of the facility's policy, Food brought from outside of the facility. He stated that [Resident #21's] FM brings food to the facility for the resident at least two times a week. He stated the food that the FM brought pureed food and was usually mashed potatoes or something like that. He stated he was unaware that the plastic container of food labeled, [Resident #21] was unsealed and exposed to air. The Interim Dietary Manager stated unsealed items in the facility's dry storage pantry, freezer and refrigerator areas can cause food-borne illnesses, which can cause anyone who eats food from the kitchen to become ill. He stated he did not know why he did not follow the facility policy and he would retrain his staff on everything that was brought to his attention by the state surveyor. During an observation of Resident #21 during the lunch meal on 02/11/26 at 12:30 PM, he was observed eating a pureed meal. Resident #21 not interviewable. On 02/11/26 the attempted telephone calls to Resident #21's family members (FM 1 and FM 2) were unsuccessful. In an interview with the Dietary Aide on 02/12/26 at 2:02 PM, he stated he had been employed at the facility for 3 months. He stated that he was unaware there were expired and unsealed items in the dry storage, and refrigerator areas. He stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. The Dietary Aide stated dented cans were to be removed from the shelf with the other dented cans and placed in area marked Dented Cans. He stated that he received education on using the FIFO method in some of his previous in-service trainings. He stated if he saw food that was expired and/or unsealed, and not labeled in the dry pantry, refrigerator, and/or freezer areas, he would immediately then notify the Dietary Manager or Interim Dietary Manager. He stated items that were unsealed or expired, he would immediately throw away because if anyone ate the food, they could get sick. The Dietary Aide stated that he was not aware of the facility's Food brought from outside of the facility policy. He stated he was unaware there was an unsealed plastic container in the kitchen's refrigerator labeled, [Resident #21. He stated he works the last shift and does not need to open the refrigerator during his shift because everything he needs for his shift is already prepared for him by other kitchen staff. The Dietary Aide stated that prior to 02/09/26, the Dietary Manager provided In-Service training to the kitchen staff on Food Storage, handling and preparation. He stated if someone ingested food from the facility's kitchen that had been unsealed or expired, they were at risk for cross-contamination and could become ill from food-borne illness. He stated that any ingestion of food that had been unsealed or expired, can cause a person to have stomach issues, diarrhea and vomiting. Record review of Resident #21's Face Sheet, dated 02/11/26, revealed that he was a [AGE] year-old male with an initial admission date to the facility of 05/30/19 and readmitted to the facility on [DATE]. Resident #21's active diagnoses included: Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement) , vitamin D deficiency (occurs when the body lacks sufficient vitamin D, causing issues with calcium absorption, bone strength, and immune function) , dysthymic disorder (chronic, long-term form of depression lasting at least two years) dementia ( a progressive syndrome, not a specific disease, characterized by a decline in memory, language, problem-solving, and other cognitive functions that interfere with daily life), protein-calorie malnutrition ( a severe, often life-threatening condition caused by an insufficient intake of protein and/or calories, or high nutrient loss that can result in muscle wasting, loss of body fat, and metabolic dysfunction), and type 2 diabetes (a chronic metabolic disorder where the body develops insulin resistance or fails to produce enough insulin, causing glucose to build up in the blood instead of entering cells for energy). Record review of Resident #21's MDS dated [DATE] revealed he had a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #21's revised Care Plan dated 02/06/2026 revealed, Focus:[Resident #21] had a diet order other than regular and is at risk for unplanned weight loss or gain.Regular diet, Mechanical Soft texture, Nectar consistencyDate Initiated: 12/29/2023Revision on: 08/15/2024 Goal:[Resident #21] will maintain ideal weight and receive proper nutrition daily x 90 days.Date Initiated: 12/29/2023Revision on: 08/15/2024Target Date: 04/30/2026 Interventions:.Administer protein supplements as ordered per facility protocol.Date Initiated: 09/21/2025 Record review of Resident #21's Hospice Orders dated 02/05/2026 revealed, a terminal diagnosis of Parkinson's disease. Resident #1's diet consists of pureed - pleasure feeding. Record review of the facility's 2012 dated policy, MENU APPROVAL AND HONORING RESIDENT SPECIAL REQUESTS, AND FOOD BROUGHT TO THE FACILITY FROM UNAPPROVED SOURCES revealed, 1.In addition to obtaining food from approved suppliers, the facility can obtain food products and produce from local producers and suppliers, as long as the products are handled and transported with protection against contamination and are then washed and stored appropriately to preserve food safety. This includes food items grown in facility gardens, if applicable. 2. If a family member or other visitor or staff brings prepared, potentially hazardous (time and temperature controlled for safety) food items for a resident, these items cannot be stored in the dietary department. This poses a problem with potential cross-contamination, as the facility is unaware of how the food was handled or whether it was maintained at appropriate temperatures during transport. These items can be stored in the individual resident room, or other approved areas available depending on the food item. 3.The dietary department cannot reheat or prepare foods for a specific resident that have been brought from home or outside of the facility within the dietary department. Again, as listed above, this increases the potential for cross-contamination and infection control issues. The facility microwave located either in the dining room or break room can be used to heat prepared foods brought from outside of the facility, if available. 4.Record review of the facility's undated policy, Food and Storage Sanitation .Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded. Record review of the facility's undated policy, Food Storage and Dry Storage Supplies, revealed, 5. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. 7. According to the USDA fact sheet on Food Product dating, product dating on manufactured goods is not required by federal regulations except baby formula. For this reason, products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. These dates do not indicate that the product is no longer safe after one year, but give a method to track the age of a product so that it can be evaluated for quality before service. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor, or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible food spoilage is observed prior to the best by date, the product will be discarded. 9. Perishable and non-perishable foods are classified based on their pH and water content. Food manufacturers must determine whether their products meet the perishable criteria when determining whether they are required to declare expiration dates according to the Food and Drug Administration which regulates their manufacturing processes. If a manufacturer is not required to declare an expiration date, then that means that time is not a criteria in determining whether the product is safe to consume. Non-perishable foods meet the criteria in the Texas Food Establishment rules for classifying foods as non-time and temperature controlled for safety foods (NTCS). NTCS foods do not use time or temperature as a criteria for determining food safety. These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the 4 medications reviewed on 2 of 2 medication carts.The facility failed to ensure proper storage and disposal of Resident# 25's tramadol 50 hcl mg (controlled medication) by taping a narcotic medicationThe facility failed to ensure proper storage and disposal Resident# 38's tramadol 50 hcl mg (controlled medication) by taping a narcotic medication The facility failed to ensure that Resident#51's opened Lantus insulin was dated after opening.The facility failed to ensure that unopened vial of insulin aspart 100unit/1ml was properly stored in the refrigerator.These failures could affect residents by diminishing the effectiveness, and therapeutic benefits of the medications and/or result contamination of the medication.Findings Included:During an observation on 02/08/2026 at 11:45 a.m., of the 100 hall nurses Cart revealed Resident #25's Tramadol hcl oral tablet 50 mg (controlled medication used for pain) had 1 blister seal broken, and Resident #38's Tramadol hcl oral tablet 50 mg (controlled medication used for pain) had 2 blister seals broken. The damaged blisters had the pills still inside and secured with tape at the time the surveyor inspected the medication cart; the count counted was correct. During an interview on 02/08/2026 at 11:50 AM, LVN A stated she was unaware Resident #25's and Resident #38's tramadol 50mg blister pack seals were broken and secured with tape. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated she did not see the broken blister during the count. She stated that medication with broken seals should be wasted and witnessed by two nurses. She stated the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated she had been in serviced on medication storage. During an observation on 02/09/2026 at 11:45 AM of 100 hall nurses Cart, Resident #51's Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) observed opened and not dated. An unopened vial of insulin aspart 100unit/1ml was stored in the medication cart and not refrigerated per manufacturers recommendation. In an interview on 02/09/2026 at 11:43 AM, RN B stated she was unaware the insulin vial was unopened and Resident #38's Lantus was not dated. She stated she did not administer Resident #38's Lantus, it was administered on the evening shift. She stated the nurses were responsible for ensuring medication in the carts were dated and properly stored. She stated that all unopened insulin should be refrigerated, and all opened insulin should be dated. She stated the risk of not following manufacturers' recommendation of storing insulin would diminish the potency of the insulin. She stated that medication(narcotic) with broken seal should be wasted and witnessed by two nurses. She stated the risk of taping narcotics medication, was contamination of the medications. She stated she had been in serviced on medication storage. In an interview on 02/11/26 at 1:04 PM, the DON stated if a blister pack seal was broken the medication should not be tapped over with tape, it should be discarded witnessed by two nurses. The DON stated it was not acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken and contaminated. She stated that all unopened insulins should be refrigerated, and all opened insulins should be dated as soon as they are opened. She stated the risk of not storing unopened insulin in the refrigerator was that it would lose its chemical stability and potency which could make it ineffective when administered to residents. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON and DON audit the medication carts weekly, and the pharmacy consultant audits the medication room, and the medication cart every month. She stated the pharmacist audited the medication carts in January 2026. She stated the nurses had been in serviced on medication storage. In an interview on 02/11/26 at 3:29PM ADON revealed she audited medication carts weekly. She stated the last time she audited the medication carts was the week prior to the recertification survey. She stated she was not aware Resident #25's and Resident #38's Tramadol 50 mg was secured with taped. She stated that medication with broken bubble seal should be wasted and witnessed by two nurses. She stated the risk was loss of the pill and contamination of the medication. She stated that all unopened insulin should be refrigerated, and all opened insulin should be dated. She stated the nurses had been in serviced on medication storage and that narcotics were not to be taped if the blister seal was broken. She stated the risk of not refrigerating unopened insulin was the insulin would lose its potency and reduce the therapeutic effectiveness. In an interview on 02/08/2026 at 11:50 AM, RN C revealed nurses were responsible for checking the medication in the carts were dated and properly stored. She stated that all unopened insulin should be refrigerated, and all opened insulin should be dated. She stated that medication with broken bubble seal should be wasted and witnessed by two nurses. She sated the risk to the patient was receiving the wrong medication because there was no guarantee what was tapped back was the original medication, and the loss of therapeutic effect from insulin if it was not stored per manufacturers recommendation. She stated she had been in serviced on medication storage. Review of the facility's policy Medication Storage in the Facility edited P&P v3-2025 reflected the following: Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure:1. Pharmcare USA dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist.11. Medications requiring refrigeration or temperatures between 36 degrees F (2 C) and 46 degrees F (8 C) are kept in a refrigerator with a thermometer to allow daily temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. All refrigerated medications will be kept in a locked area of the refrigerator and/or in a locked medication storage area.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. - The facility failed to ensure the NP's order on 12/17/25 for a UA was completed for Resident #1, after the resident's RP expressed concerns for a UTI. This failure placed residents at risk of a delay in medical evaluation and treatment, which could result in worsening of condition or serious harm.Findings included: Record review of Resident #1's face sheet, dated 12/30/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses that included: dementia (brain disorder that affects memory, thinking, and behavior), congestive heart failure, chronic kidney disease, hx cerebral infarction (stroke), and hx malignant neoplasm of breast (cancer of the breast). Record review of Resident 1's quarterly MDS assessment, dated 10/26/25, reflected the resident's BIMs score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Status (self-care), reflected Resident # 1 required substantial assistance with most ADLs. The MDS Assessment under Section H-Urinary Toileting Program, reflected Resident #1 was always incontinent. Record review of Resident 1's care plan, dated 11/14/25, reflected the resident had an ADL self-care performance deficit with interventions that included a 2-person assist with toileting. The document also reflected Resident #1 had bladder incontinence with interventions that included: incontinent care at least every 2 hours with application of barrier cream after every episode, monitoring and documenting s/sx of UTI (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating pattern), and monitoring, documenting and reporting s/sx to the MD. Record review of Resident #1's progress notes, dated 12/17/25 at 11:25 AM by the ADON, reflected the following: [Resident #1's] family requested that UA to be done on [Resident #1] that she is feeling discomfort, notified DON and sent a message to [MD], awaiting his response at these [sic] time. [Family] also brought a pressure pad for [Resident #1] whenever they get her up these [sic] morning that they should spread it on [Resident #1's] bed, DON to look at it first before usage. Record review of a facility document titled 24-Hour Nurse Report, dated 12/28/25, reflected in part the following: [Resident #1] - [Family] wants to rule [sic] UTI. [MD] notified Record review of a facility document titled 24-Hour Nurse Report, dated 12/29/25, reflected in part the following: [Resident #1] - [Family] requesting [MD] to rule out UTI. [MD] notified, no order received. No complain [sic] Record review of Resident #1's EHR reflected there was no order entered for a UA or one completed on or after 12/17/25. In an interview and observation on 12/30/25 at 10:30 AM, Resident #1 was lying awake in bed and visiting with family. Resident #1 was alert, but her thoughts were slightly scattered, and she was not a good historian. When asked how she was doing, Resident #1 stated I guess I'm okay. Observation of Resident #1 revealed she was clean with no odors or visible marks or bruises. Resident #1's family stated the charge nurse never followed up on concerns they had regarding Resident #1's health and proceeded to call another family member on the phone to provide further details. The family stated Resident #1 complained that it hurt when she urinated and that she felt discomfort. The family stated Resident #1 was confused sometimes due to her dementia, so they asked her on multiple occasions, and she consistently complained about the discomfort, so it was reported to the charge nurse. The family was unable to provide the name of the charge nurse; however, she informed the family that the MD would be notified so a UA could be completed. The family stated that it happened weeks ago, and no one had followed up with any results. The family stated someone visited Resident #1 daily and the nurses could never give an answer about whether the UA was completed, and they could never speak with the MD. In an interview on 12/30/25 at 12:20 PM, the MD stated the expectation was for the nurses to notify him of any changes in a resident's condition and they were typically good about doing so. The MD stated he could not recall being notified that Resident #1's family had concerns that the resident might have a UTI, but his NP might have received the notification. The MD stated some s/x of a UTI included an altered mental status, chills, nausea, and continued discomfort and he had not been informed that Resident #1 was experiencing any of those symptoms. The MD checked the messaging system and found a note from the NP on 12/17/25 approving an order to collect a UA from Resident #1. The MD stated he was not sure why the UA was not collected and followed up on. The MD stated a delayed UA to test for a UTI could place the resident at risk of the infection spreading to her bloodstream. In an interview on 12/30/25 at 1:08 PM, the DON stated she received notification anytime there was communication in the messaging system with the NP or MD, and she would normally check the messages so she would be aware of any changes in a resident's condition and/or new orders for them to follow up on. The DON stated she somehow missed the message regarding the order to UA Resident #1, and it was overlooked. The DON stated the ADON was the person who notified the NP on 12/17/25 and received the new order, and she should have put it in the system and ensured that it was completed. The DON stated Resident #1 was non-compliant with care and it would be difficult to collect a UA; however, it was still the facility's responsibility to the get family and MD involved to figure out the best solution. The DON stated some s/sx of UTI include a change in behavior, increased confusion, and change in appetite. The DON stated no one had reported Resident #1 exhibiting any s/sx of a UTI. The DON stated not following orders to complete a UA could place the resident at risk of an infection that could cause those symptoms. An attempted interview on 12/30/25 at 1:32 AM with the ADON was unsuccessful due to no response to call. In an interview on 12/30/25 at 2:01 PM, CNA B stated she worked at the facility since 11/2025. She stated some s/sx of a UTI included a change in smell and look of urine. She stated she worked with Resident #1 about a week ago and noticed the resident's urine smelled stronger than usual like she just needed more water, but not like there was an infection. CNA B stated she reported it to the charge nurse and was told to let them know if the smell got any stronger. CNA B stated there were no other changes in Resident #1's condition or signs of a UTI. In an interview on 12/30/25 at 2:11 PM, RN A stated she only worked PRN at the facility. RN A stated she worked with Resident #1 about 3 times within the past 2 weeks and the nurses had not reported any changes in the resident's condition. RN A stated she had not noticed any changes in Resident #1 and the resident had not expressed any discomfort to her. However, RN A recalled at the end of her shift one night, Resident #1's family reported that the resident needed to be checked for a UTI. RN A stated she documented it on the 24-hour report but was not sure if anyone followed up on it because she did not return to work until about a week later. RN A stated anything documented on the 24-hour report was supposed to be discussed during morning stand-up meetings, so she assumed it was addressed while she was off. In a further interview on 12/30/25 at 2:47 PM, the DON stated any significant concerns from the 24-hour reports were addressed daily during morning meetings; however, she relied on the nurses to inform her of the concerns, and she did not always look at the 24-hour reports herself. The DON stated concerns for Resident #1 having a UTI had not been mentioned during the morning meetings although it was recently documented on 24-hour reports. The DON stated moving forward she would be sure to look over the 24-hour reports during the meetings. Review of the facility's policy titled Resident Rights, undated, reflected in part the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. Planning and implementing care - The resident has the right to be informed of, and participate in, his or her treatment, including:. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:.d. The right to receive the services and/or items included in the plan of care. The surveyor requested a policy regarding following physician orders on 12/30/25 at 1:35 PM from the Administrator and it was not provided prior to exit.

Based on observations, interviews and record reviews, the facility to provide necessary care and services for three (Residents #1, #2 and #3) of three residents reviewed for quality of care. 1. The facility failed to monitor and assess Resident #1 who had a seizure disorder, after she had a seizure on 09/15/25. The facility did not complete any neurochecks, assessment or lab monitoring. The resident was sent out to the ER by family request later that day due to concerns for a change in condition.2. The facility failed to complete and document neurological checks following Resident #2's fall with a head strike and injury when she returned from the ER on [DATE].3. The facility failed to assess, intervene and develop a plan of care for Resident #3 who had dementia and bipolar disorder when she refused to take prescribed psychotropic and dementia medications since her admission in July 2025, resulting in behavioral decompensation requiring psychiatric hospitalization on 09/19/25. On 09/18/25 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/23/25, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility failures placed residents at risk of unmanaged seizure activity, hypoxia, traumatic brain injury, delay in recognition of intracranial bleeding or neurological deterioration, uncontrolled psychiatric symptoms, aggressive behaviors, harm to self or others, unnecessary hospitalization and risk for serious injury, significant decline, life-threatening complications and death.Findings included: RESIDENT #1Record review of Resident #1's Face Sheet dated 09/17/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). She had no listed diagnosis of a seizure disorder (A condition characterized by recurrent, unprovoked seizures due to abnormal electrical brain activity). Resident #1 had two family members listed as her emergency contacts and resident representative. Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan dated 07/02/25 and last revised on 08/02/25 reflected, [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness-Date Initiated: 07/02/2025, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated-Date Initiated: 07/02/2025, Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 07/02/2025, Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity-Date Initiated: 07/02/2025, Seizure Precautions: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain, etc.- Date Initiated: 07/02/2025. Record review of Resident #1's active physician orders dated 09/17/25 reflected, Keppra Solution 100 MG/ML (Levetiracetam) give 7.5 milliliter via g-tube two times a day for seizures (start date 07/01/25 - present). Record review of Resident #1's September 2025 MAR reflected she was administered Keppra 7.5ml twice a day from 09/01/24 twice a day with the last dose documented the morning of 09/15/25. Record review of Resident #1's nursing progress notes dated 09/15/25 reflected: -11:10 AM-[Written by RN A]-The ADON called this nurse when she noticed resident having seizures when she was doing wound dressing of her roommate. Assessed and positioned the resident and provided all necessary care during and after seizure. Vital signs checked as B.P.-142/76; P/R- 80; R/R-18; SpO2-94; Temp.-97.6 on room air. Resident opening her eyes when calling out her name. Will continue to monitor and provide care. -3:56 PM- [Written by the DON]- [EC] called and states that resident was having a seizure and two nurses in room not doing anything for her. Entered room to check on resident and lying in bed with eyes closed resting peacefully. Informed [EC] after speaking with nurse for resident and make aware of concern. Per nurse resident had seizure earlier this morning. Made [EC] aware that we have informed MD and that [Resident #1] is currently on Keppra BID for seizure. [EC] was also made aware that Keppra levels will be drawn to see what Keppra level. Will continue to monitor.-4:36 PM- [Written by RN A]- Resident awake, oriented and stable but not responding as usual according to the [EC] who came to visit her wants 911 to be called and they want her to be taken to the hospital. Vital signs checked B.P.-136/85; P/R-81; Temp.-98.1; Spo2- 95 on room air. Notified DON and ADON. Called 911 and transferred resident to hospital.-4:41 PM- Transfer Notification- [Resident #1] was transferred to a hospital on [DATE] 5:35 PM related to The family want her to be sent to hospital as she had seizure in the morning and according to them she is not responding normally. Record review of Resident #1's nursing and social services progress notes revealed no notification of her seizure immediately to the RP or the physician the morning of 09/15/25. Record review of Resident #1's clinical chart to include all assessments and progress notes, reflected no documented neurochecks or monitoring after she had a seizure the morning of 09/15/25. An interview with LVN G on 09/17/25 at 2:56 PM revealed Resident #1 went to the ER on her shift. That morning of the incident, ADON D was rounding with the wound doctor on Resident #1's roommate and noticed Resident #1 was groaning and having seizures. LVN G stated she never saw Resident #1 have the seizure, but ADON D told her when she saw her, the resident was foaming at the mouth and shaking. LVN G stated all she saw was some secretions coming out of Resident #1's mouth when she had been repositioning her. ADON D asked LVN G to come and help and checked her vitals and immediately after the seizure was over, Resident #1 was snoring and sleeping and stable. Then in the afternoon, LVN G went to administer Resident #1. Her scheduled hydromorphone saw that her vitals were fine and she continued to sleep. In the evening, LVN G stated Resident #1's family member called the facility stating the resident did not look like her normal self on the AEM footage. LVN G said she told the family member yes, Resident #1 did have a seizure but it was earlier that morning and the nurses had been doing one-hour vital checks and gave her medicine. LVN G did not believe Resident #1 had another seizure after the initial one due to the nursing staff monitoring her. She said the family member did not want Resident #1 to decline and wanted the facility to call 911 to send her to the ER. LVN G stated, I even checked the vitals prior and she was okay. I told her everything is okay. LVN G stated that when Resident #1 had the initial seizure, she did not notify the MD/NP/PA or the resident's RP. She stated, I had a discharge and an admission coming at that time of day. Typically, I would want to notify the doctor and the party responsible and we will document and check on the resident intermittently and if we see any change in condition after notifying the doctor, we will transfer them out. LVN G stated Resident #1 had remained stable since the seizure. LVN G stated, The error-I did not notify the RP, I should have done that. That is important because, like when they came in the evening, they didn't know, they need to have a choice if there is anything further they want for the resident and to keep ourselves and documentation accurate. LVN G stated the importance of notifying the doctor for a resident's change of condition such as Resident #1 because that was the first seizure she had since she had been at the facility and the doctor needed to be aware to be able to make changes to her treatment. LVN G again admitted her fault in not notifying the MD or RP of Resident #1's seizure, which she stated was a change in condition. She said with her being the only nurse on that shift and having to pass meds, do lines and injections, she did not have time for the notification. An interview with the DON on 09/17/25 at 3:48 PM revealed the day Resident #1 had a seizure, her family member called around 2-3pm and said the resident was presently having a seizure and there were two nurses that were just standing there. The DON went to Resident #1's room and there were no nurses in there and nothing was going on and the resident opened her eyes. The DON asked ADON D if Resident #1 had a seizure and ADON D said yes, at 7am that morning. Then she went to LVN G and asked if Resident #1 just had a seizure and she said no, only that morning between 7 and 9 am and she monitored her and the resident was fine. The DON said she contacted the family member back and said Resident #1 was okay, but the family member wanted her sent out because she had a seizure. The DON stated when a resident had a seizure, the expectation was for the charge nurse to take vitals, call the doctor to notify them, sometimes that doctor will order a lab or ask how long the seizure lasted. If there was no change and the resident continued to have seizures, the DON stated they would need to be sent out. The DON stated it was important to notify the doctor when a resident had a seizure because it could affect the resident's neurological status detrimentally. The DON stated it was important to notify the resident's RP for a change of condition, but with Resident #1, She has a history of it and is already taken meds for it. If she was going to be sent out or it continued, I would notify the family, but I guess she was okay because she responded to me. An interview with ADON D on 09/18/25 at 10:00 AM revealed when Resident #1 had the seizure, she was doing wound care on her roommate. She stated Resident #1 had a mouthful of saliva and was not responding, so she wiped her mouth off. ADON D said she tried to talk to Resident #1 in bed who then rolled over toward the wall. When ADON D started to leave the room, she heard the enteral feeding pump alarm beeping and when she looked at Resident #1, she was having a seizure. At that time, ADON D stated she turned Resident #1 more to her side while she had the seizure which lasted less than a minute. She thought it may have been a grand mal seizure. ADON D stated when Resident #1 stopped having the seizure, she fell asleep immediately and started snoring. ADON D then notified LVN G who checked the resident's vitals which were within normal limits. ADON D said Resident #1 was monitored post-seizure, Like if I was walking down the hall that day, I would look in. ADON D stated she asked LVN G if the doctor was aware of the seizure and LVN G responded yes and that the PA wanted a Keppra lab done for her but did not want to send her out. ADON D stated the Keppra lab was not stat because, She [Resident #1] was calm and not having a seizure. That evening, ADON D stated the business office manager came to her and said the family saw Resident #1 having a seizure on the AEM camera. ADON D went to check on Resident #1 and asked LVN G if she had any additional seizures and she replied no. ADON D stated she did not think Resident #1 had any additional seizures due to her not having any visible indicators of her having a seizure, such as no blankets or sheets looked disturbed and she felt there would have to be more signs. ADON D stated, Like if she was shaking, she did not appear to have struggled with anything because there is going to be movement with her limbs, even though she is paralyzed on one side and can't move.so if she would have had another seizure, there would have been more visible signs. ADON D told them no, that seizure happened earlier in the day . ADON D said later that shift, she saw Resident #1's family member arrive at the facility who felt the resident did not look good and wanted her sent to the ER. The family was saying Resident #1 was not responding like her normal self. ADON D stated Resident #1 was calm, but her family still wanted her sent out because they felt she was having another seizure. ADON D stated she did not feel like Resident #1 had a change in condition and felt she was just being quiet on the day she had a seizure. ADON D said a change of condition could be anything from a resident's norm and if she observed it happen, she had to check vitals, do necessary assessments and notify the doctor. ADON D stated she told the charge nurse (LVN G) that she had talked to the NP and to complete a nursing note that reflected the PA was notified. ADON D stated she notified the NP on her phone via a text message but it did not occur until close to 4:00 PM. ADON D stated she did not notify the physician or extenders timely when the seizure occurred because she thought the charge nurse did. ADON D stated the charge nurse (LVN G) did not contact the physician or extenders. She stated, I didn't know, I told her I would contact [NP] to get an order for Keppra level and she needed to write a note. ADON D stated she did not notify Resident #1's RP when she had the seizure and thought LVN G did. ADON D stated it was important to notify RPs of a seizure because, We need to let them know it happened and we are working on it. Maybe they can give a history or what has worked in the past to intervene. ADON D stated a resident who continued to have seizure activity was at risk of aspiration, even with a g-tube because of saliva. The resident could also bite their tongue or swallow their tongue, and neurologically they could go into shock. An interview with PA E on 09/18/25 at 10:23 AM revealed she remembered being notified by ADON D about Resident #1's seizure and she ordered a lab to get a Keppra level. She stated she was not notified until later in the afternoon closer to 4pm. PA E stated she should be notified on how severe a resident's seizure was, to know if immediate action needed to be taken. PA E felt a seizure longer than a minute in duration would be considered a severe seizure. PA E stated the charge nurse should monitor that resident's vitals at least once an hour after a seizure event and their baseline mental status, like drowsiness and alertness. PA E stated she relied on the nursing staff to tell her if there was a situation going on with a resident. She said she did not know Resident #1 had been sent to the ER. PA E stated the MD/PA or NP were supposed to be notified when a resident was sent to the hospital but she did not see any communication from the facility about it. She stated the only message she received was form ADON D at 4 pm related to Keppra lab and seizure notification. PA E stated the risk of a resident having continued seizure activity was altered mental status, respiratory distress and brain trauma. An interview with the DON on 09/18/25 at 12:10 PM revealed there was no baseline Keppra lab for Resident #1 since her admission to the facility. An interview with Resident #1's RP/family member on 09/17/25 at 5:27 PM and subsequent follow up interview on 09/19/25 at 10:31 AM revealed the RP was not contacted after Resident #1's seizure the morning of 09/15/25. The RP stated the family was shocked to turn on the AEM camera in Resident #1's room to see her having a seizure that afternoon (time unknown) with nurses present in the room not intervening and then covering her and leaving the room while the resident was foaming at the mouth. The RP stated, They literally just covered her up and walked away! The RP stated Resident #1 presently was in an ICU unit of the hospital where she had limited brain activity. The RP stated she showed the camera footage to the medical staff at the hospital where it showed staff doing pericare for Resident #1 while she was foaming at the mouth. The RP said the doctors were shocked at the video. The RP stated while at the hospital, they have increased her Keppra medication for seizures and done and EEG because of her left side weakness and limited talking ability. When the RP confronted the facility, the RP talked to the new DON, who told the RP she had checked on Resident #1 since the seizure that morning and she was okay. The RP was upset family was not contacted and stated the AEM showed that the nurses neglected to check Resident #1's vitals and just covered her up. The RP said when he/she talked to the DON he/she told her the situation was inhumane. The RP said after that phone call, the nurses started pulling the privacy curtain to where the resident could not be viewed through the camera. The RP stated they came to the facility immediately after that to see what was going on. The RP said he/she asked the DON to contact Resident #1's doctor but the DON replied no. The RP stated, She [DON] refused everything I asked them to do. I asked what orders were in there by the doctor to help her with seizures and could she contact him if not. The RP said the DON told him/her that the doctor would see Resident #1 the next day because in her estimation, Resident #1 was still responsive because she responded to her name earlier, so it was not an emergency. The RP then stated, They are misleading and I specifically stated I'm call (911) since you've left [Resident #1] in a non-responsive state as if she's okay, and she wasn't.I will testify in a court of law that there was nothing done or even attempted, to settle my mind that they were truly assisting [Resident #1]. Review of AEM surveillance footage for Resident #1's room provided by the RP and time stamped 09/15/25 between 6:52 AM and 10:34 AM revealed the following:-At 6:52 AM, Resident #1 was observed awake in bed, alert and watching television. She used her left arm to adjust bed linens and extend her left leg toward the floor. Her right wrist appeared flexed inward. -At 7:04 AM, Resident #1 paused her movements, reclined her head and exhibited sudden stiffening of her left leg, left foot, left and right arms. Her eyes rolled upwards. -At 7:10 AM, Resident #1 appeared to be asleep.-Between 7:10 AM and 9:46 AM, Resident #1 remained in bed with no visible movement. -At 9:46 AM, foaming at the mouth was observed, with secretions visible along the right cheek. -At 10:10 AM, ADON D entered the room, called Resident #1's name, lowered the bed towards the floor and raised the HOB upright. She wiped Resident #1's mouth of secretions. Resident #1 exhibited minimal movement of the left hand. The ADON exited the room at 10:14 AM.-At 10:19 AM, ADON D and LVN G attempted to move Resident #1's arms; both were flaccid. -The final video segment at 10:34 AM showed LVN G and two additional unidentified staff in the room. Resident #1 remained on her left side, with continued foaming at the mouth along the right cheek. Hospital records were requested on 09/18/25 and 09/29/25 for Resident #1 from two different hospitals, one identified by the facility as the hospital to which Resident #1 was sent, and one identified by the RP as the hospital she reported the resident currently received treatment. As of 10/01/25, the records had not been received. [VT1] RESIDENT #2Record review of Resident #2's Face Sheet dated 09/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses were listed as hyperlipidemia (abnormally high levels of fats in the blood) and diabetes (a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production). Record review of Resident #2's e-chart reflected due to being a new admission, she did not have an MDS completed yet. Record review of Resident #2's initial care plan dated 09/15/25 reflected the following focus areas: 1. Focus: The resident is risk for falls [Date Initiated: 09/15/2025]; Interventions: Anticipate and meet the resident's needs, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c[VT2] , Keep furniture in locked position, Keep needed items, water, etc., in reach, PT evaluate and treat as ordered or PRN, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove [VT3] any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Staff to assist with transfers, Fall r/t [VT4] weakness- send to ER, therapy notified, educated -falls-safety [revised 09/19/25], The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) [Revised 09/19/25]2. The resident has a bruise [Start date 09/15/25]-Interventions: Attempt to determine the cause of the bruising, if known attempt to alleviate that factor, Monitor bruising every shift for 72 hours. Note color and characteristics. If negative changes report to the MD, Monitor for and treat pain as indicated.3) The resident has a skin tear, laceration, or abrasion [Date Initiated: 09/15/2025]-Interventions: The residents skin injury will resolve without complications, Assess reason for skin injury occurrence. Notify staff of cause; determine measures to prevent further skin injuries, Monitor and treat pain as indicated, Monitor the skin injury every shift for 72 hours. Assess for bleeding, signs of infection (increased redness, warmth, drainage, odor) Notify the MD for any negative changes, Perform any wound care as ordered. An interview with LVN G on 09/17/25 at 1:20 PM revealed she was not at the facility when Resident #2 fell and had to be sent to the ER, but came back the next day and there were no new orders or clinical documentation, so she did not know if Resident #2 sustained any injuries. LVN G stated if a resident came back from the hospital with no documentation, then the charge nurse would need to document it and report it to the nursing management who could follow up to obtain them. LVN G stated it was out the charge nurses' control if the resident came back with no hospital documentation and the nurse would not know what happened as a result. An interview and observation with Resident #2 on 09/17/25 at 1:30 PM revealed she was in a wheelchair by the nurses station with non-slip socks on. She was observed with a large fading greenish yellow bruise around her right eyebrow extending down into her right eyelid about three inches in diameter. Resident #2 had approximately a one-inch cut with stitches above her right eyebrow. She was verbal but not oriented to questions. When asked what happened to her right eye, she motioned towards the injury and said her [AGE] year-old sister scratched her but it did not hurt. She said what hurt was the other side of her head where two women had thrown rocks at her. She was unable to give any other details due to her limited cognition. An interview with CNA H on 09/19/25 at 1:45 PM revealed the day of Resident #2's fall, they were short-staffed one CNA that day and she heard Resident #2's family member yell out saying the resident had tripped and fallen. CNA H stated she was the first staff member to enter the her room and found her on the floor with blood coming from her head. CNA H and LVN B then got Resident #2 up and she had a gash above her eye with blood coming out. She said an ambulance was called and Resident #2 said her head was hurting. After she came back from the ER post fall, CNA H stated she had been different, calmer and not as erratic with behaviors as before. An interview with RN A on 09/20/25 at 8:57 AM revealed Resident #2 did not fall on her shift, but she heard about it. She did not feel Resident #2 was acting any different than her baseline since the fall. RN A stated when a resident hit their head, neurochecks were required to be completed. She said neurochecks were important because there could be an internal injury inside the head and it could become a serious problem. An interview with LVN B on 09/21/25 at 11:34 AM revealed she was in the med room when she heard Resident #2's family member calling out for help. LVN B went to see Resident #2 and found her moaning face down on the floor by the bathroom door with a gash on the right side of her forehead. The family member told LVN B that Resident #1 took another resident's walker and when the family member was putting it behind the nurses' station, the resident had the unwitnessed fall in her room. At that point, LVN B stated Resident #2's vitals were checked and the charge nurse assigned to her that shift was LVN F. LVN F came to Resident #2's room and assessed her and there did not appear to be any other injuries, however, due to the head wound and amount of blood, they wanted to send her out. LVN B stated Resident #2 came back from the ER right before her shift was over around 7:00 PM. She stated LVN F checked the resident's vitals and talked with the family and had her hospital paperwork. LVN B stated she helped by putting Resident #2 back into the e-charting system. LVN B stated the charge nurse working when Resident #2 came back from the ER was responsible for charting and doing neuros on her per protocol. LVN B stated the DON and ADON D were texting and calling her to come in during the past week to complete the risk management form (incident report). She told them she was not the nurse, it was LVN F. She said LVN F should have done an incident report that day for Resident #2. LVN B stated she did not know the facility's protocol for doing neurochecks on residents post-fall, including when to start them if they were sent out to the ER. LVN B said when a resident sustained a head strike from a fall, the charge nurse was supposed to do a risk assessment (incident report) and check if the resident took blood thinner medication, get vitals and call the physician and family to see if they want the resident sent out. LVN B stated when a resident hits their head, they could potentially have a brain bleed which could be fatal, so they should be monitored for three days. She said even if the resident was sent out and they returned within 72 hours, neurochecks still had to be completed. An interview with Resident #2's RP on 09/21/25 at 12:07 PM revealed the resident had dementia and when she was visiting her, she could not find her initially and then saw her a few doors down with another resident's walker. The RP stated Resident #2 did not use a walker for ambulation and she was holding the walker backwards, using it like she was driving a car. Resident #2 told the RP that she did not know whose walker it was but some guy was chasing her. The RP removed the walker and guided Resident #2 to her chair and went to place the walker behind the nurses' station. When she went back to Resident #2's room, she was on the floor. The RP started hollering for help and several staff showed up and checked for bleeding. The RP told them she wanted Resident #2 to go out to the ER. At the ER, Resident #2 received some stitches and her CT scan was clear. The RP stated she brought the ER discharge documentation and gave the originals to the evening charge nurse. An interview with the DON on 09/21/25 at 2:10 PM revealed she had located Resident #2's records from the facility's online hospital portal from the ER visit. She stated the hospital records had not been on Resident #2's chart. The DON stated that she had only started employment on 09/15/25 and she had not yet gotten around to seeing if the neurological assessments for Resident #2 were done post-fall. The DON stated neuros should be done for four days and there was a schedule the nursing staff had to follow that started off with 15-minute monitoring, then to one hour, then to once per shift. The DON stated the nurse who did record Resident #2's vitals on the e-transfer form stated the resident was stable when she was sent to the ER. Review of Resident #2's ER hospital records provided by the DON on 09/21/25 reflected the resident seen by the ER on [DATE] due to a head laceration and a head injury from a fall. She had a diagnosis of a closed head injury and a facial laceration. Resident #2 had a CT cervical spine without contrast and a CT head without contrast. Resident #2 had ice applied to the affected area and was given Lidocaine-Epinephrine. The after-visit summary was completed at 2:56 pm on 09/14/25. An interview with LVN F on 09/21/25 at 2:36 PM revealed she was a PRN nurse who worked primarily on the weekends. For a resident who had a fall with a head strike, LVN F stated she would assess the resident for injuries and start neurochecks on them every 15 minutes until they were sent out to the hospital. She stated neurochecks included looking at the eyes to see if they were equal and reactive, checking if a resident could squeeze the nurse's hand and with what force, and if the resident was alert and oriented. LVN F stated she had not seen what neurochecks looked like for the facility's residents. She stated, I actually have not seen one [neuro eval] per say, but I know there are questions pertaining to the neurological in the system itself. I am just learning [online e-charting system]. LVN F stated if neurochecks were not completed after a head strike, a resident could become comatose and the nurse would not be aware when their consciousness slipped if we are not on top of that. LVN F said she was present when Resident #2 fell. She said that day she was working with two CNAs in another resident's room when she could hear the Resident's RP screaming that the resident was on the floor. LVN F entered the room and saw Resident #2 had hit her head on the right side of her forehead on the wooden dresser and her arm was bent in the back position and she was moaning in discomfort. LVN F stated Resident #2 never lost consciousness but was in a chronic state of dementia and due to the heavy bleeding coming from the wound, she called 911 to have her sent to the ER. LVN F stated another nurse named [LVN B] did the incident report for her because she was not as comfortable with the online charting as LVN B was. Also, LVN F stated, I didn't know what to look for in order to generate the report. When Resident #2 came back fro

Based on interview and record review, the facility failed to ensure each resident received and was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to include but not limited to, the prevention and treatment of mental and substance use disorders for one (Resident #3) of three residents reviewed for behavioral health care. The facility failed to assess, monitor and implement appropriate behavioral health interventions for Resident #3, who lived with bipolar disorder and dementia and repeatedly refused prescribed psychotropic medications.The facility failed to ensure Resident #3's care plan was revised or initiated timely psychological or psychiatric services in response to the refusals. As a result, Resident #3's behaviors escalated, leading to physical aggression towards another resident on 09/19/25 and subsequent transfer to an inpatient hospital for stabilization. An Immediate Jeopardy (IJ) situation was identified on 09/21/25. While the IJ was removed on 09/23/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility needing to evaluate the effectiveness of their corrective systems. Findings include: Record review of Resident #3's face sheet, dated 09/21/24, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit (Impairment in communication abilities due to deficits in attention, memory or other cognitive processes), dementia with behavior disturbance (progressive cognitive decline accompanied by agitation, aggression or other behavioral symptoms), bipolar disorder (a mental health condition marked by alternating periods of depression and elevated mood/mania or hypomania), major depressive disorder (mood disorder involving persistent sadness, loss of interest and impaired daily functioning) and insomnia (persistent difficulty staying asleep). Resident #1 had two family members listed as her emergency contacts. Record review of Resident #3's admission MDS Assessment, dated 08/06/25, reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, beliefs, and behaviors), which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Resident #3's activity preferences that were very important and included, having books/newspapers/magazines, being around people and pets, doing favorite activities, going outside to get fresh air when the weather is good and participate in religious services or practices. Record review of Resident #3's care plan, initiated 08/02/25, reflected the following focus areas were added after the resident-to resident behavioral aggression incident on 09/18/25: 1) [Resident #3] has Bipolar Disorder [Date Initiated: 09/18/25]; 2) The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident to resident encounter [Date initiated 09/18/25];3) [Resident #3] is at risk for wandering- disoriented to place [Date Initiated: 09/19/2025]; 4) [Resident #3] has potential to demonstrate physical behaviors-Poor impulse control [Date Initiated: 09/19/2025]; 5) [Resident #3] has potential to demonstrate physical behavior- Poor impulse control [Date Initiated: 09/19/2025]; 6) [Resident #3] has potential to demonstrate verbally abusive behaviors-Dementia, Mental / Emotional illness [Date Initiated: 09/18/2025]; Resident #3's care plan did not discuss a focus area related to Resident #3's medication refusals. Record review of Resident #3's Physician Order Summary for September 2025 reflected she was prescribed, Buspirone 10mg once a day related to bipolar disorder, current mixed episode (start date 07/26/25, discontinued 09/11/25), Lamictal 25 mg twice a day related to bipolar disorder (start date 07/26/25), Trazadone 100 mg at bedtime related to insomnia (start date 07/26/25), Memantine 10 mg once a day for unspecified dementia with behavioral disturbance (start date 07/26/25 and Aricept 5 mg at bedtime for dementia (start date 07/26/25). Additionally, there was an order dated 07/30/25 to refer Resident #3 for in-house psychiatric and counseling services. On 09/19/25, there was a physician's order which stated, Send to ER for Psyche Evaluation. Record review of Resident #3's August 2025 MAR reflected documented refusals of the following medications: -Buspirone was refused 18 times: (August 2nd ,3rd ,7th ,9th ,10th-13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st).-Lamictal was refused 18 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th, 15th-23rd) on the AM dose and 16 times (August 2nd, 3rd, 7th, 11th-13th,15th-17th, 20th ,21st, 25th, 26th, 29th-31st) on the PM dose.-Trazadone was refused 16 times (August 2nd, 3rd, 7th, 11th, 12th, 13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st).-Memantine was refused 23 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th,15th-23rd, 25th-27th, 29th-31st). Record review of Resident #3's September 2025 MAR reflected documented refusals of the following medications:-Buspirone was refused nine times (September 1st, 3rd, 5th-11th). The medication was documented as discontinued on the MAR on 09/11/25 at 12:47 PM. -Lamictal was refused 16 times (September 1st, 3rd, 5th-13th, 15th-19th) on the AM shift and seven times of the PM shift (September 3rd, 4th,7th-9th, 14th and 18th).-Trazadone was refused seven times (September 3rd, 4th, 7th, 8th, 9th, 14th and 18th).-Memantine was refused 15 times (September 1st, 3rd, 5th, 6th, 8th-13th, 15th-19th). Record review of Resident #3's e-administration medication notes starting 08/22/25 through 09/19/25 reflected the main reasons for refusals of medications were because the resident did not think she needed them. Record review of NP K's progress notes (extender for MD J) reflected she saw Resident #3 twice when she first admitted to the facility on [DATE] and 07/30/25. On 07/28/25, NP K documented, Plan:.Monitor for changes in mood or behaviors, refer to psyche for support, monitor for changes in neuro or functional status, does not take routine medications. On 07/30/25, NP K documented the exact same verbiage during the visit. Record review of Resident #3's clinical chart reflected she was seen by MD J on 08/05/25 which reflected, Continue present medication management, we will collaborate with psychiatry services. MD J stated he was unable to complete a full assessment due to Resident #3 having an angry demeanor, cognitive deficits and refusals to engage with him. Record review of Resident #3's e-clinical chart to include all provider progress notes reflected she was not seen by the facility's contracted psych services until 08/25/25. During that visit, the PMHNP reflected Resident #3 was seen for confusion, dementia, depression/sadness, resistance to care or ADLs/meds and insomnia and bipolar disorder. The PMHNP stated, The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse of hospitalization and to improve restorative potential. The assessment further stated, Patient reports I am doing fine. Staff report there are no issues.Plan: Patient will continue with current medications. The Treatment Plan of Care recommendations included, Ongoing medication management and behavioral management techniques to include reduction in psychotic thinking, stabilization of anxious/irritable mood and stabilization of cognitive problems. The PMHNP reflected Resident #3 had the capacity to participate in treatment and future visits were recommended one to four times a month and treatment was recommended for six months. Record review of nursing progress notes related to Resident #3's behaviors included on 08/28/25, 09/08/25 she refused to take medications. On 09/08/25, Resident #3 slapped a staff who tried to help her find a jacket, then later that day she tried to block a resident from wheeling himself to the dining room. On 09/11/25, Resident #3 was documented as being aggressive and scratched an aide's hand which the aide was trying to stop her from taking other residents' belongings. On 09/14/25, Resident continues with confusion-wandering and taking food off of other residents' tray.Resident came to nurse's station and just started yelling at the staff but was not making any sense - resident was redirected and taken back to her room.Resident is going into other residents' rooms and taking their things - claiming their items as her own - nurse asked her to stop which made the resident angry and she tried to throw a bottle of body wash at this nurse - nurse was able to deescalate the situation and walked away [LVN B]. A CMP and CMP Lab was ordered on 09/18/25 as well as a Lamictal lab. Family notification was documented as attempted with no success. On 09/18/25, Resident #3 also was documented as being aggressive towards another resident in the dining room during breakfast and refused all medications. PA E was notified of the refusals and order to continue to offer resident her medications, responsible party was notified. On 09/18/25, Resident #3 refused her PM medications, became aggressive towards another resident trying to grab the blanket wrapped around the other resident, and then sat on the floor and stated she was mad at ADON D for trying to make her go to her room. The next day on 09/19/25, Resident #3 was noted by the DON to be in the dining room and appeared guarded, uncooperative with cues and not rational, hyperactive and rapidly talking, her mood is anxious with flight of ideas, she continues to be interjecting others and with poor insight to current situations, she is being offered activities, hydration.Resident is very combative to staff and other residents.Resident continues to refuse medication. MD made aware of concerns. Unable to reach family members. ADON D wrote a nursing note on 09/19/25 that reflected Resident #3 was transferred to the hospital for behaviors per PA E for refusing medications, refusing care and being combative. Record review of Resident #3's SW progress note, dated 09/11/25, reflected an attempt was made to contact Resident #3's family member to provide updates on the resident's care and overall well-being. On 09/18/25, a SW progress note reflected a voicemail was left informing the resident's emergency contact that referrals were sent to other facilities with memory care units to better meet the resident's evolving needs. Record review of a Behavior Event Nurses' Notes, dated 09/18/25 at 2:48 PM, written by a Corporate Compliance Nurse reflected a verbal behavioral event occurred in the dining room where Resident #3 was waving a fork in the air, rambling loudly incoherent words at the table with another resident. Neither resident made physical contact with each other. Resident #3's cognition/behavior at the time of the incident was documented as cognitive impairment, refuses to call for assistance, requires cueing, resists redirection, new or increased confusion, combative, agitated, restless. There were no injuries to Resident #3 or the other resident. Resident #3 was noted to be removed from the dining room and redirected back to her room to rest. She was assessed and placed on checks every 15 minutes. Resident #3 was incoherently mumbling, unable to discern words and did not make a statement about the event. The MD and the primary emergency contacts were notified of the incident on 09/18/25 at 2:30 PM. An interview with RN A on 09/20/25 at 8:57 AM revealed if a resident refused to take medications, the med aides and charge nurses should wait a few minutes and try again. If three attempts were unsuccessful, the physician had to be notified, Because we keep these meds for a reason, so if they are not taking them, then that problem isn't being taken care of and maybe the doctor can give an alternative. RN A stated Resident #3 always refused medications and her compliance was unpredictable, like sometimes she would take night meds but not the morning meds. RN A stated Resident #3 was sent out the day before on 09/19/25 and it was reported the resident was being aggressive. An interview with LVN B on 09/21/25 at 11:34 AM revealed when a resident refused medications, the charge nurse should try several attempts and then see if another nurse could convince the resident to take it. If still refusing, the charge nurse should notify the family and physician. LVN B stated since Resident #3 admitted , the resident had never taken any medications from LVN B, she always refused. LVN B stated she last worked with Resident #3 two weeks prior and remembered she was acting weirder than normal, like taking things from people's rooms. She said if staff looked at Resident #3 a certain way or asked her too many questions, she would get upset. LVN B stated she was telling other staff and management about the behaviors but did not know if any follow up was done. LVN B stated if Resident #3 did not take her prescribed medications, it could cause her to become more aggressive and make the dementia worsen. LVN B stated she documented the refusal of medications in Resident #3's progress notes and MD J knew of her behaviors. LVN B said the psychiatrist during a visit mentioned adding more medication to her orders, but LVN B had to explain the resident did not take medications so it would not make sense to change her meds around. LVN B stated she never figured out how to get Resident #3 to take her medications and the resident would often tell her she was healthy and did not need them. LVN B stated if Resident #3's medication refusals were not addressed, her aggressive behaviors could result in self-injury, hurting others, and she would slowly lose her ability to talk. An interview with Resident #3's family member and secondary emergency contact on 09/21/25 at 10:25 AM revealed she did not know the facility sent the resident to a psych hospital for evaluation. She stated on Thursday-09/18/25, the BOM called to see if she knew how to contact Resident #1's primacy emergency contact because he had not called her back. The family member stated there was some negative energy between Resident #1 and that family member as she felt he had stuck her in a nursing home and took away her independence. The family member stated Resident #1 had lived prior to last year in an apartment on her own, with an emotional support service dog and had a caregiver that came in every day to care for her and ensure she was taking her medications. She stated living in a nursing home was the last thing Resident #3 ever wanted and that family member used the threat of putting her in a nursing home as a way to punish her. As a result, the resident was upset about her living situation. The family member stated Resident #3 lived with bipolar disorder from a young age and began treating it with medications when she was in her mid-20's. The family member said, Her temper is terrible since she was a kid, she will get mouthy, hurt your feelings, but would settle down after a few days. She said if Resident #3 did not take her medications for bipolar disorder, she would become agitated and angry. She stated Resident #3 had a history of not taking her medications and a misconception she thought was fine and had been an issue when she lived at home independently. The family member stated with Resident #3's dementia and bipolar disorder, the things that made her happy would be music, specifically country western and gospel. She also said just talking to the resident to get her onto a different topic and taking her outside because she loved plants and flowers. The family member stated, Also being kind.you have to learn to work with her, you get her to do things, but you want to make her think she is doing it because she likes to have control of her decisions and wants to be as independent as possible. The family member stated Resident #3 always was a social person, and sometimes would join games, do activities and reading if she could concentrate, and if there was a pastor or church services she would enjoy that as well for relaxation. The family member stated no one from the facility notified her Resident #3 had been refusing her medications consistently since she was admitted to the facility. The family member stated, I would have been very upset if I would have known they were letting her get by with refusing and I am surprised with those medications.it is not like they are vitamins or over the counter meds, those are for bipolar, thyroid and dementia. She said the resident could not be off them for long before they would, mess her up and she would not make good decisions. An interview with the DON on 09/21/25 at 3:10 PM revealed she was not aware of Resident #3's medication refusals since admission as she had just started employment on 09/15/25. She stated at some point during her first week, she remembered ADON D reported Resident #1 had some behaviors and was not taking her medications. She stated on Tuesday, 09/16/25, she saw Resident #3 calm drinking coffee and talking to herself in third person. She said two days later, on 09/18/25, was when things worsened and she tried to take a blanket from another resident while she was holding a fork in her hand and stemming. The DON stated the facility asked for labs and got them ordered, but it was decided she needed to be sent out on 09/19/25. The DON stated she looked at Resident #3's chart and did not see a psych evaluation, so she called the contracted company who said they saw the resident once on 08/25/25 for what the DON thought was her initial visit. She said going forward, the facility was going to notify the physician and RP of any residents' medication refusals and after three days, the facility would initiate a psych eval for that resident. If that was not possible, then the DON stated they would send the resident out for a psych evaluation. She stated she did not know what the process was prior to her becoming the DON. The DON stated if Resident #3 did not take her prescribed dementia-related and psychotropic medications, It could make her go into many stages and escalate, not just towards the residents, staff.anyone. An interview with CCN K on 09/22/25 at 8:06 PM revealed she did not know about Resident #3's medication refusals and escalating behaviors. She stated her expectation was if there was a resident with continuous medication refusals, the family and MD should be notified to see if there were alternate interventions. CCN K stated if Resident #3 had dementia, then psych should have been seeing her. CCN K stated sometimes a facility could do a Negotiated Risk Assessment (a written contract in long-term care settings that documents a resident's informed decision to accept a specific safety or health risk, such as the risk of falls, despite being aware of the potential consequences) if a resident was non-compliant with medications, It lets them [family] know this can happen. An interview with SW C on 09/23/25 at 10:13 AM revealed she knew Resident #3 had been refusing her medications since she first admitted . She stated Resident #3 had verbal behaviors more than anything and was easily irritated and she did not know what her triggers were. She stated the resident was not aggressive towards self, staff or other residents as far as she knew. If a resident with dementia or psych concerns refused medications, SW C said it would be the nursing staff who would need to address it and notify the resident's emergency contact. SW C stated she did not recommend any interventions when Resident #3 began refusing her medications. She said the nurses were in charge of ensuring residents received psychiatric services and SW C did not communicate any issues with the PMHNP related to Resident #3. SW C stated when Resident #3 began having increased behaviors, she tried to reach out to her EC but was only able to leave a voice mail. SW C stated she was not included in the decision to send Resident #3 to a psych hospital. She said normally the nursing staff would ask her if she saw a change in condition or any incidents, but ultimately that would be up to nursing staff for an evaluation. SW C stated Resident #3 was sent out, based on mood and behaviors. Record review of the facility's, undated, policy titled, Behavioral Health reflected, Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.Individualized Assessment and Person-Centered Planning: In addition to the facility-wide approaches that address residents' emotional and psychosocial well-being, the facility will ensure that residents' individualized behavioral health needs are met.It is also important for the facility to use an interdisciplinary team (IDT) approach that includes the resident, their family, or resident representative. This was determined to be an Immediate Jeopardy (IJ) on 09/21/25 at 3:35 PM. The R-AD and DON were notified. The R-AD and DON were provided with the IJ template on 09/21/25 at 4:38 PM. The following Plan of Removal submitted by the facility was accepted on 09/22/25 at 9:22 PM: Date: 9/21/25-Plan of Removal-F740 Behavioral Health Services Resident#3 refused dementia and psychotropic medication. There were no care planned interventions addressing refusals. The resident experienced escalated behaviors and was transferred to the psychiatric hospital on 9/19/25. Interventions: 1. Resident #3 was admitted to the hospital on [DATE]. Resident #3 remains in the hospital as of 9/21/25. 2. All residents on dementia and psychotropic medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse. Completion date 9/22/25. 3. The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication. Completion date 9/22/25. 4. All residents on psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions are in place to address medication refusals and history of behaviors. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse. Completion date 9/22/25. 5. New Process: The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals 7 days per week. The medication administration report will also be reviewed during this process 7 days per week to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The care plan will be updated by the DON, ADON, or MDS Nurse. Completion date 9/22/25. 6. The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/18/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors. 7. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25 and 9/21/25. 8. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/21/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced as of 9/21/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. Completion date 9/21/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors. Monitoring the Plan of Removal implementation occurred on 09/21/25, 09/22/25 and 09/23/25 through daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs, medication refusal logs, behavior monitoring logs and care plan revisions to ensure interventions were implemented for residents with behavioral health needs. Record reviews for additionally sampled residents with psychotropic medication refusals to verify the assessments, physician notifications, psychiatric referrals and care plan updated were completed. No concerns were noted. Record review of staff in-services conducted on 09/21/25, 09/22/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services reflected that training was completed for all shifts and addressed required documentation, behavioral health concerns and notification procedures. Interview with twenty nursing staff were conducted on 09/21/25, 09/22/25 and 09/23/25 across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize the facility's procedures for identifying and documenting medication refusals, to include immediate notification of the charge nurse, documentation in the medication administration record and timely notification to the physician and psychiatric provider. Staff also verbalized the process for escalating behavioral changes, including notifying supervisory staff, initiating behavior monitoring and contacting psychiatric services as needed. Record review of the facility's Ad HOC QAPI meeting on 09/21/25 was conducted to review the facility progress, monitor for additional resident medication refusals or escalations, and verify interventions and physician/psychiatric notifications were completed timely. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one of three residents (Resident #3) reviewed for dementia care. The facility failed to ensure Resident #3 received the appropriate treatment and services for her dementia diagnoses. Resident #3's behavior escalation resulted in a physical aggression incident on 09/19/25 towards another resident and subsequent transfer to an inpatient psychiatric hospital for further evaluation. An Immediate Jeopardy (IJ) situation was identified on 09/21/25. While the IJ was removed on 09/23/25, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need evaluate the effectiveness of the corrective systems. This failure could place residents at risk for untreated dementia symptoms and behavior escalation, aggression towards residents and staff, physical altercations, injuries, worsening cognitive decline, psychiatric destabilization and the need for emergency interventions such as hospitalization. Findings include: Record review of Resident #3's Face Sheet dated 09/21/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit (Impairment in communication abilities due to deficits in attention, memory or other cognitive processes), dementia with behavior disturbance (progressive cognitive decline accompanied by agitation, aggression or other behavioral symptoms), bipolar disorder (a mental health condition marked by alternating periods of depression and elevated mood/mania or hypomania), major depressive disorder (mood disorder involving persistent sadness, loss of interest and impaired daily functioning) and insomnia (persistent difficulty staying asleep). Resident #1 had two family members listed as her emergency contacts. Record review of Resident #3's admission MDS assessment dated [DATE] reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis, which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Resident #3's activity preferences that were very important and included, having books/newspapers/magazines, being around people and pets, doing favorite activities, going outside to get fresh air when the weather is good and participate in religious services or practices. Record review of Resident #3's care plan, initiated 08/02/25, reflected the following focus areas were added after the resident-to resident behavioral aggression incident on 09/18/25: -[Resident #3] is at risk for wandering- disoriented to place [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate physical behaviors-Poor impulse control [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate physical behavior- Poor impulse control [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate verbally abusive behaviors-Dementia, Mental / Emotional illness [Date Initiated: 09/18/2025]; Resident #3's care plan did not discuss Resident #3's medication refusals and did not address her dementia and related behavioral interventions. Record review of Resident #3's Physician Order Summary for September 2025 reflected she was prescribed, Memantine 10 mg once a day for unspecified dementia with behavioral disturbance (start date 07/26/25) and Aricept 5 mg at bedtime for dementia (start date 07/26/25). Additionally, there was an order dated 07/30/25 to refer Resident #3 for in-house psychiatric and counseling services. On 09/19/25, there was a physician's order which stated, Send to ER for Psyche Evaluation. Record review of Resident #3's August 2025 MAR reflected documented refusals of the following medications: -Aricept was refused 18 times (August 2nd, 3rd, 7th, 9th-13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st)-Memantine was refused 23 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th,15th-23rd, 25th-27th, 29th-31st). Record review of Resident #3's September 2025 MAR reflected documented refusals of the following medications:-Aricept was refused five times (September 3rd, 4th, 7th, 8thand 9th) -Memantine was refused 15 times (September 1st, 3rd, 5th, 6th, 8th-13th, 15th-19th). Record review of Resident #3's e-administration medication notes, starting 08/22/25 through 09/19/25, reflected the main reasons for refusals of medications were because the resident did not think she needed them. Record review of NP K's progress notes (extender for MD J) reflected she saw Resident #3 twice when she first admitted to the facility on [DATE] and 07/30/25. On 07/28/25, NP K documented, Plan:.Monitor for changes in mood or behaviors, refer to psyche for support, monitor for changes in neuro or functional status, does not take routine medications. On 07/30/25, NP K documented the exact same verbiage during the visit. Record review of Resident #3's clinical chart reflected she was seen by MD J on 08/05/25 which reflected, Continue present medication management, we will collaborate with psychiatry services. MD J stated he was unable to complete a full assessment due to Resident #3 having an angry demeanor, cognitive deficits and refusals to engage with him. Record review of Resident #3's e-clinical chart to include all provider progress notes reflected she was not seen by the facility's contracted psyche services until 08/25/25. During that visit, the PMHNP reflected Resident #3 was being seen for confusion, dementia, depression/sadness, resistance to care or ADLs/meds and insomnia and bipolar disorder. The PMHNP stated, The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse of hospitalization and to improve restorative potential. The assessment further stated, Patient reports I am doing fine. Staff report there are no issues.Plan: Patient will continue with current medications. The Treatment Plan of Care recommendations included, Ongoing medication management and behavioral management techniques to include reduction in psychotic thinking, stabilization of anxious/irritable mood and stabilization of cognitive problems. The PMHNP reflected Resident #3 had the capacity to participate in treatment and future visits are recommended one to four times a month and treatment was recommended for six months. Record review of nursing progress notes related to Resident #3's behaviors included on 08/28/25, 09/08/25 she refused to take medications. On 09/08/25, Resident #3 slapped a staff who tried to help her find a jacket, then later that day she tried to block a resident from wheeling himself to the dining room. On 09/11/25, Resident #3 was documented as being aggressive and scratched an aide's hand which the aide was trying to stop her from taking other residents' belongings. A few days later on 09/14/25, Resident continues with confusion-wandering and taking food off of other residents' tray.Resident came to nurse's station and just started yelling at the staff but was not making any sense - resident was redirected and taken back to her room.Resident is going into other residents' rooms and taking their things - claiming their items as her own - nurse asked her to stop which made the resident angry and she tried to throw a bottle of body wash at this nurse - nurse was able to deescalate the situation and walked away [LVN B]. A CMP and CMP Lab was ordered on 09/18/25 as well as a Lamictal lab. Family notification was documented as attempted with no success. On 09/18/25, Resident #3 also was documented as being aggressive towards another resident in the dining room during breakfast and refusing all medications. PA E was notified of the refusals and order to continue to offer resident her medications, responsible party was notified. Later that day on 09/18/25, Resident #3 refused her PM medications, became aggressive towards another resident trying to grab the blanket wrapped around the other resident, and then sat on the floor and stated she was mad at ADON D for trying to make her go to her room. The next day on 09/19/25, Resident #3 was noted by the DON to be in the dining room and appeared guarded, uncooperative with cues and not rational, hyperactive and rapidly talking, her mood is anxious with flight of ideas, she continues to be interjecting others and with poor insight to current situations, she is being offered activities, hydration.Resident is very combative to staff and other residents.Resident continues to refuse medication. MD made aware of concerns. Unable to reach family members. ADON D wrote a nursing note on 09/19/25 that reflected Resident #3 was transferred to the hospital for behaviors per PA E for refusing medications, refusing care and being combative. Record review of Resident #3's SW progress note dated 09/11/25 reflected an attempt was made to contact Resident #3's son to provide updates on the resident's care and overall well-being. On 09/18/25, a SW progress note reflected a voicemail was left informing the resident's emergency contact that referrals had been sent to other facilities with memory care units to better meet the resident's evolving needs. Record review of a Behavior Event Nurses' Notes dated 09/18/25 at 2:48 PM written by a corporate compliance nurse reflected a verbal behavioral event occurred in the dining room where Resident #3 was waving a fork in the air, rambling loudly incoherent words at the table with another resident. Neither resident made physical contact with each other. Resident #3's cognition/behavior at the time of the incident was documented as cognitive impairment, refuses to call for assistance, requires cueing, resists redirection, new or increased confusion, combative, agitated, restless. There were no injuries to Resident #3 or the other resident. Resident #3 was noted to be removed from the dining room and redirected back to her room to rest. She was assessed and placed on checks every 15 minutes. Resident #3 was incoherently mumbling, unable to discern words and did not make a statement about the event. The MD and the primary emergency contacts were notified of the incident on 09/18/25 at 2:30 PM. An interview with RN A on 09/20/25at 8:57 AM revealed if a resident refused to take medications, the med aides and charge nurses should wait a few minutes and try again. If three attempts are unsuccessful, the physician had to be notified, Because we keep these meds for a reason, so if they are not taking them, then that problem isn't being taken care of and maybe the doctor can give an alternative. RN A stated Resident #3 had always refused medications and her compliance was unpredictable, like sometimes she would take night meds but not the morning meds. RN A stated Resident #3 had been sent out the day before on 09/19/25 and it was reported the resident was being aggressive. An interview with LVN B on 09/21/25 at 11:34 AM revealed when a resident refused medications, the charge nurse should try several attempts and then see if another nurse could convince the resident to take it. If still refusing, the charge nurse should notify the family and physician. LVN B stated since Resident #3 admitted , the resident had never taken any medications from LVN B, she always refused. LVN B stated she last worked with Resident #3 two weeks prior and remembered she was acting weirder than normal, like taking things from people's rooms. She said if staff looked at Resident #3 a certain way or asked her too many questions, she would get upset. LVN B stated she had been telling other staff and management about the behaviors but did not know if any follow up was done. LVN B stated if Resident #3 did not take her prescribed medications, it could cause her to become more aggressive and make the dementia worsen. LVN B stated she documented the refusal of medications in Resident #3's progress notes and MD J knew of her behaviors. LVN B said the psychiatrist during a visit mentioned adding more medication to her orders, but LVN B had to explain that the resident did not take medications so it would not make sense to change her meds around. LVN B stated she had never figured out how to get Resident #3 to take her medications and the resident would often tell her she was healthy and did not need them. LVN B stated if Resident #3's medication refusals were not addressed, her aggressive behaviors could result in self-injury, hurting others, and she would slowly lose her ability to talk. An interview with Resident #3's family member and secondary emergency contact on 09/21/25 at 10:25 AM revealed she did not know the facility sent the resident to a psyche hospital for evaluation. She stated on Thursday-09/18/25, the BOM called to see if she knew how to contact Resident #1's primacy emergency contact because he had not called her back. The family member stated there was some negative energy between Resident #3 and that family member as she felt he had stuck her in a nursing home and taken away her independence. The family member stated Resident #3 had lived prior last year in an apartment on her own, with an emotional support service dog and had a caregiver that came in every day to care for her and ensure she was taking her medications. She stated living in a nursing home was the last thing Resident #3 ever wanted and that family member used the threat of putting her in a nursing home as a way to punish her. As a result, the resident was upset about her living situation. The family member stated Resident #3 lived with bipolar disorder from a young age and began treating it with medications when she was in her mid-20's. The family member said, Her temper is terrible since she was a kid, she will get mouthy, hurt your feelings, but would settle down after a few days. She said if Resident #3 did not take her medications for bipolar disorder, she would become agitated and angry. She stated Resident #3 had a history of not taking her medications and a misconception that she thought she was fine and that had been an issue when she lived at home independently. The family member stated with Resident #3's dementia and bipolar disorder, the things that have made her happy would be music, specifically country western and gospel. She also said just talking to the resident to get her onto a different topic and taking her outside because she loved plants and flowers. The family member stated, Also being kind.you have to learn to work with her, you get her to do things but you want to make her think she is doing it because she likes to have control of her decisions and wants to be as independent as possible. The family member stated Resident #3 had always been a social person, sometimes would join games, do activities and reading if she can concentrate, and if there was a pastor or church services she would enjoy that as well for relaxation. The family member stated no one from the facility notified her that Resident #3 had been refusing her medications consistently since she was admitted to the facility. The family member stated, I would have been very upset if I would have known they were letting her get by with refusing and I am surprised with those medications.it is not like they are vitamins or over the counter meds, those are for bipolar, thyroid and dementia. She said the resident could not be off them for long before they would, mess her up and she would not make good decisions. An interview with the DON on 09/21/25 at 3:10 PM revealed she was not aware of Resident #3's medication refusals since admission as she had just started employment on 09/15/25. She stated at some point during her first week, she remembered ADON D reported that Resident #1 was having some behaviors and not taking her medications. She stated on Tuesday 09/16/25, she saw Resident #3 calm drinking coffee taking to herself in third person. She said two days later, on 09/18/25 was when things worsened and she tried to take a blanket from another resident while she was holding a fork in her hand and stemming. The DON stated the facility asked for labs and got them ordered, but it was decided she needed to be sent out on 09/19/25. The DON stated she looked at Resident #3's chart and did not see a psyche evaluation, so she called the contracted company who said they did see the resident once on 08/25/25 for what the DON thought was her initial visit. She said going forward, the facility was going to notify the physician and RP of any residents' medication refusals and after three days, the facility would initiate a psyche eval for that resident. If that was not possible, then the DON stated they would send the resident out for a psyche evaluation. She stated she did not know what the process was prior to her becoming the DON. The DON stated if Resident #3 did not take her prescribed dementia-related and psychotropic medications, It could make her go into many stages and escalate, not just towards the residents, staff.anyone. An interview with CCN K on 09/22/25 at 8:06 PM revealed she did not know about Resident #3's medication refusals and escalating behaviors. She stated her expectation was if there was a resident with continuous medication refusals, the family and MD should be notified to see if there were alternate interventions. CCN K stated if Resident #3 had dementia, then psyche should have been seeing her. CCN K stated sometimes a facility could do a Negotiated Risk Assessment if a resident was non-compliant with medications, It lets them [family] know this can happen. An interview with SW C on 09/23/25 at 10:13 AM revealed she knew Resident #3 had been refusing her medications since she first admitted . She stated that Resident #3 had verbal behaviors more than anything and was easily irritated and she did not know what her triggers were. She stated the resident had no aggressive towards self, staff or other residents as far as she knew. If a resident with dementia or psyche concerns refused medications, SW C said it would be the nursing staff that would need to address it and notify the resident's emergency contact. SW C stated she did not recommend any interventions when Resident #3 began refusing her medications. She said the nurses were in charge of ensuring residents received psychiatric services and SW C did not communicate any issues with the PMHNP related to Resident #3. SW C stated when Resident #3 began having increased behaviors, she tried to reach out to her EC but was only able to leave a voice mail. SW C stated she was not included in the decision to send Resident #3 to a psyche hospital. She said normally the nursing staff would ask her if she had seen a change in condition or any incidents, but ultimately that would be up to nursing staff for an evaluation. SW C stated Resident #3 was sent out, based on mood and behaviors. Record review of the facility's, undated, policy titled, Dementia and Behavioral Health Policy reflected, .Some individuals with dementia may have coexisting symptoms or psychiatric conditions such as depression or bipolar affective disorder, paranoia, delusions or hallucinations. Progressive dementia may exacerbate these and other symptoms.Therapeutic Interventions or Approaches: The use of any approach must be based on a careful, detailed assessment of physical, psychological and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors.Identifying the frequency, intensity, duration and impact of behaviors, as well as the location, surroundings or situation in which they occur may help staff and practitioners identify individualized interventions or approaches to prevent or address the behaviors. Individualized, person-centered interventions must be implemented to address behavioral expressions of distress in persons with dementia. The resident and family/representatives should be involved in helping staff to understand the potential underlying causes of behavioral distress and to participate in the development and implementation of the resident's care plan.Facilities should be able to identify how they have involved residents/families/representatives in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication, the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives. The discussion should be documented in the resident's record.Involvement of the Medical Team: Residents who exhibit new or worsening BPSD should have an evaluation by the interdisciplinary team, including the physician and knowledgeable staff, in order to identify and address, to the extent possible, treatable medical, physical, emotional, psychiatric, psychological, functional, social, and environmental factors that may be contributing to behaviors, in order to develop a comprehensive plan of care to address expressions of distress. This was determined to be an Immediate Jeopardy (IJ) on 09/21/25 at 3:35 PM. The R-AD and DON were notified. The R-AD and DON were provided with the IJ template on 09/21/25 at 4:38 PM. The following Plan of Removal submitted by the facility was accepted on 09/22/25 at 2:40 PM: Date: 9/22/25-Plan of Removal-F744 Dementia Care Resident #3 was admitted in July 2025 with a diagnosis of dementia. MARs and nursing notes documented ongoing refusals of medications for dementia (donepezil, memantine) since her admission and escalating dementia related behaviors. The resident's behaviors escalated culminating in psychiatric hospitalization on 09/19/25. Interventions: 1. Resident #3 was admitted to the hospital on [DATE]. Resident #3 remains in the hospital as of 9/22/25. 2. All residents on dementia medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse. Completion date 9/22/25. 3. The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication. Completion date 9/22/25. 4. All residents with a diagnosis of dementia and/or require psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Interventions will also include pharmacological and non-pharmacological approaches to care. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse. Completion date 9/22/25. 5. New Process: The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals 7days per week. The medication administration report will also be reviewed during this process 7 days per week to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The orders will include monitoring for any changes in condition after refusals. The care plan will be updated by DON, ADON, MDS or designee. Completion date 9/22/25. 6. The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/22/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days for dementia medications, increased or escalating behaviors. B. Dementia/Behavior Health Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors. 7. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25 and 9/22/25. 8. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/22/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced as of 9/22/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. Completion date 9/22/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include dementia medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Dementia/Behavior Health Policy- - to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors. Monitoring the Plan of Removal implementation occurred on 09/21/25 through 09/23/25 through daily onsite visits. Facility monitoring activities included review of 24-hour reports for 09/21/25, 09/22/25 and 09/23/25, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted on 09/21/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services. Twenty nursing staff were interviewed across all shifts on 09/21/25, 09/22/25 and 09/23/25 (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize dementia care protocols, recognition of escalating behaviors and required notification procedures. Nurses were able to correctly identify procedures for notifying physicians and responsible parties after three or more medication refusals and demonstrated understanding of non-pharmacological intervention expectations. Review of the facility's 24-hour report for other sampled residents with dementia diagnoses from 09/21/25-09/23/25 reflected there were no changes in condition, no behavioral symptoms or care interventions occurred that required documentation during the monitoring period. Review of dementia care plans and behavior monitoring logs from 09/21/25-09/23/25 reflected interventions were the in the process of being updated with individualized, non-pharmacological approaches were identified and documentation was consistent with the residents' assessed needs. Record review of Ad HOC QAPI meeting on 09/21/25 reflected the medical director and interdisciplinary team provided oversight and reviewed the implementation of the corrective actions. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of three residents reviewed for notification of changes. The facility failed to notify Resident #1's physician and responsible party of a witnessed seizure on 09/15/25. Facility staff did not initiate neurological checks, perform an assessment or obtain labs following the event and the physician was not informed to direct further care. Resident #1 remained without clinical intervention until later that day, when the family requested a hospital transfer due to unaddressed changed in condition. On 09/18/25 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/23/25, the facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk for delayed medical evaluation, treatment, lack of timely involvement by the responsible party and the physician in resident care decisions and the potential for worsening of the resident's condition. Findings included:Record review of Resident #1's Face Sheet dated 09/17/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). She had no listed diagnosis of a seizure disorder (a condition characterized by recurrent, unprovoked seizures due to abnormal electrical brain activity). Resident #1 had two family members listed as her emergency contacts and resident representative.Record review of Resident #1's admission MDS assessment dated [DATE] reflected she a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan dated 07/02/25 and last revised on 08/02/25 reflected, [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness-Date Initiated: 07/02/2025, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated-Date Initiated: 07/02/2025, Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 07/02/2025, Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity-Date Initiated: 07/02/2025, Seizure Precautions: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain, etc.- Date Initiated: 07/02/2025.Record review of Resident #1's active physician orders dated 09/17/25 reflected, Keppra Solution 100 MG/ML (Levetiracetam) give 7.5 milliliter via g-tube two times a day for seizures (start date 07/01/25 - present).Record review of Resident #1's September 2025 MAR reflected she was administered Keppra 7.5ml twice a day from 09/01/25 twice a day with the last dose documented the morning of 09/15/25. Record review of Resident #1's nursing progress notes dated 09/15/25 reflected: -11:10 AM-[Written by RN A]-The ADON called this nurse when she noticed resident having seizures when she was doing wound dressing of her roommate. Assessed and positioned the resident and provided all necessary care during and after seizure. Vital signs checked as B.P.-142/76; P/R- 80; R/R-18; SpO2-94; Temp.-97.6 on room air. Resident opening her eyes when calling out her name. Will continue to monitor and provide care. -3:56 PM- [Written by the DON]- [EC] called and states that resident was having a seizure and two nurses in room not doing anything for her. Entered room to check on resident and lying in bed with eyes closed resting peacefully. Informed [EC] after speaking with nurse for resident and make aware of concern. Per nurse resident had seizure earlier this morning. Made [EC] aware that we have informed MD and that [Resident #1] is currently on Keppra BID for seizure. [EC] was also made aware that Keppra levels will be drawn to see what Keppra level. Will continue to monitor.-4:36 PM- [Written by RN A]- Resident awake, oriented and stable but not responding as usual according to the [EC] who came to visit her wants 911 to be called and they want her to be taken to the hospital. Vital signs checked B.P.-136/85; P/R-81; Temp.-98.1; Spo2- 95 on room air. Notified DON and ADON. Called 911 and transferred resident to hospital.-4:41 PM- Transfer Notification- [Resident #1] was transferred to a hospital on [DATE] 5:35 PM related to The family want [sic] her to be sent to hospital as she had seizure in the morning and according to them she is not responding normally.Record review of Resident #1's nursing and social services progress notes revealed no notification of her seizure immediately to the RP or the physician the morning of 09/15/25.Record review of Resident #1's clinical chart to include all assessments and progress notes, reflected no documented neurochecks or monitoring after she had a seizure the morning of 09/15/25. An interview with LVN G on 09/17/25 at 2:56 PM revealed Resident #1 went to the ER on her shift. That morning of the incident, ADON D was rounding with the wound doctor on Resident #1's roommate and noticed Resident #1 was groaning and having seizures. LVN G stated she never saw Resident #1 have the seizure, but ADON D told her when she saw her, the resident was foaming at the mouth and shaking. LVN G stated all she saw was some secretions coming out of Resident #1's mouth when she had been repositioning her. ADON D asked LVN G to come and help and checked her vitals and immediately after the seizure was over, Resident #1 was snoring and sleeping and stable. Then in the afternoon, LVN G went to administer Resident #1's scheduled hydromorphone saw that her vitals were fine and she continued to sleep. In the evening, LVN G stated Resident #1's family member called the facility stating the resident did not look like her normal self on the AEM footage. LVN G said she told the family member yes, Resident #1 did have a seizure but it was earlier that morning and the nurses had been doing one hour vital checks and gave her medicine. LVN G did not believe Resident #1 had another seizure after the initial one due to the nursing staff monitoring her. She said the family member did not want Resident #1 to decline and wanted the facility to call 911 to send her to the ER. LVN G stated, I even checked the vitals prior and she was okay. I told her everything is okay. LVN G stated that when Resident #1 had the initial seizure, she did not notify the MD/NP/PA or the resident's RP. She stated, I had a discharge and an admission coming at that time of day. Typically, I would want to notify the doctor and the party responsible and we will document and check on the resident intermittently and if we see any change in condition after notifying the doctor, we will transfer them out. LVN G stated Resident #1 had remained stable since the seizure. LVN G stated, The error-I did not notify the RP, I should have done that. That is important because, like when they came in the evening, they didn't know, they need to have a choice if there is anything further they want for the resident and to keep ourselves and documentation accurate. LVN G stated the importance of notifying the doctor for a resident's change of condition such as Resident #1 because that was the first seizure she had since she had been at the facility and the doctor needed to be aware in order to be able to make changes to her treatment. LVN G again admitted her fault in not notifying the MD or RP of Resident #1's seizure, which she stated was a change in condition. She said with her being the only nurse on that shift and having to pass meds, do lines and injections, she did not have time for the notification .An interview with the DON on 09/17/25 at 3:48 PM revealed the day Resident #1 had a seizure, her family member called around 2-3pm and said the resident was presently having a seizure and there were two nurses that were just standing there. The DON went to Resident #1's room and there were no nurses in there and nothing was going on and the resident opened her eyes. The DON asked ADON D if Resident #1 had a seizure and ADON D said yes, at 7am that morning. Then she went to LVN G and asked if Resident #1 just had a seizure and she said no, only that morning between 7 am and 9 am and she monitored her and the resident was fine. The DON said she contacted the family member back and said Resident #1 was okay, but the family member wanted her sent out because she had a seizure. The DON stated when a resident had a seizure, the expectation was for the charge nurse to take vitals, call the doctor to notify them, sometimes that doctor will order a lab or ask how long the seizure lasted. If there was no change and the resident continued to have seizures, the DON stated they would need to be sent out. The DON stated it was important to notify the doctor when a resident had a seizure because it could affect the resident's neurological status detrimentally. The DON stated it was important to notify the resident's RP for a change of condition, but with Resident #1, She has a history of it and is already taking meds for it. If she was going to be sent out or it continued, I would notify the family, but I guess she was okay because she responded to me.An interview with ADON D on 09/18/25 at 10:00 AM revealed when Resident #1 had the seizure, she was doing wound care on her roommate. She stated Resident #1 had a mouthful of saliva and was not responding, so she wiped her mouth off. ADON D said she tried to talk to Resident #1 in bed who then rolled over toward the wall. When ADON D started to leave the room, she heard the enteral feeding pump alarm beeping and when she looked at Resident #1, she was having a seizure. At that time, ADON D stated she turned Resident #1 more to her side while she had the seizure which lasted less than a minute. She thought it may have been a grand mal seizure. ADON D stated when Resident #1 stopped having the seizure, she fell asleep immediately and started snoring. ADON D then notified LVN G who checked the resident's vitals which were within normal limits. ADON D said Resident #1 was monitored post-seizure, Like if I was walking down the hall that day, I would look in. ADON D stated she asked LVN G if the doctor was aware of the seizure and LVN G responded yes and that the PA wanted a Keppra lab done for her but did not want to send her out. ADON D stated the Keppra lab was not stat because, She [Resident #1] was calm and not having a seizure. That evening, ADON D stated the business office manager came to her and said the family saw Resident #1 having a seizure on the AEM camera. ADON D went to check on Resident #1 and asked LVN G if she had any additional seizures and she replied no. ADON D stated she did not think Resident #1 had any additional seizures due to her not having any visible indicators of her having a seizure, such as no blankets or sheets looked disturbed and she felt there would have to be more signs. ADON D stated, Like if she was shaking, she did not appear to have struggled with anything because there is going to be movement with her limbs, even though she is paralyzed on one side and can't move.so if she would have had another seizure, there would have been more visible signs. ADON D told the BOM no, that seizure happened earlier in the day. ADON D said later that shift, she saw Resident #1's family member arrive at the facility who felt the resident did not look good and wanted her sent to the ER. The family was saying Resident #1 was not responding like her normal self. ADON D stated Resident #1 was calm, but her family still wanted her sent out because they felt she was having another seizure. ADON D stated she did not feel like Resident #1 had a change in condition and felt she was just being quiet on the day she had a seizure. ADON D said a change of condition could be anything from a resident's norm and if she observed it happen, she had to check vitals, do necessary assessments and notify the doctor. ADON D stated she told the charge nurse (LVN G) that she had talked to the NP and to complete a nursing note that reflected the PA was notified. ADON D stated she notified the NP on her phone via a text message but it did not occur until close to 4:00 PM. ADON D stated she did not notify the physician or extenders timely when the seizure occurred because she thought the charge nurse did. ADON D stated the charge nurse (LVN G) did not contact the physician or extenders. She stated, I didn't know, I told her I would contact [NP] to get an order for Keppra level and she needed to write a note. ADON D stated she did not notify Resident #1's RP when she had the seizure and thought LVN G did. ADON D stated it was important to notify RPs of a seizure because, We need to let them know it happened and we are working on it. Maybe they can give a history or what has worked in the past to intervene. ADON D stated a resident who continued to have seizure activity was at risk of aspiration, even with a g-tube because of saliva. The resident could also bite their tongue or swallow their tongue, and neurologically they could go into shock.An interview with PA E on 09/18/25 at 10:23 AM revealed she remembered being notified by ADON D about Resident #1's seizure and she ordered a lab to get a Keppra level. She stated she was not notified until later in the afternoon closer to 4pm. PA E stated she should be notified on how severe a resident's seizure was, to know if immediate action needed to be taken. PA E felt a seizure longer than a minute in duration would be considered a severe seizure. PA E stated the charge nurse should monitor that resident's vitals at least once an hour after a seizure event and their baseline mental status, like drowsiness and alertness. PA E stated she relied on the nursing staff to tell her if there was a situation going on with a resident. She said she did not know Resident #1 had been sent to the ER. PA E stated the MD/PA or NP were supposed to be notified when a resident was sent to the hospital but she did not see any communication from the facility about it. She stated the only message she received was from ADON D at 4 pm related to Keppra lab and seizure notification. PA E stated the risk of a resident having continued seizure activity was altered mental status, respiratory distress and brain trauma . An interview with the DON on 09/18/25 at 12:10 PM revealed there was no baseline Keppra lab for Resident #1 since her admission to the facility. An interview with Resident #1's RP/family member on 09/17/25 at 5:27 PM and subsequent follow up interview on 09/19/25 at 10:31 AM revealed the RP was not contacted after Resident #1's seizure the morning of 09/15/25. She stated the family was shocked to turn on the AEM camera in Resident #1's room to see her having a seizure that afternoon (time unknown) with nurses present in the room not intervening and then covering her and leaving the room while the resident was foaming at the mouth. The RP stated, They literally just covered her up and walked away! She stated Resident #1 presently was in an ICU unit of the hospital where she had limited brain activity. She stated she showed the camera footage to the medical staff at the hospital where it showed staff doing pericare for Resident #1 while she was foaming at the mouth. The RP said the doctors were shocked at the video. The RP stated while at the hospital, they have increased her Keppra medication for seizures and did and EEG because of her left sided weakness and limited talking ability. When the RP confronted the facility, she talked to the new DON, who told her she had checked on Resident #1 since the seizure that morning and she was okay. The RP was upset family was not contacted and stated the AEM showed that the nurses neglected to check Resident #1's vitals and just covered her up. The RP said when she talked to the DON she told her the situation was inhumane. After that phone call, the RP stated the nurses started pulling the privacy curtain to where the resident could not be viewed through the camera. The RP stated she came to the facility immediately after that to see what was going on. She said she asked the DON to contact Resident #1's doctor but the DON replied no. The RP stated, She [DON] refused everything I asked them to do. I asked what orders were in there by the doctor to help her with seizures and could she contact him if not. The RP said the DON told her that the doctor would see Resident #1 the next day because in her estimation, Resident #1 was still responsive because she responded to her name earlier, so it was not an emergency. The RP then stated, They are misleading and I specifically stated I'm call (911) since you've left [Resident #1] in a non-responsive state as if she's okay, and she wasn't.I will testify in a court of law that there was nothing done or even attempted, to settle my mind that they were truly assisting [Resident #1].Review of AEM surveillance footage for Resident #1's room provided by the RP and time stamped 09/15/25 between 6:52 AM and 10:34 AM revealed the following:-At 6:52 AM, Resident #1 was observed awake in bed, alert and watching television. She used her left arm to adjust bed linens and extend her left leg toward the floor. Her right wrist appeared flexed inward. -At 7:04 AM, Resident #1 paused her movements, reclined her head and exhibited sudden stiffening of her left leg, left foot, left and right arms. Her eyes rolled upwards. -At 7:10 AM, Resident #1 appeared to be asleep.-Between 7:10 AM and 9:46 AM, Resident #1 remained in bed with no visible movement. -At 9:46 AM, foaming at the mouth was observed, with secretions visible along the right cheek. -At 10:10 AM, ADON D entered the room, called Resident #1's name, lowered the bed towards the floor and raised the HOB upright. She wiped Resident #1's mouth of secretions. Resident #1 exhibited minimal movement of the left hand. The ADON exited the room at 10:14 AM.-At 10:19 AM, ADON D and LVN G attempted to move Resident #1's arms; both were flaccid. -The final video segment at 10:34 AM showed LVN G and two additional unidentified staff in the room. Resident #1 remained on her left side, with continued foaming at the mouth along the right cheek.Hospital records were requested on 09/18/25 and 09/29/25 for Resident #1 from two different hospitals, one identified by the facility as the hospital to which Resident #1 was sent, and one identified by the RP as the hospital she reported the resident currently received treatment. As of 10/01/25, the records had not been received .Review of the facility's policy titled, Resident Rights (undated) reflected, The resident has a resident to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility,.3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: a. Facilitate the inclusion the resident and/or resident representative, b. Include an assessment of the resident's strength and needs.14. Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is: a) An accident involving the resident which results in injury and has the potential for requiring physician intervention; b) A significant change in the resident's physical, mental, or psychosocial status.; c) A need to alter treatment significantly. An Immediate Jeopardy (IJ) was identified on 09/18/25 at 1:00 PM related to Resident #1's seizure incident. The R-AD and DON were notified and they were provided with the IJ template on 09/18/25 at 1:41 PM. A Plan of Removal was requested.The following Plan of Removal submitted by the facility was accepted on 09/19/25 at 8:12 PM and reflected: Date: 9/18/25- Plan of Removal- F580 Notification of Change in Condition The facility failed to promptly notify the MD of Resident's #1s change in condition when she sustained a seizure on 9/15/25.Interventions: 1. Resident #1 was admitted to the hospital on [DATE]. Resident #1 remains in the hospital as of 9/15/25 [sic]. 2. All residents in the facility that have a seizure diagnosis and are on an anticonvulsant medication were assessed by the DON, ADON, and Charge Nurses for seizure activity or a change in condition that required notification to the MD and post-monitoring of the resident. No additional changes in condition including seizure activity were noted that required notification to the RP and MD or post-monitoring of seizure activity. Completion date 9/18/25. 3. New Process: The DON/ADON/Designee will review the 24hr report and PCC dashboard seven days per week for seizure activity or changes in condition to ensure that assessments, notifications to MD/RP were made to receive orders for post-monitoring, assessment, and documentation. This review will be documented on the morning clinical meeting form. Verification on the review will be completed at minimum of weekly by the Area Director of Operations and/or Regional Compliance Nurse. Completion date 9/18/25. 4. The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25 . A. Abuse and Neglect Policy: to include the lack of notification of the MD could prolong appropriate treatment for a resident which could be considered neglect. Also, failure to notify the RP immediately could prolong decisions for the resident's care. B. Notification of Change in Condition Policy: charge nurses will notify the MD and RP immediately of all changes in conditions to include seizure activity. Signs and symptoms of seizures include shaking, jerking, twitching, stiffening of the body, loss of muscle control, falling to the ground, nausea and vomiting. The nurses will notify the MD and implement the seizure management protocol. Any additional orders by MD will be implemented by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notifications. Notifications will be documented in PCC in the SBAR or progress notes. C. Documentation: Charge nurses will document changes in condition, notification to the MD/RP, orders, and subsequent assessments and monitoring ordered by the MD. 5. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25. 6. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/18/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all staff. All staff not present or in-serviced as of 9/18/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will be in serviced prior to assuming their next assignment. Completion date 9/19/25. A. Abuse and Neglect Policy: to include the lack of notification of the MD could prolong appropriate treatment for a resident which could be considered neglect. Also, failure to notify the RP immediately could prolong decisions for the resident's care. B. Notification of Change in Condition Policy: charge nurses will notify the MD and RP immediately of all changes in conditions to include seizure activity. Signs and symptoms of seizures include shaking, jerking, twitching, stiffening of the body, loss of muscle control, falling to the ground, nausea and vomiting. The nurses will notify the MD and implement the seizure management protocol. Any additional orders by MD will be implemented by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notifications. Notifications will be documented in PCC in the SBAR or progress notes. C. Documentation: Charge nurses will document changes in condition, notification to the MD/RP, orders, and subsequent assessments and monitoring ordered by the MD.Monitoring the Plan of Removal implementation occurred on 09/19/25 through 09/23/25 daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs,, change in condition documentation and hospital transfer records to identify any additional incidents that involved seizures, falls, medication refusals or changes in condition. Additional records for three residents were reviewed to verify timely assessments, physician notifications, orders and follow-up actions to verify that timely physician and RP notifications were completed. Additionally, staff in-service records and competency validation tools were reviewed for charge nurses, medication aides and CNAs. In-services covered neurological assessments, changes in conditions protocols, documentation standards, medication refusal and abuse/neglect reporting procedures. Twenty nursing staff were interviewed across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD , CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V) and demonstrated awareness of the facility's expectations, policies and procedures. An Ad Hoc QAPI Committee meeting dated 09/18/25 and 09/21/25 were reviewed to confirm the facility had analyzed the notification system failure, implemented corrective actions and established enhanced monitoring processes to ensure compliance with physician and RP notification requirements. No additional failures were identified related to notifications during the monitoring period . An interview with the R-AD on 09/23/25 at 11:22 AM revealed his expectation as the interim ADM for a change in condition would be for the charge nurse to call the physician right away, call the DON, call the RP and then the DON would let the R-AD know what happened and keep him up to date. The R-AD stated if a resident had a seizure going forward, the nursing staff were to make sure the resident was safe remove anything from around the head and then call the physician and get an order, get labs if ordered and monitor, but we also want to make sure the resident is not acting different. If interventions were not implemented, the R-AD stated the resident's health could be affected. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The Facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure required physician visits were completed at least once every 30 days during the first 90 days of admission, as required, for three (Resident #1 and Resident #3 ) of five residents reviewed for physician services. The facility failed to ensure Resident #1 and Resident #3 were seen by a physician at least once every 30 days during the first 90 days following their admission, as required. During this time frame, Resident #1 sustained a seizure and Resident #3 had behavioral decompensation requiring in-patient psychiatric hospitalization. The failure placed residents at risk of not receiving timely medical oversight and increased the risk that changes in condition could go unrecognized or untreated. Findings included: 1. Record review of Resident #1's Face Sheet dated 09/17/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). She had no listed diagnosis of a seizure disorder (A condition characterized by recurrent, unprovoked seizures due to abnormal electrical brain activity). She had no listed diagnosis of a seizure disorder. MD J was listed as the primary medical doctor for Resident #1. Record review of Resident #1's admission MDS assessment dated [DATE] reflected she a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan dated 07/02/25 and last revised on 08/02/25 reflected, [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. The care plan dated 07/02/25 revealed no discussion related to physician visits, follow-up or coordination of care for the resident post-admission. Record review of Resident #1's September 2025 physician's orders from MD J reflected she was prescribed: Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth two times a day (supplement), Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day (supplement), Eliquis Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day (for atrial fibrillation), Entresto Oral Tablet 49-51 MG Give 1 tablet by mouth two times a day (for heart failure), Esomeprazole Magnesium Capsule Delayed Release 20 MG Give 1 capsule by mouth one time a day (for GERD), Farxiga Oral Tablet 10 MG Give 1 tablet by mouth one time a day (for diabetes), Ferrous Sulfate Oral Tablet 325 Give 1 tablet by mouth one time a day (supplement), Humalog Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously two times a day (for diabetes), Isosorbide Dinitrate Oral Tablet 10 MG Give 1 tablet by mouth three times a day (for hypertension), Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml Inject 19 units subcutaneously one time a day (for diabetes), Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day (for hypertension), Miralax Powder 17 gm/scoop Give 17 gram by mouth one time a day (for constipation), Multivitamin Adult Oral Tablet Give 1 tablet by mouth one time (supplement), Oxybutynin Chloride Oral Tablet 5 MG Give 1 tablet by mouth two times a day (for overactive bladder), Pantoprazole Sodium Oral Tablet Delayed Release 40 mg Give 1 tablet by mouth one time a day (for GERD), Sertraline HCl Oral Tablet 25 MG Give 1 tablet by mouth one time a day (for depression), Tylenol Tablet 325 MG Give 2 tablets by mouth every 4 hours as needed for Fever/Pain. Record review of Resident #1's clinical chart on 09/17/25 reflected one visit was completed by MD J on her date of admission on [DATE]. There were no face-to-face physician visits completed for the 30-day and 60-day time frame after Resident #1's admission. MD J's extenders (NP K and PA E) completed visits on 07/02/25, 07/04/25 and 08/07/25. There was no documented evidence Resident #1 had been seen face to face by MD J or his extenders between 08/07/25 and 09/17/25, a span of 41 days. Record review of Resident #1's nursing progress notes dated 09/15/25 reflected she had a seizure observed by ADON D and subsequently was sent to the ER due to a change in condition. Record review of Resident #1's nursing and social services progress notes revealed no notification of her seizure immediately to the RP or the physician the morning of 09/15/25. 2. Record review of Resident #3's Face Sheet dated 09/21/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit (Impairment in communication abilities due to deficits in attention, memory or other cognitive processes), dementia with behavior disturbance (progressive cognitive decline accompanied by agitation, aggression or other behavioral symptoms), bipolar disorder (a mental health condition marked by alternating periods of depression and elevated mood/mania or hypomania), major depressive disorder (mood disorder involving persistent sadness, loss of interest and impaired daily functioning) and insomnia (persistent difficulty staying asleep). MD J was listed as the primary medical doctor for Resident #3. Record review of Resident #3's admission MDS assessment dated [DATE] reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis, which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Record review of Resident #3's care plan initiated 08/02/25 revealed no discussion related to physician visits, follow-up or coordination of care for the resident post-admission. Record review of Resident #3's Physician Order Summary for September 2025 reflected MD J was the prescriber and ordered: Buspirone 10mg once a day (for bipolar disorder), Lamictal 25 mg twice a day (for bipolar disorder), Trazadone 100 mg at bedtime (for insomnia), Memantine 10 mg once a day (for unspecified dementia with behavioral disturbance), Aricept 5 mg at bedtime (for dementia), Clopidogrel Bisulfate 75 mg once a day (blood clot prevention), Levothyroxine Sodium 100 mcg in the morning (for hypothyroidism) and Atorvastatin Calcium 40 mg at bedtime (for hyperlipidemia), Record review of Resident #3's August 2025 MAR reflected she refused the Buspirone 18 times, Lamictal 18 times, Trazadone 16 times, Memantine 23 times, Atorvastatin 19 times, Clopidogrel Bisulfate 24 times, Levothyroxine 15 times and Tylenol Extra Strength 500 mg (for mild pain). Record review of Resident #3's September 2025 MAR she refused her Buspirone nine times, Lamictal 23 times, Trazadone seven times, Memantine 15 times, Tylenol Extra Strength 25 times and Levothyroxine seven times. Record review of Resident #3's e-administration medication notes starting 08/22/25 through 09/19/25 reflected the main reasons for refusals of medications were because the resident did not think she needed them. Record review of NP K's progress notes (extender for MD J) reflected she saw Resident #3 twice when she first admitted to the facility on [DATE] and 07/30/25. On 07/28/25, NP K documented, Plan:.Monitor for changes in mood or behaviors, refer to psyche for support, monitor for changes in neuro or functional status, does not take routine medications. On 07/30/25, NP K documented the exact same verbiage during the visit. Record review of Resident #3's clinical chart reflected she was seen by MD J on 08/05/25 which reflected, Continue present medication management, we will collaborate with psychiatry services. MD J stated that he was unable to complete a full assessment due to Resident #3 having an angry demeanor, cognitive deficits and refusals to engage with him. There was no documented evidence Resident #3 had been seen face to face by MD J or his extenders between 08/05/25 and 09/17/25, a span of 43 days. Record review of nursing progress notes related to Resident #3's behaviors included on 09/08/25 when she refused to take medications and on 09/08/25, she slapped a staff who tried to help her find a jacket, then later that day she tried to block a resident from wheeling himself to the dining room. On 09/11/25, Resident #3 was documented as being aggressive and scratched an aide's hand which the aide was trying to stop her from taking other residents' belongings. A few days later on 09/14/25, Resident continues with confusion-wandering and taking food off of other residents' tray.Resident came to nurse's station and just started yelling at the staff but was not making any sense - resident was redirected and taken back to her room.Resident is going into other residents' rooms and taking their things - claiming their items as her own - nurse asked her to stop which made the resident angry and she tried to throw a bottle of body wash at this nurse - nurse was able to deescalate the situation and walked away [LVN B]. Later that day on 09/18/25, Resident #3 refused her PM medications, became aggressive towards another resident trying to grab the blanket wrapped around the other resident, and then sat on the floor and stated she was mad at ADON D for trying to make her go to her room. The next day on 09/19/25, Resident #3 was noted by the DON to be in the dining room and appeared guarded, uncooperative with cues and not rational, hyperactive and rapidly talking, her mood is anxious with flight of ideas, she continues to be interjecting others and with poor insight to current situations, she is being offered activities, hydration.Resident is very combative to staff and other residents.Resident continues to refuse medication. MD made aware of concerns. Unable to reach family members. ADON D wrote a nursing note on 09/19/25 that reflected Resident #3 was transferred to the hospital for behaviors per PA E for refusing medications, refusing care and being combative. An interview with the DON on 09/17/25 at 10:00 AM revealed she was new to the facility and had started two days prior. She stated she was in contact with the CCN K to help her assimilate into the position. She did not know who the physician was or his schedule. An interview with LVN G on 09/17/25 at 2:56 PM revealed MD J came to the facility every Thursday and saw residents whom the nursing staff had concerns with, reviewed documents and rounded on residents. She did not know how he determined who he saw each week. An interview with ADON D on 09/18/25 at 10:00 AM revealed MD J came to the facility once a week and saw everyone on his caseload as well as reviewed any concerns the charge nurses had. ADON D stated during those visits, MD J wrote orders for acute issues and he would document his progress notes for the resident's e-chart. ADON D stated, We make sure he is doing them. Sometimes when you tell a doctor about a resident, out of curiosity, you check (MD progress notes) to make sure he covered what the issue was. ADON D stated when a resident was admitted to the facility, there was a way to contact MD J through an app if there was a need for a medication review for that resident, or a special diet, code status and high-risk medications to be reviewed. ADON D stated she did not know how often MD J was required in the first 90 days to see the residents assigned as his patients. She said he had a nurse practitioner and a physician's assistant who also came out weekly to complete visits as well. An interview with PA E on 09/18/25 at 10:23 AM revealed she was an extender for MD J and came every Thursday to the facility and MD J came every Tuesday. PA E stated if a new resident admitted and she was the first in the building, then she could complete the first visit. PA E stated from what MD J had explained to her and his team was that he completed the official Health and Physical Assessment, but if an extender saw the resident before he came to the facility, they still can see the resident, but not for an H&P. PA E stated, We have it that a clinician has to see the resident for 90 days every 30 days and it can alternate between the MD and the extenders. PA E looked for some visits for Residents #1 and #3 and stated she thought there were some MD visits on her end that had not been uploaded into the residents' e-charts yet. PA E stated there had been a lot of turnover recently with staff and there was no current staff for medical records, and that person was the one who uploaded the visits into the e-chart. She stated MD J's team faxed their progress notes to the facility and also emailed the medical records staff with the information. PA E stated, So maybe that is why it looks like he is not doing his visits. An interview with the R-AD on 09/21/25 at 2:00 PM revealed MD J was presently on vacation and one of his fellow attendings was sitting in as the physician on duty for emergencies. A follow-up interview with ADON D on 09/23/25 at 10:30 AM revealed the physician needed to see the residents for their initial visits immediately. She stated, We can facetime them, do it in person, maybe the NP or PA comes in to see them. ADON D stated the physician needed to complete the first visit in 24-48 hours. After that, the physician would need to see the resident twice a week. She stated, The PA, NP and MD come out weekly so there are three opportunities for the residents to be seen. ADON D stated it was the responsibility of herself and the DON to ensure the physician visits were completed.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two of five residents (Resident #1 and Resident #4) reviewed for medication administration.1. The facility failed to ensure Resident #1's blood pressure was obtained and documented prior to the administration of physician-ordered antihypertensive medications with parameters in July 2025 on 12 occasions. 2. The facility failed to ensure Resident #4's blood pressure was obtained and documented prior to the administration of physician-ordered antihypertensive medications with parameters 12 times in August 2025 and seven times in September 2025. These failures could place residents at risk for receiving antihypertensive medications without confirmation of safe blood pressure parameters, which could result in sudden hypertension leading to fainting, falls or dizziness. It also placed residents at risk for missed or delayed treatment, potentially leading to uncontrolled hypertension, stroke or other adverse cardiovascular events. 1. Record review of Resident #1's face sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). Record review of Resident #1's admission MDS Assessment, dated 07/02/25, reflected a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan, dated 07/02/25 and last revised on 08/02/25, reflected no discussion of her need for hypertensive medications or an issue with high or low blood pressure. Record review of Resident #1's active physician orders, dated 09/17/25, reflected she was prescribed Carvedilol Oral Tablet 25 mg via g-tube twice a day-Hold for SBP < 100, DBP < 55 or HR < 60 bpm for hypertension (start date 07/01/25).Record review of Resident #1's July 2025 MAR reflected her AM dose of Carvedilol was not administered and was documented as X on 07/07/25 and 07/30/25. It was documented as NA on 07/04/25, 07/05/25, 07/10/25, 07/14/25, 07/15/25, 07/20/25, 07/24/25, 07/27/25, 07/28/25 and 07/29/25. No blood pressure readings or vitals were recorded on the MAR for those administration times. Record review of Resident #1's July 2025 nursing progress notes reflected no blood pressure readings when the Carvedilol was held in July 2025. 2. Record review of Resident #4's face sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included essential hypertension (persistently high blood pressure without a known secondary cause), cardiomyopathy (disease of the heart muscle that makes it hard for the heart to pump blood effectively), chronic obstructive pulmonary disease (progressive lung disease that cause airflow blockage and breathing problems), atrial fibrillation (irregular, often rapid heart rhythm that can lead to poor blood flow), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning) and diabetes (chronic high glucose levels fur to problems with insulin production).Record review of Resident #4's care plan dated 07/02/25 reflected she was on anticoagulant therapy, had congestive heart failure, diabetes and hypertension. She was also care planned for adverse medication risks and care planning, was on diuretic therapy related to edema and had a stage 3 pressure ulcer related to immobility. Record review of Resident #4's Physician's Order Summary, dated 09/17/25, reflected she was prescribed the following blood pressure medications, Isosorbide Dinitrate Oral Tablet 10 mg Give 1 tablet by mouth three times a day for hypertension- Hold for SBP < 110, DBP < 60 or HR < 60 bpm (start date 07/01/25) and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 mg Give 1 tablet by mouth one time a day for hypertension. Hold for SBP < 110, DBP < 60 mmHg or HR < 60 bpm.Record review of Resident #4's August 2025 MAR reflected her Isosorbide Dinitrate was not administered and documented as X on 08/01/25-bedtime, 09/03/25-midday, 08/06/25-bedtime, 08/12/25-bedtime, 08/17/25-midday and 09/29/25-bedtime. It was documented as NA on 08/16/25-midday and bedtime, 08/17/25-midday and bedtime, 08/29/25-midday, 08/30/25-miday and bedtime. The MAR reflected Metoprolol was not administered and documented as NA on 08/02/25 and 08/17/25. No blood pressure readings or vitals were recorded on the MAR for those administration times.Record review of Resident #4's September 2025 MAR reflected her Isosorbide Dinitrate was not administered and documented as X on 09/03/25-bedtime. It was documented as NA on 09/04/25-morning and bedtime and 09/14/25-morning. The MAR reflected Metoprolol was not administered and documented as NA on 09/04/25 and 09/14/25 and as X on 09/10/25 and 09/11/25. No blood pressure readings or vitals were recorded on the MAR for those administration times.Record review of Resident #4's August 2025 and September 2025 nursing progress notes reflected no blood pressure readings that corresponded to when the Isosorbide and Metoprolol were held with no administrations. An interview with LVN G on 09/17/25 at 2:56 PM revealed if a resident took blood pressure medication with parameters, it should be charted on the MARs next to the administration time. If the mediation was held due to the vitals being out of parameters, the nurse was supposed to document it in a progress note as well as the blood pressure reading.An interview with ADON D on 09/18/25 at 10:00 AM revealed staff were supposed to take vitals and document prior to administering a resident's medication if it had parameters. She stated, You have to make sure the resident is stable. ADON D stated when a nurse or med aide could not give a medication and left it blank on the MAR, they were supposed to indicate the reason why, such as vitals out of parameter. She stated the nurses and med aides could not just click no, they had to indicate a reason via a code. ADON D stated, When they are busy, they may forget. She said the harm in not documenting blood pressure readings could cause a drastic change in condition if the resident was not supposed to receive it or was, and it was withheld or given incorrectly. An interview with MA J on 09/19/25 at 2:01 PM revealed the medications aides could check resident blood pressures prior to administering their corresponding medications and if it was out of parameters, they were supposed to notify the charge nurse who then would watch the resident. MA J stated the medication aide would then document on the MAR that the vital was out of parameter and the charge nurse had to complete a progress note. MA J stated without verifying the blood pressure reading, You don't know if it is low and if you give it, it could go lower or higher, we don't know what the number is.An interview with LVN B on 09/21/25 at 11:34 AM revealed when a blood pressure medication was held due to the vitals being out of parameters, the online charting system would not let the person administering it move forward in the MAR unless they entered the vitals such as the blood pressure. She stated the nurse or medication aide usually wrote the blood pressure down because it was quicker than entering it into the e-chart. She stated, We hit the button and know to do a skilled assessment later with the [blood pressure] numbers. But if they are not skilled, you just move on because it does not make you put in vitals if the med was skipped. LVN B stated if a resident's blood pressure reading was not taken or documented, it could make the blood pressure spike or fall, cause lethargy and the resident could have a stroke if their blood pressure ran high and they did not get the medication. An interview with LVN F on 09/21/25 at 2:36 PM revealed when a blood pressure medication had parameters to be taken prior to administration, the e-chart would not let the nurse or med aide proceed if they entered they held a medication on the e-chart, unless they entered in the blood pressure and pulse first. If that was unsuccessful, LVN F stated the nurse could document the parameters in a progress note and reflect why it was held. LVN F stated, The system should make the nurse tell the blood pressure, you can't get around just ignoring it.An interview with the DON on 09/21/25 at 3:10 PM revealed when medications were not given due to being out of parameters, she expected the nursing staff to notify the DON and the MD and then write a progress note immediately. The DON stated a resident could have distress and heart problems if they were not administered their blood pressure medications per physician orders. A follow up interview with ADON D on 09/23/25 at 10:30 AM revealed when a medication was held due to being out of parameters, the MAR would indicate why it was not given and would generate an e-administration note the nurse or med aid could complete. ADON D stated if the med aide/nurse forgot to record the resident's blood pressure, they should immediately re-check it and administer the medication per orders, Don't wait for later. She said the med aide/nurse should notify the MD, DON and ADON. Record review of the facility's policy titled, Medication Administration and General Guidelines, revised March 2025 reflected, .2. Medications are administered in accordance with written orders of the attending physician.12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given.

Based on observation, interview and record review, the facility's governing body failed to provide effective oversight and ensure systems were in place and operational to protect resident health and safety for three (Residents #1, #2 and #3) of three residents reviewed for administration.The facility's governing body failed to ensure that administrative oversight and monitoring systems were maintained during a period in which the facility operated without and assigned administrator (09/12/25-09/17/25). During this time, three Immediate Jeopardy situations occurred, including failure to notify the physician/responsible party following a seizure for Resident #1, failure to complete neurological checks after a fall with a head strike and injury for Resident #2, and failure to address repeated psychotropic medication refusals for Resident #3 who had dementia and bipolar disorder.This failure could place residents at risk of systemic breakdowns in care oversight, lack of leadership and accountability necessary to ensure timely interventions, regulatory compliance and the protection of resident health and safety.Findings Include: 1. Record review of Resident #1's face sheet, dated 09/17/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included anemia (decreased red blood cell count causing fatigue and weakness), hyperlipidemia (elevated cholesterol levels), major depressive disorder (chronic mood disorder with persistent depression), insomnia (difficulty initiating or maintaining sleep), hypertensive heart disease (cardiac complications resulting from long term high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis affecting right side of the body), acute respiratory failure (sudden inability of the lings to provide adequate oxygenation or ventilation), gastro-esophageal reflux disease (chronic and acid reflux causing heartburn and potential esophageal irritation), osteoarthritis (degenerative joint disease causing pain and stiffness), muscle wasting and atrophy (loss of muscle mass and strength). She had no listed diagnosis of a seizure disorder. Resident #1 had two family members listed as her emergency contacts and resident representative. Record review of Resident #1's admission MDS Assessment, dated 07/02/25, reflected a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan, dated 07/02/25 and last revised on 08/02/25, reflected [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness-Date Initiated: 07/02/2025, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follows up as indicated-Date Initiated: 07/02/2025, Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 07/02/2025, Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity-Date Initiated: 07/02/2025, Seizure Precautions: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain, etc.- Date Initiated: 07/02/2025. Record review of Resident #1's e-chart, to include progress notes, assessments, clinical documents and monitoring forms reflected the facility failed to promptly notify the MD of Resident #1's change in condition when she sustained a seizure on 09/15/25 during the morning shift around 7-9am. Resident #1 admitted with a known seizure disorder and was administered daily seizure medication but had not had a documented seizure since admission. On 09/15/25, the facility notified the MD/NP/PA via an online physician's messaging app around 4 pm in the afternoon that Resident #1 had a seizure earlier in the morning. PA E ordered for the resident to have a Keppra lab (not stat). The family had Resident #1 sent to the ER later that evening when they observed the resident having seizures on the AEM and were unaware there had been a seizure episode earlier that morning due to not being notified. There was no documented evidence that the facility monitored the resident's neurological status or assessed her after the seizure. There was no evidence of neurological monitoring, no documentation of post-seizure assessments, and no follow up physician involvement. 2. Record review of Resident #2's face sheet, dated 09/19/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her active diagnoses were listed as hyperlipidemia (elevated levels of fats in the blood) and diabetes (chronic condition characterized by impaired glucose regulation) only. Record review of Resident #2's e-chart reflected due to being a new admission, she did not have an MDS completed yet. Record review of Resident #2's initial care plan, dated 09/15/25, reflected the following focus areas: 1. Focus: The resident is risk for falls [Date Initiated: 09/15/2025]; Interventions: Anticipate and meet the resident's needs, [NAME] the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Keep furniture in locked position, Keep needed items, water, etc., in reach, Pt evaluate and treat as ordered or PRN, Review information on past falls and attempt to determine cause of falls. Record possible root causes. remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Staff to assist with transfers, Fall r/t weakness- send to er, therapy notified, educated -falls-safety [revised 09/19/25], The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) [Revised 09/19/25]2. The resident has a bruise [Start date 09/15/25]-Interventions: Attempt to determine the cause of the bruising, if known attempt to alleviate that factor, Monitor bruising every shift for 72 hours. Note color and characteristics. If negative changes report to the MD, Monitor for and treat pain as indicated.3. The resident had a skin tear, laceration, or abrasion [Date Initiated: 09/15/2025]-Interventions: The residents skin injury will resolve without complications, Assess reason for skin injury occurrence. Notify staff of cause; determine measures to prevent further skin injuries, Monitor and treat pain as indicated, Monitor the skin injury every shift for 72 hours. Assess for bleeding, signs of infection (increased redness, warmth, drainage, odor) Notify the MD for any negative changes, Perform any wound care as ordered. Record review of Resident #2's e-chart, to include progress notes, assessments, clinical documents and monitoring forms revealed she sustained an unwitnessed fall on 09/14/25, striking her head against a dresser. She was sent to the ER and returned the same day with sutures. Record review showed no nursing progress notes documenting the fall, the incident report was blank, no ER records were filed, and there was no evidence of neurological monitoring (neuro checks) upon her return to the facility the same shift. Interview on 09/17/25 at 10:00 AM with the DON did not know who the ADM was. The DON stated the facility did not have an administrator and she was reporting to. She said she only started working at the facility two days prior on (Monday 09/15/25). 3. Record review of Resident #3's face sheet, dated 09/21/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit, dementia with behavior disturbance, bipolar disorder, major depressive disorder and insomnia. Resident #1 had two family members listed as her emergency contacts. Record review of Resident #3's admission MDS Assessment, dated 08/06/25 reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis, which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Resident #3's activity preferences that were very important and included, having books/newspapers/magazines, being around people and pets, doing favorite activities, going outside to get fresh air when the weather is good and participate in religious services or practices. Record review of Resident #3's e-chart, to include progress notes, assessments, clinical documents and monitoring forms revealed MARs and nursing notes documented ongoing refusals of dementia (donepezil, memantine) and psychiatric medications (lamotrigine, buspirone) over approximately eight weeks. Despite repeated refusals, there was no evidence of physician notification, no follow-up of a psychiatric evaluation ordered at admission that addressed her medication refusals. The psych eval reviewed stated staff reported no concerns. There were no care plan interventions addressing refusals. On 09/19/25, the resident's untreated conditions escalated to behavioral crises, which included attempting to grab items from peers and waving utensils in the dining room. Staff documented the resident had escalated behaviors and she was transferred to a psychiatric hospital on [DATE]. An observation of the facility's posting on 09/17/25 at 11:40 AM reflected the previous ADM and previous DON's names and contact information were posted. Information on how to contact an interim administrator was not provided as well as no contact information on the R-AD. An interview with ADON D on 09/18/25 at 10:00 AM revealed the previous administrator left on 09/12/25 and it was planned because she gave a two week notice. The ADON stated she had not seen an interim administrator and was not sure if there was one. ADON D stated, Now we have to deal with [CCN K], I don't know where she is at so we send emails to her. I think she comes once or twice a week depending on how busy she is. Usually we send an email. ADON D stated the abuse/neglect coordinator right now would be the new DON. An interview with the VPCO on 09/18/25 at 1:35 PM revealed he did not know who the current administrator on record was for the facility but he knew the facility did not have an administrator. The VPCO stated the company had interim administrators that could be used and they contracted with them externally. He stated the area director (R-AD) would likely be the abuse/neglect coordinator for the facility, but he was not sure. An interview with SW C on 09/18/25 at 2:53 PM revealed the person currently acting as the administrator for the facility was the new DON and she was in charge. She stated the DON would be in charge of overseeing the facility grievances and if SW C had any administrative concerns, she would go to the DON or ADON D. She said the morning meetings were still occurring with the department heads and they covered the current census, pending admissions, upcoming discharges, anyone in the process of Medicaid applications and if there were any residents who had switched over to hospice and were they care planned for it. SW C stated if there was no administrator in the facility, I would say if there is a concern that a resident may have or family may have, it would not be addressed in a proper amount of time. An interview with the R-AD on 09/18/25 at 3:25 PM revealed he arrived at the facility. He stated he was the area director over ten nursing facilities and a new administrator would be starting on 09/29/25 and he was helping cover until then. The R-AD stated the previous administrator had gave a 30-day notice. He stated the daily stand-up meetings were being done by the new DON and the BOM also helped, although she had been out sick a few days the past week. The R-AD stated the abuse/neglect coordinator presently was himself and the DON. He stated he did have any self-reported incidents for the facility since the previous administrator left. The R-AD also stated grievances were handled by SW C and the DON was supposed to review them and let him know if she needed assistance. The R-AD stated he texted the DON on her first day of employment-Monday 09/15/25 and I notified her I am here to help her out. The R-AD stated the company had 30 days to hire an administrator and the facility did not have to have one on site every day. The R-AD stated, for example, if an administrator went on vacation for a week, the facility's DON would cover, so it was okay for the DON to be a stand in for some of the ADM's responsibilities until a new one started employment. An interview with CNA, on 09/19/25 at 1:35 PM revealed abuse/neglect and exploitation was currently supposed to be reported to the ADM, but since there was not one, she would report it to ADON D. An interview with CNA on 09/19/25 at 1:45 PM revealed she did not know who the current/interim administrator was for the facility until 09/18/25 when she was notified it was the R-AD. A follow-up interview with the R-AD on 09/21/25 at 9:46 AM revealed he was aware CMS required the facility to be continuously administered by a qualified administrator. He stated that during the period of 09/12/25 through 09/17/25, facility staff contacted corporate leadership of the clinical consultant nurse if issues arose and he remained in communication with the department heads remotely. He explained that from a financial standpoint, he monitored approvals and invoices, but clinical oversight during that time was handled by the clinical consultant nurse (CCN K). The R-AD stated he was not aware that Resident #1's physician and responsible party had not been notified of her seizure until after the fact and he explained this would typically fall under clinical monitoring. He also stated he was not aware of Resident #3's medical refusals or that neurological assessments for Resident #2 had not been completed following her hall until those issues were brought forward by the HHSC investigator. The R-AD stated the administrator would usually become aware of such incidents through daily review of resident chart, and if not notified at the time of the event, he expected to be informed the following day. The R-AD stated in absence of an ongoing administrator, delays in addressing operational issues such as hiring approvals or staff injuries could occur and corporate oversight relied heavily on clinical leadership and department heads to communicate concerns promptly. He emphasized it was important for clinical leadership and staff to know who to notify when administrative leadership is off-site. Record review of an Active Employee Roster provided by the DON on 09/17/25 at 12:27 PM listed the previous Administrator who resigned effective 09/12/25 as current one with a hire date of 07/01/24. Record review of TULIP on 09/18/25 reflected the R-AD had a current NFA license with an expiration date on 02/03/27.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one (Resident #2) of five residents reviewed for hospitalizations. 1. The facility failed to complete an incident report after Resident #2 fell, struck her head and had to be sent to the ER due to excessive bleeding. 2. The facility failed to ensure Resident #2's clinical record included hospital documentation following a return to the facility from the ER after a fall with head strike and sutures. These failures placed residents at risk for unmet medical needs, delayed treatment, poor clinical decision-making, and placed them at risk for decline, injury or other adverse outcomes. Findings included: Record review of Resident #2's Face Sheet dated 09/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses were listed as hyperlipidemia (abnormally high levels of fats in the blood) and diabetes (a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production). Record review of Resident #2's e-chart reflected due to being a new admission, she did not have an MDS completed yet. Record review of Resident #2's initial care plan dated 09/15/25 reflected the following focus areas: 1. Focus: The resident is risk for falls [Date Initiated: 09/15/2025]; Interventions: Anticipate and meet the resident's needs, [NAME] the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Keep furniture in locked position, Keep needed items, water, etc., in reach, Pt evaluate and treat as ordered or PRN, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Staff to assist with transfers, Fall r/t weakness- send to er, therapy notified, educated -falls-safety [revised 09/19/25], The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) [Revised 09/19/25]2. The resident has a bruise [Start date 09/15/25]-Interventions: Attempt to determine the cause of the bruising, if known attempt to alleviate that factor, Monitor bruising every shift for 72 hours. Note color and characteristics. If negative changes report to the MD, Monitor for and treat pain as indicated.3. The resident has a skin tear, laceration, or abrasion [Date Initiated: 09/15/2025]-Interventions: The residents skin injury will resolve without complications, Assess reason for skin injury occurrence. Notify staff of cause; determine measures to prevent further skin injuries, Monitor and treat pain as indicated, Monitor the skin injury every shift for 72 hours. Assess for bleeding, signs of infection (increased redness, warmth, drainage, odor) Notify the MD for any negative changes, perform any wound care as ordered. Record review of Resident #2's written by LVN B revealed, [Resident #2 was transferred to a hospital on [DATE] 12:45 PM related to fell [sic] and hit her head. This is intended serve as notice of an emergency transfer. There were no other details provided. Record review of Resident #2's nursing progress notes from 9/14/25 to 09/17/25 reflected no documentation related to a fall. Review of an incident report started on 09/17/25 for Resident #2 by LVN B revealed the form was incomplete and no required areas were assessed on the form until 09/19/25 and 09/20/25 when the DON and LVN B did late entry documentation . There was no immediate incident description at the time of occurrence, no documentation of immediate actions taken, no injury assessment, no mental status assessment, and no narrative notes describing the fall or subsequent clinical follow-up. Multiple fields in the form read, No records found. An interview with LVN G on 09/17/25 at 1:20 PM revealed she was not at the facility when Resident #2 fell and had to be sent to the ER but came back the next day and there were no new orders or clinical documentation, so she did not know if Resident #2 sustained any injuries. LVN G stated if a resident came back from the hospital with no documentation, then the charge nurse on duty needed to document it and report it to the nursing management who could follow up to obtain them. LVN G stated it was out the charge nurses' control if the resident came back with no hospital documentation and the nurse would not know what happened as a result. An interview and observation with Resident #2 on 09/17/25 at 1:30 PM revealed she was in a wheelchair by the nurses station with non-slip socks on. She was observed with a large fading greenish yellow bruise around her right eyebrow extending down into her right eyelid about three inches in diameter. Resident #2 had approximately a one inch cut with stitches above her right eyebrow. She was verbal but not oriented to questions. When asked what happened to her right eye, she motioned towards the injury and said her [AGE] year-old sister scratched her but it did not hurt. She said what hurt was the other side of her head where two women had thrown rocks at her. She was unable to give any other details due to her limited cognition. An interview with CNA H on 09/19/25 at 1:45 PM revealed the day of Resident #2's fall, they were short-staffed one CNA that day and she heard Resident #2's family member yell out saying the resident had tripped and fallen. CNA H stated she was the first staff member to enter the her room and found her on the floor with blood coming from her head. CNA H and LVN B then got Resident #2 up and she had a gash above her eye with blood coming out. She said an ambulance was called and Resident #2 said her head was hurting. After she came back from the ER post fall, CNA H stated she had been different, calmer and not as erratic with behaviors as before. An interview with LVN B on 09/21/25 at 11:34 AM revealed she was in the med room when she heard Resident #2's family member calling out for help. LVN B went to see Resident #2 and found her moaning face down on the floor by the bathroom door with a gash on the right side of her forehead. The family member told LVN B that Resident #1 took another resident's walker and when the family member was putting it behind the nurses' station, the resident had the unwitnessed fall in her room. At that point, LVN B stated Resident #2's vitals were checked and the charge nurse assigned to her that shift was LVN F. LVN F came to Resident #2's room and assessed her and there did not appear to be any other injuries, however, due to the head wound and amount of blood, they wanted to send her out. LVN B stated Resident #2 came back from the ER right before her shift was over around 7:00 PM. She stated LVN F checked the resident's vitals and talked with the family and had her hospital paperwork. LVN B stated she helped by putting Resident #2 back into the e-charting system. LVN B stated the charge nurse working when Resident #2 came back from the ER was responsible for charting and doing neuros on per protocol. LVN B stated the DON and ADON D were texting and calling her to come in during the past week to complete the risk management form (incident report). She told them she was not the nurse, it was LVN F. She said LVN F should have done an incident report that day for Resident #2. LVN B stated she did not know the facility's protocol for doing neurochecks on residents post-fall, including when to start them if they were sent out to the ER. LVN B said when a resident sustained a head strike from a fall, the charge nurse was supposed to do a risk assessment (incident report) and check if the resident took blood thinner medication, get vitals and call the physician and family to see if they want the resident sent out. LVN B stated when a resident hits their head, they could potentially have a brain bleed which could be fatal, so they should be monitored for three days. She said even if the resident was sent out and they returned within 72 hours, neurochecks still had to be completed. An interview with Resident #2's RP on 09/21/25 at 12:07 PM revealed the resident had dementia and when she was visiting her, she could not find her initially and then saw her a few doors down with another resident's walker. The RP stated Resident #2 did not use a walker for ambulation and she was holding the walker backwards, using it like she was driving a car. Resident #2 told the RP that she did not know whose walker it was but some guy was chasing her. The RP removed the walker and guided Resident #2 to her chair and went to place the walker behind the nurses' station. When she went back to Resident #2's room, she was on the floor. The RP started hollering for help and several staff showed up and checked for bleeding. The RP told them she wanted Resident #2 to go out to the ER. At the ER, Resident #2 received some stitches and her CT scan was clear. The RP stated she brought the ER discharge documentation and gave the originals to the evening charge nurse. An interview with the DON on 09/21/25 at 2:10 PM revealed she had located Resident #2's records from the facility's online hospital portal from the ER visit. She stated the hospital records had not been on Resident #2's chart. The DON stated that she had only started employment on 09/15/25 and she had not yet gotten around to seeing if the neurological assessments for Resident #2 were done post-fall. The DON stated neuros should be done for four days and there was a schedule the nursing staff had to follow that started off with 15-minute monitoring, then to one hour, then to once per shift. The DON stated the nurse who did record Resident #2's vitals on the e-transfer form stated the resident was stable when she was sent to the ER. Review of Resident #2's ER hospital records provided by the DON on 09/21/25 reflected the resident seen by the ER on [DATE] due to a head laceration and a head injury from a fall. She had a diagnosis of a closed head injury and a facial laceration. Resident #2 had a CT cervical spine without contrast and a CT head without contrast. Resident #2 had ice applied to the affected area and was given Lidocaine-Epinephrine. The after-visit summary was completed at 2:56 pm on 09/14/25. An interview with LVN F on 09/21/25 at 2:36 PM revealed she was a PRN nurse who worked primarily on the weekends. LVN F said she was present when Resident #2 fell. She said that day she was working with two CNAs in another resident's room when she could hear the resident's RP screaming that the resident was on the floor. LVN F entered the room and saw Resident #2 had hit her head on the right side of her forehead on the wooden dresser and her arm was bent in the back position and she was moaning in discomfort. LVN F stated Resident #2 never lost consciousness but was in a chronic state of dementia and due to the heavy bleeding coming from the wound, she called 911 to have her sent to the ER. LVN F stated another nurse named [LVN B] did the incident report for her because she was not as comfortable with the online charting as LVN B was. Also, LVN F stated, I didn't know what to look for in order to generate the report. When Resident #2 came back from the hospital with the RP, LVN F was still working the floor. She said the RP told her she had the hospital ER paperwork but it was at home and she would provide them the next day. LVN F stated she assessed Resident #2 at that point to make sure she was alert. LVN F stated, She wasn't really oriented as such. She could still tell me her name. She had seven sutures in her head, no other injuries. LVN F stated she took a set of vitals on the resident, but did not complete any neuro follow up. Subsequent record review of a revised incident report for Resident #2 revealed comprehensive information was entered into the record on 09/19/25 and 09/20/25, several days after the fall occurred and only after investigator inquiry. The revised documentation included detailed assessments, injury descriptions, vital signs, notifications and care plan review. An interview with the DON on 09/21/25 at 3:10 PM revealed if a resident came back from the hospital ER without any discharge documentation, the charge nurse could call her and she could retrieve the documents through the online portal. Review of the facility's policy titled, Documentation (not dated) reflected, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medications sheets, incident reports, and summary sheets. Documentation also occurs in the clinical software PCC.Goal: 1) The facility will maintain complete and accurate documentation for each resident on all appropriate clinical sheets.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of X residents (Resident #1's) reviewed for drug diversion. The facility failed to prevent an employee with access to controlled medications from diverting 44 Tablets of Hydrocodone-Acetaminophen ,d+[DATE] MG tablets (a schedule II-controlled substance opiate used to treat pain) belonging to Resident #1 from a medication cart. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for unrelieved pain due to his medication not being readily available. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], reflected an [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had a diagnosis which included senile degeneration of brain (a decline in cognitive functioning), malignant neoplasm of colon (cancer of large intestine), and intra-abdominal and pelvic swelling (growth or swelling in abdomen). Record review of Resident #1's Physician orders dated [DATE], reflect she was prescribed Hydrocodone-Acetaminophen ,d+[DATE] MG tablets, 1 tablet by mouth every 6 hours for pain, on [DATE]. Record review of the facility's Provider Investigation Report, dated [DATE], reflected on [DATE] between 7:00PM and 10:00PM 44 Hydrocodone-Acetaminophen ,d+[DATE] MG tablets prescribed to Resident #1 were reported missing from a nurse's medication cart. Medication Aide A, who had access to the cart between 7 PM and 10 PM claimed she was unaware of the Hydrocodone in the cart and only administered narcotics to two other residents. Charge Nurse B confirmed the Hydrocodone was missing during her 10 PM count with Medication Aide A, while Charge Nurse B verified it was present during her 7 PM count with Medication Aide A. The discrepancy indicates the Hydrocodone disappeared between 7 PM and 10 PM, with Medication Aide A as the sole individual with access during that time. The missing count sheet further obscured the discrepancy until Charge Nurse B discovered the loss the next day. Each personnel with access to the medication cart was drug tested at the facility. Medication Aide A failed a drug test in which she tested positive for Benzodiazepine and marijuana for which she was prescribed neither. Medication A's employment with the facility was terminated. The police department was notified, and a report was filed for the missing Hydrocodone-Acetaminophen. Record review of Facility staff in-service was completed on the facility's-controlled substance policy which included receiving, storing, and handling narcotic medications. A card count for all controlled substances was enforced every shift. Record review of a pharmacy packing slip addressed to Resident #1 reflected 45 Hydrocodone-Acetaminophen tablets were delivered to the facility on [DATE]. Record review of Resident #1's Medication Administration Record show she was administered one Hydrocodone-Acetaminophen tablet on [DATE] at 1PM by Charge Nurse B. Observation of the medication cart on [DATE] at 11:40 a.m., which included a review of narcotic logs and count sheets, reflected no evidence of a current drug diversion. The facility staff were following the facility's policies and procedures to prevent a drug diversion. The observation was completed with Charge Nurse B. During a phone interview with Medication Aide A on [DATE] at 12:47 p.m., she stated the medication count was correct when she left her shift at 10 p.m. but admitted she was not paying full attention when counting with the nurse. She insisted the numbers matched in the book and pill count but could not recall details clearly. Medication Aide A stated she believed she was being set up but could not name anyone with a specific grudge against her. During an interview with the Administrator on [DATE] at 2:00 p.m., she stated the Hydrocodone-Acetaminophen arrived at the facility on [DATE] and Charge Nurse B administered one tablet to Resident #1 on [DATE] at 1 p.m. She stated that on [DATE] Charge Nurse B worked from 7 a.m. to 7 p.m. She stated the standard protocol was a nurse completed the medication counts with the medication aides. The Administrator stated that on [DATE], Charge Nurse B counted medications with Medication Aide A at 7 p.m. and all medications, including the Hydrocodone-Acetaminophen were accounted for. She stated Medication Aide A passed medications on [DATE] between 7 p.m. and 10 p.m. She stated at 10 p.m. Medication Aide A counted the medications with Nurse C. The Administrator stated that Nurse C did not count any Hydrocodone-Acetaminophen tablets because the tablets were not in the cart. She stated that Nurse C had no knowledge of the Hydrocodone-Acetaminophen being prescribed to Resident #1 prior to her shift. She stated if the Hydrocodone-Acetaminophen and count sheet were in the cart as they should have been, Nurse C would have counted them. She stated everything else Nurse C counted was accurate. The administrator stated Medication Aide A's drug test was positive and she was terminated due to her results, and she reported Medication Aide A to the state survey agency. She stated the facility never recovered the missing Hydrocodone-Acetaminophen tablets. The Administrator stated Resident #1's hospice was notified about the missing Hydrocodone-Acetaminophen. She stated hospice directed the facility to administer Morphine for pain management. Resident #1 was deceased at time of the survey, therefore surveyor was unable to interview Resident #1. Review of the facility's Controlled Substances Policy, dated ,d+[DATE], reflected, .All controlled medications will be stored under double lock and checked for accountability at each change of shift by the nurse going off duty and the nurse coming on duty. Documentation of the audit will be completed on the appropriate form Entries are to be made in pen each time a controlled substance is used. The nurse administering the medication will record the following information: Date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug. If the pharmacy does not provide a controlled substance audit sheet, the nursing staff will utilize the facilities-controlled drug audit sheet and fill in all of the required information from the Rx label of the medication being audited.

Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 4 of 4 areas (1 storage room and 2 shower rooms and 1 activity room), reviewed for accidents and hazards. 1. The facility failed to ensure that the mechanical lift (Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) in the Activity Room was locked and secured when not in use. 2.The facility failed to ensure that the sit-to-stand lift (a device that helps move a resident from a seated position to a standing position) in the Activity Room was locked and secured when not in use. 3. The facility failed to ensure that the Shower Room door on Station 1 was locked and secured. 4. The facility failed to ensure that the Shower Room door on Station 2 was locked and secured. 5. The facility failed to ensure that the door to the Medical Supply Storage Room on Station 1 was locked and secured. These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products. Findings Include: Observation of the facility's Shower Area on Station 1 on 11/06/24 at 9:50 AM, revealed that there was not an exterior lock on the door. The door was observed ajar and was not locked and secured. Upon entry into the Shower Room, there was a wooden cabinet with a hole for a lock, but the lock was not on the wooden cabinet. Inside of the wooden cabinet were the following items: 1 open bottle labeled, Cleanser for shampoo and body wash. 1 container of deodorant, 2 bottles of shaving cream (1 bottle was open), 1 container of mouthwash, 1 container of Vaseline petroleum jelly, 1 rubber band and 1 unlocked master lock. An observation of the facility's Shower Area on Station 2 on 11/06/24 at 10:01 AM, revealed there was an exterior keypad on the door, but the door was not locked and secured. Upon entry into the Shower Room, there was a wooden cabinet with a hole for a lock, but the lock was not on the wooden cabinet. Inside of the wooden cabinet were the following items: 3 razors, 1 hair clipper, 1 beaded necklace, 1 box of denture cleanser tablets (90 tabs), 1 package of 25 pack lemon glycerin swab sticks. On the floor in the shower room was an open bottle of 1 gallon of Total Bath and Skin and Hair Cleanser. In an interview with LVN C on 11/06/24 at 10:13 AM, she stated that she had been employed at the facility for 1 month. LVN C was escorted to the Shower Area on Station 2 and informed about the findings in the Shower Room. She stated that the open bottle of 1 gallon of Total Bath and Skin and Hair Cleanser on the floor was used by staff during the evening shift the day before. She stated that she was the charge nurse on Station 2 but had not perform walkthroughs of the Shower Room areas during her shift. She stated that staff have been educated and trained on in-services regarding safety and the bottle of 1 gallon of Total Bath and Skin and Hair Cleanser on the floor should have been sealed and stored in a safe area to prevent ingestion. She stated that the razors in the wooden closet should have been locked and secured to prevent injury. She stated that she felt that there were not any risks to residents being hurt or harmed because of the wooden closet where the 3 razors were located. She stated that there were not any risks for any residents to ingest the open bottle of 1 gallon of Total Bath and Skin and Hair Cleanser on the floor because the facility currently does not have any residents that are confused and disoriented. Observation of the facility's Medical Supply Storage Room on Station 1 on 11/06/24 at 3:20 PM, revealed that the door had a keypad, but was ajar and was unlocked. Upon entry into the Medical Supply Storage Room, there were four metal racks that had medical supplies. The medical supplies observed included several boxes of lancets, and syringes, supplies for tube feeding, gastrostomy tubes and tracheostomy tubes and other medical liquids. , such as intravenous (IV) fluids, saline solutions, antiseptic solutions, sterile irrigation fluids, topical medications, and cleaning solutions. In an Interview with LVN C on Station 1 on 11/06/24 at 3:28 PM, she was informed about the door to the Medical Supply Storage Room being opened. She stated, Did you leave the door open? LVN C was told that the door to the Medical Supply Storage Room was already open. LVN C stated that the door to the Medical Supply Storage Room was not supposed to be open and unsecured to prevent a resident from having access to the items in the room and possibly hurting or harming themselves. Observation of the facility's Activity Room on 11/06/24 at 3:39 PM, revealed an unlocked and unsecured mechanical lift parked against the wall adjacent to the entryway of the Activity Room. Observation of the facility's Activity Room on 11/06/24 at 3:41 PM, revealed an unlocked and unsecured sit-to-stand lift parked against the wall adjacent to the entryway of the Activity Room. In an interview with LVN G on 11/06/24 at 3:52 PM, revealed that they had several residents on the unit's Station 2 that required usage of the mechanical lift and the sit-to-stand lift for assistance. LVN G stated that she was unaware that the mechanical lift and sit-to-stand lift were unlocked. She stated that both devices were supposed to be locked when not in use. She stated that all staff and the facility have been trained via in-service training on safety and locking both devices when not in use. She stated that the risks of both devices being unlocked when not in use can cause injury to any resident who tries to lift up on either device. LVN G stated that a resident can sustain an injury including a fracture if the devices were not locked when not in use. Observation of the facility's Medical Supply Storage Room on Station 1 on 11/06/24 at 4:03 PM, revealed that the door was ajar and was unlocked. In an interview with the DON on 11/06/24 at 4:11 PM, revealed that all equipment including mechanical lifts and wheelchairs were to be locked and always secured. The DON revealed that everyone was responsible for ensuring safe storage and maintenance of all facility equipment. She stated that the staff have been in-serviced on safety, accidents, and abuse and neglect. She stated that staff have been told on several occasions that if they see something, such as the mechanical lifts and sit-to-stand lifts not secured, they were to lock and secure them and report what they observed to management. The DON revealed that razors were to be kept in a secured area, which means they were to be always locked and never to be kept in an unlocked compartment. She reported that Station 1 currently does not have any residents and only Station 2 is occupied with residents. She stated that she was unaware that both Shower Rooms on Station 1 and Station 2 were unlocked with the doors ajar. She stated that the door lock for Shower Room in Station 2 sometimes does not lock. She stated that there is a piece on the inside of the door if hit will cause the door not to lock. She stated that she would speak with the Maintenance Director to repair the locks for the doors for the Shower Rooms on Station 1 and Station 2, and the Medical Supply Storage Room. She revealed that risks of improperly storing equipment could be residents potentially cutting or injuring themselves. She stated that the harm of having any liquids not stored properly could be the resident ingesting the liquid which will lead to sickness and possibly death. The DON stated that no liquids should be stored on any floors in the facility and should be locked and always secured. She stated that if supplies in the Shower Rooms and Medical Storage Supply Room areas were accessible to a resident, they could harm themselves by hurting themselves, or someone else such as another resident or staff. She stated that access to a sharp instrument can possibly cause death. On 11/07/24 at 3:20 PM, a request was made to the facility's for policies related to mechanical lifts, sit-to-stand lifts, razor blade storage and accidents and hazards. On 11/07/2024 at 3:27 PM, received policies for hydraulic lifts and the policies did not reflect any pertinent information. The facility did not provide a policy related to mechanical lifts, sit-to-stand lifts, razor blade storage and accidents and hazards.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. 2. The facility failed to ensure that 2 dented cans were removed and separated from the other canned food. 3. The facility failed to seal open items in plastic bags in the dry storage pantry. 4. The facility failed to ensure that expired items in the dry storage pantry and refrigerator were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on [DATE] at 7:21 AM, revealed that inside the large refrigerator were 3 clear plastic containers of watermelon, 2 clear plastic containers of apple sauce, 1 clear plastic container of grated cheese and all items were not labeled and dated. The refrigerator also contained 1 clear plastic container with a yellow liquid substance which was not labeled and dated. There were also 5 pans of cheesecake that were not sealed and were exposed to air in the refrigerator. Inside the second refrigerator, there was an opened box with 6 Activia Low Fat Yogurt (3 strawberry and 3 peach) 4 ounce containers with an expiration date of [DATE] on each yogurt container. The label on box reflected, an expiration date of [DATE]. The dry storage pantry revealed 3 Twist Lemonade packages with an expiration date of [DATE]. There was an open package of 2.75 oz of Lemon Gelatin Mix, a box of 22 packages of Hidden Valley Ranch which included 15 packages that expired on [DATE]. There were 2 packages of [NAME] Italian Pasta and both packages were open and were not sealed and exposed to air. There was 1 package of the [NAME] Italian Pasta that had a hole in the bottom of the bag . There was 1 package of [NAME] Pasta 10 lb. bag that was not sealed and exposed to air. There were 4 packages of Pioneer Complete Cornbread Mix 5 lb. bags that were dated [DATE] . There was a 6 pack of V8 Vegetable Juice with an expiration date of [DATE] . There was 1 package of 16 oz. Snowflake shredded coconut that was open, unsealed and exposed to air. There was 1 package of 16 oz. [NAME] Cornstarch that was open, unsealed and exposed to air . In the dry storage area, there were 2 dented 15 oz. cans of dark red kidney beans on the shelf with the other canned goods. In an interview with the [NAME] F on [DATE] at 7:45 AM, she was informed about the dented cans in the kitchen. She stated that the Dietary Manager was responsible for storing the canned goods in the dry storage pantry area. She stated that she did not observe the two dented 15 oz. cans of dark red kidney beans on the shelf in the dry storage pantry. She stated that the dented cans were to be separated and placed in a separate area for the dented cans. She stated that the risk of a resident possibly ingesting foods from a dented can could cause the resident to become sick and ill. In an Interview with the Dietary Manager on [DATE] at 8:15 AM, he stated that it was his responsibility to ensure that there were not any dented cans in the dry storage area with the other canned goods. He stated that he has a routine of checking the dry storage area to ensure that everything is labeled, dated and that there were not any dented cans on the shelf with the other canned goods. He stated that during his routine of checking the dry storage and refrigerator, he will also ensure that there are not any expired food or beverages in both areas. He stated that the risks of expired items being in the dry storage and refrigerators is that giving a resident expired food can cause the resident to become sick and ill and that he would not like to ingest any food that was expired. He stated that if food is not properly sealed, it could cause air-borne illness to occur and can get the residents who eat the food at the facility sick. He stated that he recently received a shipment of the Twist Lemonade from his vendor. He stated that the vendor delivered the items, and they were expired. He reported that he signed the shipment from the manufacturer for the delivery. In an Interview with the Administrator on [DATE] at 1:15 PM, he was informed about the findings in the kitchen during the initial tour of the kitchen. He stated that he was surprised to hear about the findings in the kitchen because he recently conducted a Mock Survey prior to the visit to the facility and he did not have any concerns. He stated that the residents, himself and staff have eaten from the kitchen, and no one has gotten sick from the food, and he had not received any reports from anyone regarding the food that is served from the kitchen. He stated that the risk to anyone that eats food from the kitchen can cause them to get sick, if they were to eat any expired food from the kitchen. Record review of the facility's undated policy, Food and Storage Sanitation .Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded. Record review of the facility's undated policy, Food Storage and Dry Storage Supplies, revealed, 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. 7. According to the USDA fact sheet on Food Product dating, product dating on manufactured goods is not required by federal regulations except baby formula. For this reason, products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. These dates do not indicate that the product is no longer safe after one year, but give a method to track the age of a product so that it can be evaluated for quality before service. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible food spoilage is observed prior to the best by date, the product will be discarded. 9. Perishable and non-perishable foods are classified based on their pH and water content Food manufacturers must determine whether their products meet the perishable criteria when determining whether they are required to declare expiration dates according to the Food and Drug Administration which regulates their manufacturing processes. If a manufacturer is not required to declare an expiration date, then that means that time is not a criteria in determining whether the product is safe to consume. Non-perishable foods meet the criteria in the Texas Food Establishment rules for classifying foods as non-time and temperature controlled for safety foods (NTCS). NTCS foods do not use time or temperature as a criteria for determining food safety. These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 (#85, #5,#24, & #8) of 8 residents observed for infection control. - The facility failed to ensure RN B cleaned the glucometer in between each resident's use. - The facility failed to ensure LVN C disinfected the blood pressure cuff in between each resident's blood pressure checks. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Observation on 11/06/24 at 07:35 AM revealed RN B getting a glucometer machine from the medication cart and proceeded to Resident #24 and checked her blood sugar. After checking the resident's blood sugar RN B placed the glucometer on top of the medication cart, took off gloves her and completed hand hygiene. RN B documented and proceeded to administer the resident's medication. After administering Resident #24's medications RN B proceeded to Resident #5's room. RN B got the same glucometer she had used that was on top of the medication cart, put on gloves and proceeded to Resident #5's room and checked her blood sugar. After checking the blood sugar RN B returned to the medication cart and placed the glucometer machine on top of the medication cart and did not clean and glucometer. RN B took off her gloves, completed hand hygiene and administered insulin to Resident #5. After she was done with Resident #5, RN B proceeded to Resident #85's room. RN B checked the resident's blood sugar with the same glucometer that she had not cleaned between the residents. After she checked the resident's blood sugar, she did not clean the glucometer machine and then placed the glucometer machine in the cart. In an interview on 11/06/24 at 08:15 am with RN B she stated she was supposed to clean the glucometer in between resident use, but she forgot. She stated she was supposed to clean the glucometer to prevent cross contamination. She stated had an in-service on infection control about 1 week ago. Observation on 11/05/24 at 08:40 AM revealed LVN C checking Resident #27's blood pressure then administered the resident's medication, LVN C did not clean the blood pressure machine. LVN C completed hand hygiene after medication administration and proceeded to Resident # 8's room and with the same blood pressure machine checked the resident's blood pressure. After checking the blood pressure LVN C did not clean the blood pressure machine. LVN C then proceeded to Resident #20's room and used the same blood pressure machine to check the residents blood pressure. LVN C was observed using the blood pressure machine and did not clean in between resident use. In an interview on 11/05/25 at 09:18 with LVN C regarding cleaning the blood pressure machine between resident's use, LVN C stated she was no longer required to clean the blood pressure machine between the residents LVN C stated staff were only required to clean the blood pressure machine during a covid out break and since there were no cases of covid she did not need to clean the blood pressure machine between residents use. In an interview on 11/06/24 at 04:37 PM with the DON she stated she started re-educating the nurses on 11/05/24 on making sure the glucometer machine and blood pressure machines were cleaned in between resident use to prevent contamination from one resident to another. The DON stated she expected the staff to clean any shared machines/equipment used with multiple residents due to infection control. Review of the facility policy titled infection control policy and procedure manual 2019 reflected, .Resident care equipment and articles.3. Non-invasive resident care equipment is cleaned daily or as needed between use . Equipment that is visibly with blood or body fluids will be cleaned immediately with an approved disinfectant .

Based on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 1(Residents #5) of 6 residents reviewed for activities. The facility failed to provide individualized and group activities for Resident #5. The facility failed to ensure Resident #5 had an individualized activity care plan. These failures could place resident at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings included: Record review of Resident #5's face sheet dated 11/07/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's active diagnoses included respiratory failure, dysphagia (difficulty swallowing), muscle weakness, gastrostomy status (surgical opening in the abdomen that provides a route for feeding or draining the stomach), lack of coordination, hypertension (chronic condition where the pressure of blood in your arteries is consistently too high). Record review of Resident #5's MDS assessment dated ,d+[DATE] reflected she had a BIMS score of 15, which indicated no cognitive impairment. Resident #5 was usually understood. Resident #5 required minimum to total assistance with activities of daily living. Record review of Resident #5's care plan initiated 12/23/22 and last revised on 08/16/24 reflected, Focus, (Resident #5) expresses preferred activities pursuits. Goal, (Resident #5) will be able to participate in enjoyable activities during their stay. Interventions, Assist (Resident #5) in obtaining any supplies or materials needed for independent activity pursuits. Provide an activities calendar and assist (Resident #5) in planning as needed. Review of Resident #5's clinical chart and assessments between May, 2024 and November, 2024 reflected no documented evidence of an activities assessment. Review of Resident #5's progress notes from May 2024 through November 2024 reflected no documented evidence of any activities progress notes. An observation and interview on 11/05/24 at 11:23 AM revealed Resident #5 in bed. She was awake and alert watching the television. Resident #5 stated she spent all her time in bed and mostly watching television. When asked if she participated in activities, Resident #5 stated she had not participated in in-room or group activities. Resident #5 stated she would like to participate in group activities like bingo and shakers which she liked. Resident # 5 stated no one had asked her if she wanted to participate in group activities. Follow up with Resident #5 on 11/07/24 at 10:34 AM she stated she had participated in group activities on 11/05/24 and 11/06/24 and liked it, and she would attend the 2 pm bingo that was scheduled on 11/07/24. In an interview on 11/05/24 at 11:33 AM CNA A stated she provided care to Resident #5. Resident #5 was alert and oriented and she did not attend activities. CNA A stated on admission Resident #5 participated in group activities and liked bingo. CNA A stated she did not know why Resident #5 did not attend activities. CNA A stated the Activity Director got the resident from the rooms who participated in activities. CNA A stated the Activity Director had not informed her Resident #5 needed to attend group activities. CNA A stated a resident's lack of activities could lead to isolation. In an interview on 11/05/24 at 11:41 AM with the Activity Director, she stated she had worked in the facility for about 6 months and Resident #5 had not participated in any activity. She stated the resident was to receive in-room activities because she was mostly in bed. The Activity Director stated she checked on the resident in the mornings and the resident was asleep, so she was not able to complete any activity with the resident. The Activity Director stated she had not met with the resident to find out the best time for the resident to complete the in-room activities. The Activity Director stated she would assess the resident and find out the best time to complete the in-room activities. The Activity Director stated the resident required activities to be active and prevent the resident being isolated and keep the mind busy. In an interview on 11/05/24 at 01:15 PM with the DON, she stated Resident #5 was alert and oriented. The DON stated she was notified. That the resident liked to spend time watching television, the DON did not mention the time she was notified. The DON stated she was not aware why Resident #5 was not attending activities. The DON stated she was to follow up and find out why the resident was not attending activities. In a follow up interview with the DON on 11/05/24 at 02:45 PM she stated she had talked with Resident #5 and the resident wanted to get up to play bingo, and the resident was able to participate. The DON stated the resident required to participate in activities prevented the loss of social interaction, decreased the quality of life, and isolation or depression. In an interview on 11/07/24 at 12:34 PM with RN B, she stated she had not observed Resident #5 being involved in any activities and had not seen the Activity Director completing any in-room activity with the resident. The resident was at risk of isolation, depression if she was not completing any activity. Review of the facility policy, undated and titled activity program calendar reflected, The Activity Director and staff will inform residents, staff, family, visitors, and volunteers of a monthly program schedule, utilizing Calendars, daily announcements, and personal invitation. 6. Individual programs are scheduled for those residents who cannot or choose not to attend group programs. A. This schedule reflects days and frequency of each resident's individual program.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of one resident (Resident #5) reviewed for feeding tubes. 1. The facility failed to ensure LVN B flushed Resident #5's G-Tube with 30 cc of water prior to the medication administration per physician's orders. 2. The facility failed to ensure LVN B flushed Resident #5's G-Tube with 10 cc of water in between each medication. 3. The facility failed to ensure LVN B checked Resident #5's G-Tube placement and residual (the process of aspirating (drawing out) a small amount of fluid from the stomach through the feeding tube to measure the volume of liquid remaining in the stomach) during medication administration. These failures could affect residents by placing them at risk of abdominal discomfort and obstruction of the G-tube. Findings included: Record review of Resident #5's face sheet dated 11/07/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's active diagnoses included respiratory failure, dysphagia (difficulty swallowing), muscle weakness, gastrostomy status (surgical opening in the abdomen that provides a route for feeding or draining the stomach), lack of coordination, hypertension (chronic condition where the pressure of blood in your arteries is consistently too high) Record review of Resident #5's Physicians Order Report dated 11/07/24 with order date of 10/24/24 reflected, Flush feeding tube with 30 ml of water before and after feeding and medication administration. Flush tube feeding with 10 ml of water between each medication. Observation on 11/05/24 at 07:51 AM and 09:36 AM revealed RN B administering the following mediations via the G-Tube to Resident #5: tramadol 50 mg 1 tablet, acetazolamide 250 mg, cetirizine 10 mg, One-day vitamin, gemtesa 75 mg, Vitamin B-6 50mg. RN B crushed the medications on the medication cart in different medication cups. RN B then proceed to Resident #5's room and paused the feeding tube. Then RN B disconnected the G-Tube feeding from the pump machine. RN B then mixed the medications in each medication cup with 5-10 cc of water. RN B then proceeded to administer the medications without flushing the G-Tube, she did not check for placement or check for residual before medication administration. In an interview on 11/05/24 at 08:08 AM with RN B, she stated she checked the residual by placing the open syringe on the g-tube and if there was nothing coming out then the resident did not have residual. RN B was asked if that was the right procedure for checking residual, and she stated that was how she checked for residual. RN B stated she did not check for placement and flush before medications administration. RN B stated she did not flush in between medications because there was no order to flush in between medications. RN B stated she would check the orders for the flushes. In an interview on 11/06/24 at 04:37 PM with the DON, she stated she talked with RN B regarding G-Tube medication administration, and she noted she had made some mistakes. The DON stated she expected RN B to follow the physician's orders by flushing before and after medication administration and she was supposed to flush in between medications. The DON stated RN B was supposed to check the resident's G-Tube for placement and residual before medication administration. The DON stated she had in-serviced the nurses on the right way to administer medication administration. The DON stated the staff were to follow the physician's orders and facility policy during G-Tube medication administration to prevent complications like the G-Tube clogging and aspiration (When food, liquid, or other material is accidentally inhaled into the lungs. This can occur when swallowing or when material comes back up from the stomach.) In an interview on 11/07/24 at 01:09 PM with RN B, she stated she was not aware of the flushing in between medications but if the order stated she was supposed to flush in-between meds, then she was expected to flush to prevent the g-tube from clogging and medication interactions. RN B stated she was expected to check the resident's G-Tube placement to confirm the g-tube was at the right place and she was supposed to check for residual G-Tube to make sure the resident was absorbing the feeding well and if she did not and she was having too much in the stomach that could lead to aspiration. Review of the facility policy dated 1/25/13 and titled enteral medication administration reflected, 6. Check the placement of the tube by aspiration of contents or auscultation. Elevate the resident per facility policy. 7. Flush the tube with 30ml water or according to physician order. 8. Administer one medication at a time with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the final medication is administered. Verify that medication cups are clear of any remnants of crushed pills or liquid medication. Alternate fluid may be used if the facility policy and diet orders permit. 9. Once all medications have been administered, flush the tube with 30ml water or according to physician order.

Based on interview and record review the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 residents (Resident #11) reviewed for hospice services. The facility did not update Resident #11's care plan to reflect that she was on hospice. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Record review of Resident #11's Face Sheet, dated 11/07/24, revealed that she was a [AGE] year-old male with an initial admitted to the facility of 06/08/23 and readmitted to the facility on [DATE]. Resident #11's active diagnoses included: dysphagia (difficulty swallowing), dementia, behavioral disturbance, psychotic disturbance, anxiety, hyperthyroidism (occurs when the thyroid gland produces too much thyroid hormones), hyperlipidemia (a condition where there are abnormally high levels of lipids in the blood), and heart failure. Record review of Resident #11's MDS dated [DATE] revealed she had a BIMS score of 11/15 indicating a moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed no documentation of for Hospice Services. Record review of Resident #11's Hospice Binder revealed a Hospice Contract starting Hospice Services with [Hospice Company] on 09/20/24. Record Review of Resident #11's Physician Order revealed that Resident #11 was to begin on hospice services on 09/20/24. Record review of Resident #11's progress notes reflected: Hospice Care Changes. 09/20/24 . Record review of Resident #11's Significant Change MDS dated [DATE] revealed she had a BIMS score of 6/15 indicating a severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed that Resident #11 had Hospice Care while a resident at the facility. Record review of Resident #11's Care Plan, no date indicated, did not reveal that she was on hospice. In an interview with Resident #11 on 11/05/2024 at 2:11 PM, she stated that she had been at the facility for almost a year. Resident #11 stated that she had dementia and was forgetful at times. She stated that she was currently on hospice and had someone from the hospice come visit her on a regular basis. In an interview with the ADON on 11/05/2024 at 2:11 PM she confirmed that Resident #11 was on h ospice and receives hospice services. She stated that she was not sure why Resident #11's care plan did not reflect that she received Hospice Services. She stated that the risk of Resident #11's Care Plan not reflecting that she is on Hospice can affect the care she receives from staff at the facility. In an interview with the DON on 11/06/2024 at 4:11 PM, revealed that she was not aware that Resident #11's Care Plan reflects that she was not on Hospice. She stated that Resident #11 started hospice services on 09/20/24. She stated that she was responsible for updating Resident #11's Care Plan to reflect that she is on hospice. She stated that she has several residents to update information for and that the revision and update of Resident #11's Care Plan, must have fell through the cracks. She stated that she is responsible for updating each resident's Care Plan. She stated that the risk of Resident #11's Care Plan not being updated to reflect that she is on Hospice can affect the care she receives from staff. She stated that if a resident, such as Resident #11 is on hospice, the residents care is provided by the hospice company, and they are notified of any changes if they occur with the residents. A record review of the facility's undated policy, Comprehensive Care Planning reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record. There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment, but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weaknesses or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team (IDT), in conjunction with the resident and/or resident's representative, if applicable, will develop and implement the comprehensive care plan and describe how the facility will address the resident's goals, preferences, strengths, weaknesses, and needs. In situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan. In addition to addressing preferences and needs assessed by the MDS, the comprehensive care plan will coordinate with and address any specialized services or specialized rehabilitation services the facility will provide or arrange as a result of PASARR recommendations. If the IDT disagrees with the findings of the PASARR, it will indicate its rationale in the resident's medical record. The rationale should include an explanation of why the resident's current assessed needs are inconsistent with the PASARR recommendations and how the resident would benefit from alternative interventions. The facility should also document a resident's the resident's preference for a different approach to achieve goals or refusal of recommended services. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. The comprehensive care plan will address a resident's preference for future discharge, as early as upon admission, to ensure that each resident is given every opportunity to attain his/her highest quality of life. This encourages facilities to operate in a person-centered fashion that addresses resident choice and preferences. Comprehensive Care Plans A comprehensive care plan will be- Developed within 7 days after completion of the comprehensive assessment. Prepared and/or contributed to by an interdisciplinary team .Prepared and/or contributed to by an interdisciplinary team .

Based on interviews and record review, the facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), for 1 (Resident #1) of 1 resident reviewed for discharge planning. The facility failed to complete a reconciliation of Resident #1's medications when she discharged home. This failure placed residents at risk of a lack of continuity of care and adequate medication administration after they are discharged home. Findings included: Record review of Resident #1's Admission Record dated 9/19/24 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and was discharged home on 8/20/24. Record review of Resident #1's Admission MDS assessment dated [DATE] reflected she was cognitively intact. Her diagnoses included presence of a right artificial hip joint, osteoarthritis of hip (occurs when the tissue at the ends of a bone wears down), hypertension (high blood pressure), and lumbar region radiculopathy (injury to the nerves in the lower back causing pain). Record review of Resident #1's Care Plan reflected the following entries: Date initiated 8/17/24. [Resident #1] is on anticoagulant therapy (prevents blood from clotting too quickly). Enoxaparin (medication used to prevent blood clots in the leg in patients on bedrest or after having surgery). Interventions included daily skin inspections; report bruising, nosebleeds, bleeding gums, prolonged bleeding from a wound, blood in urine/feces/vomit, coughing up blood . [Resident #1] teaching to include: Take/give medication at the same time each day. Use soft toothbrush. Avoid activities that could cause injuries . Record review of Resident #1's progress notes reflected the following entries: 8/16/24: [Resident #1] is a [AGE] year-old female admitted from [hospital name]. Dx: right hip total replacement. Hx: HTN, hyperlipidemia (high levels of fat particles in the blood), cataracts (clouding of the normally clear lens of the eye), spinal fx . A&Ox4 [alert and oriented to person, place, time, and situation] .verbally makes needs known . Signed by RN A 8/20/24: May DC home on/after 8/20/24. Home Health Eval & treat as appropriate (SN, PT/OT , Home Health Aide) . Signed by the SW Record review of Resident #1's Discharge to Home Instructions dated 8/20/24 and provided by the DON reflected the following: A. Nursing Discharge. This section is to be completed immediately prior to discharge .Discharging Nurse before completing this, you will need to print off the resident's 'Transfer/Discharge Record.' This will be used for medication education and can be used as an inventory of medications the resident will be dc'd with. To print the Transfer/Discharge Record if not already, exit the screen click Reports. At the report screen search for and clickclick [sic] Transfer Discharge Record New, enter the resident's name, then run the report. Then return to this assessment. 1. Discharge instructions given to 'Resident'. 2. Discharging to 'Home' .7. Review the medications on the Transfer/Discharge Record, note any special instructions below: 'Yes, all medications given to resident.' . The Document was signed by Resident #1. Record review of Resident #1's electronic clinical record revealed no transfer/discharge record or other record containing a reconciliation of Resident #1's pre-discharge medications with her post-discharge medications could be located. During a telephone interview on 9/19/24 at 10:09 AM, Resident #1 stated she received medications when she discharged from the facility, but the staff did not give her blood thinners. She stated she did not contact the facility afterward and had addressed the issue with her physician after her discharge and got her medication reordered. Resident #1 could not recall whether they had provided her with a list of her medications when she left. During an interview on 9/19/24 at 12:01 PM, RN A stated she had provided care for Resident #1 but was not there when she discharged home. She stated, when a resident was to be discharged , a medication list was pulled from the computer, the medications and instructions were reviewed with the residents, and all their medications were sent home with the resident. RN A stated a copy of the medication list with instructions, the Discharge Summary, and the Admission Record were also sent home with the resident. She stated a copy of the documents should also be in the resident's electronic record. RN A stated it was important the resident had a copy of everything and their medications when they leave so they do not miss any medication doses . During an interview on 9/19/24 at 12:52 PM, the SW stated she had assisted with Resident #1's discharge by setting up home health care for her with the company she had chosen. She stated she was unaware of any complaints or concerns related to Resident #1's medications. In an interview and record review on 9/19/24 at 2:35 PM, the DON reviewed a copy of the signed discharge instructions provided to Resident #1 along with a signed inventory list for Resident #1's hydrocodone (narcotic pain medication) tablets dated 8/20/24. The inventory list included a note indicating the medications were counted and released to Resident #1. The DON stated she had been unable to locate a list of the other medications sent home with Resident #1 when she was discharged , but believed all her medications were released with her. The DON stated she had checked the medication carts after Resident #1 had been discharged and none of her medications remained at the facility. She stated a medication reconciliation list was typically pulled when a resident was discharged that included their medications ordered as well as the instructions for taking the medications. She stated she was unable to pull the list from the computer after the resident was discharged from the facility. She stated she would check with the medical records for the missing documentation. During a telephone interview on 9/19/24 at 3:09 PM, RN B stated she had discharged Resident #1 and had provided her medications along with a list of her medications, her Discharge Summary, and a copy of her face sheet. She stated the medication discharge forms were pulled from the computer whenever a resident was getting discharged and was used to reconcile their medications and orders. She stated a copy of the signed documents should have been added to her clinical record. RN B stated she believed she had provided Resident #1 with her blood thinner, enoxaparin, upon discharge. RN B stated Resident #1's discharge planning had been completed and her home health had been arranged. She stated she did not recall Resident #1 having any complaints or concerns at the time she was discharged home. RN B stated she did not know why Resident #1's medication reconciliation was not located in her electronic record . In an interview on 9/19/24 at 4:30 PM, the DON stated she was unable to locate any medication reconciliation documentation for Resident #1 and was previously unaware the documentation had not been completed. She stated the risk to residents was they may not be aware of any dosing changes or proper instructions for taking their medications . In an interview on 9/19/24 at 4:42 PM, the Administrator stated the discharge summary and medication reconciliation documents were important for all involved because a resident may go home and be unsure of what they need to do or what medications they needed to take . Record review of the facility's policy titled, Discharge Planning Process Policy, dated Revised 11/28/16 reflected the following: Nursing facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility .Discharge Summary must include: .B) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) .E) The Final discharge summary will be filed in the resident's medical record.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for one of eight residents (Residents #177) reviewed for baseline care plans. The facility failed to complete a baseline care plan for Residents #177 within 48 hours of admission which included the minimum required healthcare information which included physician orders, dietary orders, therapy services and social services. This failure could place residents at risk of not receiving effective and person-centered care. Findings include: Record review of Resident#177's faced sheet, dated 09/27/2023, reflected a 95 -years-old-male who was admitted to the facility on [DATE]. His diagnoses included: hemiplegia (paralysis of one side of the body) affecting left non-dominant side, hypertension, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) following cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain), muscle weakness, lack of coordination, and repeated fall. Record review of Resident #177's electronic clinical record, on 09/26/23, revealed no Baseline Care Plan. An incomplete baseline care plan was done on 09/27/2023. Interview on 09/27/23 at 02:06 PM with the DON revealed Resident #177's base line care plan was not done after 48 hours of admission and stated the care plan was posted today, 09/27/2023. The DON stated Resident # 177's admission paper was not reviewed, and she was not aware of the missing base line care plan. The DON stated baseline care plans should be completed by the nurses completing the residents' admission. She stated the baseline care plans were important because they captured the immediate care needs of residents coming into the facility. She stated they should be completed within 24 - 48 hours. she stated the facility's expectation was they be completed with 24 hours. She stated not having a baseline care plan could limit the facility's ability to meet the resident's care needs. She said would typically complete admission reviews to ensure all care plans were completed. Interview on 09/28/23 at 10:00 AM with MDS coordinator nurse D revealed she worked as the MDS coordinator nurse at a corporate level and was no longer assigned to the facility starting last Thursday 09/21/2023. She stated baseline care plans should be completed by the nurses completing the residents' admission and the MDS Nurse Coordinator revised it when developing the MDS and the comprehensive care plan after 14 days of residents' admissions. Interview on 09/28/23 at 10:19 AM with RN P revealed she had been with the facility for two weeks and was not able to do an admission yet. RN P stated the RNs were responsible for initiating a base line care plan in the first 48 hours of residents' admission. RN P stated the care plan outlined the care residents needed. RN P stated without a base line care plan the residents' care would not be accurately provided. RN P stated the DON was responsible for completing admission reviews to ensure all admission documentation was completed, which included baseline care plan. Interview on 09/28/23 at 10:27 AM, MDS Coordinator Nurse S revealed she started with the facility yesterday, 09/27/2023, as travel nurse MDS coordinator. She stated the purpose of care plans were to basically monitor the residents, and their needs. She stated the baseline care plan was a tool used for the residents in the planning of their care and their needs. She stated the MDS coordinator nurses had 14 days to revise, and develop the residents' comprehensive care plan, and MDS after admission. She stated the nurses in the ward, and the DON were responsible for developing the baseline care plan for the resident after 48 hours of admission. Record review of the facility policy, Base Line Care Plan, dated 03-2019, reflected, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate supervision and assistive devices were provided to prevent an accident for one (Resident #1) of three residents. Resident #1 fell from the bed while being provided incontinent care by CNA A. The CNA's assignment sheet did not specify the need for two people to provide assistance to the resident during incontinent care. There were only two quarter size bed rails on the resident's bed (instead of four), one of which became loose and extended away from the bed. Resident #1 was unable to hold on to the bedrail and fail to the floor, which resulted in a fracture of the left femur. These failures could affect the four residents, who were in the four bariatric beds belonging to the facility, including Resident #1, and placed them at risk for the potential of falling with injury, pain and discomfort, emotional pain and suffering, and at risk for further medical complications. Findings included: 1. Review of Resident #1's Face Sheet dated 01/06/11 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident's current MDS assessment dated [DATE] reflected active [DIAGNOSES REDACTED]. The assessment also reflected Resident #1 required extensive assistance with toileting, which included how the resident used the "toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; and adjusts clothes." Review of Resident #1's Nursing Care Plan dated 06/09/10 revealed, "Resident requires total two-person assist with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene, bathing, requires limited one person assist with meals related to decline in cognition and mobility." The care plan also reflected Resident #1 needed the side rails up when she was in bed to assist with self bed mobility. Approaches included keeping the side rails up when the resident was in bed and to monitor the resident's need for assistance with bed mobility every shift and to assist as needed. The care plan was reviewed on 09/08/10 and 12/08/10, and recommendations were made to continue with the plan. Nurses' Notes dated 01/06/11 at 1:30 AM, reflected Resident #1 fell at 12:45 AM. CNA A reported the resident was on the floor on her back, and she was alert and oriented. CNA A reported she (CNA A) was attempting to give incontinent care to the resident. The resident was positioned on her left side against the side rail. The side rail was loose, and the resident fell out of bed. The Notes further reflected Resident #1 complained of severe left knee pain and swelling. An area of discoloration and swelling was noted on the right mid outer leg. The resident's blood pressure and pulse were abnormally high. Pain medication was administered, and the physician was notified. The physician ordered an x-ray of the left knee. Nurses' Notes dated 01/06/11 reflected x-rays were done at 2:15 AM with the results reported to the physician at 5:15 AM (method of reporting was not identified). Additional pain medication was administered at 5:20 AM. At 7:20 AM, the physician recommended Resident #1 be sent to the hospital. Resident #1 was transported by ambulance at 8:00 AM. The Incident Report dated 01/06/11 reflected the nurse aide (CNA A) reported she was trying to give Resident #1 incontinent care. As the resident turned against the side rail, "the rail was loose," and the resident slipped out of bed and fell to the floor. The bed had been raised to a high level at the time of the incident. The facility's conclusion of the incident investigation reflected, "Resident's bed too high due to her preference and her control. SR (side rail) on bed too loose it not properly secured. (sic)" Below the conclusion was an additional note dated 01/06/11 that reflected, "Bed rails secure on bed. Not loose. Only has half rails @ top of bed." The Hospital Emergency Department Nursing Record dated 01/06/11 at 8:19 AM reflected Resident #1's blood pressure was 182/118 (abnormally high), and the resident was experiencing pain rated at 10, on a 1 to 10 scale. The resident received Morphine (narcotic pain medication) 6 mg with Phenergan (for nausea) 25 mg injection injection twice for the pain. The hospital x-ray report dated 01/06/11 reflected Resident#1 had a "comminuted (broken in pieces) fracture of the end of the femur (upper leg bone) with a 4 mm lateral displacement of the distal fracture fragment...." A prior below the knee amputation was noted. Resident #1 was treatment with a knee immobilizer and referred to an orthopedic doctor. The resident was discharged to return to the facility at 1:50 PM on 01/06/11. An interview with the DON on 01/18/11 at 11:00 AM revealed he thought it was difficult for one person to provide incontinent care to Resident #1. The resident could hold onto the side rail, but weighed 350 pounds. He stated due to the resident's weight, a CNA assisting her on or off the bedpan could be on one side but "couldn't hold her in position to wipe or clean the resident. A person on the other side {of the bed) needed to help hold the hips over to allow the bedpan to be removed." Observation of Resident #1's empty bed on 01/18/11 at 12:05 PM, accompanied by the Maintenance Supervisor, revealed a bariatric bed (specially sized bed) with an alternating air mattress. At that time, the Maintenance Supervisor demonstrated the operation of the bed. Four quarter side rails were observed to be attached to the bed. The side rails were all functioning in a normal manner. No malfunction was observed. An interview with the Maintenance Supervisor on 01/18/11 at the time of the observation revealed the inspection of the side rails was done by him at the request of the Administrator at 10:00 AM on 01/06/11. He stated he found the side rails were functioning as designed; he found no malfunction. He stated only the upper two side rails were on the bed when he examined it. He noted the side rails had a button release located on the underside of the mattress, which allowed the side rail adaptation to fit different mattress sizes on the bariatric bed. When he inspected the side rail on 01/06/11, the button release was working normally. The extension mechanism was locked in place. He stated when the button was pressed inward, the side rail expansion feature was initiated. Normally, the button release extended through a hole, which acted as a locking mechanism. The button had to be pushed down and held at the same time for the expansion feature to work. No repair or replacement of parts was necessary based on his inspection 01/06/11. The facility had four other bariatric beds; three had the same mechanism for expansion of the side rails. The maintenance supervisor had inspected the other three bedrails after 01/06/11 and had found them to also be functioning normally. An interview with the DON on 01/18/11 at 2:00 PM revealed Resident #1 required a two-person assist for bed mobility and other activities. The Nursing Care Plan for Resident #1 was not transmitted onto the nurse aide worksheet. The DON stated the ADONs were responsible for the accuracy of the nurse aide worksheet. The DON stated, "I marked on the nurse aide worksheet (in the incident report) that another column needed to be added, because it does not have information about how many should help with incontinent care. (Resident #1) ____ was a two-person assist for everything. The Resident Data Sheet does not show she was a two-person assist for incontinent care, but was coded as an extensive assist. (Resident #1) ____ weighs over 350 pounds. There is no way the resident could be given incontinent care after a bowel movement with just one person, so we have changed that to a two-person for incontinent care." The DON explained each nurse aide received an assignment sheet at the beginning of the shift. Information related to their assignment was transmitted on the assignment sheet. The aides were held responsible for knowing what was on the assignment sheet. The assignment sheet included the nurse aide responsibilities for residents and included information regarding turning, mobility, side rails, continence status, transfer assistance requirements, seizure risk, fall risk diabetic status, as well as other needs. The assignment sheets were updated as necessary when changes occurred. The Nurse Aide Worksheet Group, Section 5 for Resident #1 used on 01/06/11 was attached to the incident report and indicated Resident #1's need for side rails, off loading, three-person Hoyer lift transfer and identification as a fall risk. The notation "need to add incontinent care" was handwritten on the nurse aide worksheet accompanying the incident report. An interview with Resident #1 on 01/18/11 at 3:10 PM revealed that immediately before the accident, the resident was rolled facing toward the window on her right side for incontinent care. She reported she had a bowel movement and asked the aide to clean her up. The aide wanted to get another aide to assist her, but "I didn't want to wait, 'cause it takes too long." Resident #1 stated the side rail did not come off the bed, but had "slid out," and she could not keep hold of it. She revealed this was the first time the side rail had extended out when she pressed against it. She did not recall the last time she had used the side rails to turn prior to the accident, but she was sure she had used them some time that (same) day and did not have any problem with the rails being loose. Resident #1 stated, "I can turn myself. It don't take two of them to turn me." Observation on 01/19/11 at 3:15 PM revealed Resident #1 was crying. At that time, she revealed she was crying due to "the pain in her stump." She stated she had received pain medication "about an hour ago," but it was not helping. She indicated she was angry at the aide who "did this to her" (caused the fracture), because she had wanted a "new leg" for her stump. She believed this was not possible for several months because of the fracture. She stated, "That aide just goes about her business, gets a new job, but me, I'm stuck here." 2. Review of the facility's Daily Census dated 01/18/11 revealed the resident census was 110. A telephone interview with the DON on 02/07/11, post-exit, revealed 15 residents were totally dependent for ADLs.