Every finding on record at Brentwood Terrace Healthcare and Rehabilitation

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff on 07/04/2026, 07/05/2026, 07/08/2026, 07/11/2026, 07/12/2026, 07/14/2026, 07/16/2026, 07/19/2026, 07/25/2026, 07/26/2026, 07/27/2026. This failure placed residents at risk of inadequate supervision, an unsafe environment, and not receiving timely care. Findings included: During a confidential group interview at an undisclosed date and time, residents in the group stated that they waited up to 3 hours for their call light to be answered. Residents stated these prolonged wait times occurred most frequently on the night shift and weekends. Residents stated staff would tell them they were short staffed when explaining delays in responding to call lights or providing care. Residents stated they believed there were not enough staff members available at times to meet their needs in a timely manner. Residents reported experiencing delays with assistance with their ADLs. Residents stated the extended response times caused them to feel they needed to delay requesting assistance because they anticipated lengthy wait times. Residents stated they felt their needs were not addressed promptly due to the lack of available staff. Residents stated they had expressed their concerns to the DON and Ombudsman. During an interview on 07/27/2026 at 12:21 PM, the Ombudsman said the residents had reported to her call lights not being answered, not being provided with incontinent care and not being assisted in and out of bed in a timely manner due to not having enough staff on the night shift and on the weekends. The Ombudsman said this was an ongoing issue over the past months. During a confidential interview at an undisclosed date and time, Anonymous Staff #1 said when staff called in, they did the best they could to provide the residents' care. Anonymous Staff #1 said when they did not have enough staff it was hard to answer the call lights and provide the residents with their personal care. During a confidential interview at an undisclosed date and time, Anonymous Staff #2 said she had not received any complaints from the residents about the call lights not being answered or not getting assistance with ADLs in a timely manner. Anonymous Staff #2 said when staff did not show up to work the ADON tried to fill the position, but there were times when the ADON was unable to fill the position and they had to work without the staff. Anonymous Staff #2 said it was difficult to provide the residents' care when they were short staffed, but they did the best they could. Anonymous Staff #2 said not having sufficient staff could result in the residents not getting the same care as if they had all the staff present at work. During an interview on 07/29/2026 at 5:09 PM, the ADON said she was responsible for the staffing. She said the facility required a PPD of 3.0 for nursing staff (a calculation used by the facility to determine the nursing staff hours per day and the calculation for the facility should be equivalent to 3.0), but if they had call-ins (someone did not show up for work) they were not meeting the requirements for staffing. The ADON said when someone called-in she tried to find someone to replace them, but if she could not find anyone to replace them, she divided the staff available between all the halls. The ADON said none of the residents reported to her that their call lights were not answered or not receiving assistance with their ADLs in a timely manner. The ADON said if the facility did not have enough staff it could result in the staff not being able to meet the residents' needs in a timely manner and could result in weight loss or skin breakdown. During an interview on 07/29/2026 at 5:42 PM, the DON said there had been a time when the residents reported to her that their call lights were not answered in a timely manner or they were not provided care in a timely manner. The DON said the ADON was responsible for staffing, and she did not feel they were ever short staffed because if staff called in nurse management tried to help. The DON said not having sufficient nursing staff could result in the residents having to wait a little longer to have their needs met. During an interview on 07/29/2026 at 5:53 PM, the Administrator said there were always grievances about the call lights not being answered. He said he could not remember if he received any complaints about not being provided with ADL care in a timely manner. The Administrator said he did not feel like they did not have enough staff available to provide the residents' care. He said he was aware sometimes they were not meeting their required staffing PPD of 3.0 because of call-ins. The Administrator said not having sufficient nursing staff could result in the residents not being seen as quickly as they should have been. The Administrator said the facility did not have a policy on staffing. Record review of the facility's July 2026 Nursing Direct Care PPD indicated the PPD for nursing staff was less than 3.0 on 07/04/2026, 07/05/2026, 07/08/2026, 07/11/2026, 07/12/2026, 07/14/2026, 07/16/2026, 07/19/2026, 07/25/2026, 07/26/2026, 07/27/2026.

Based on observations and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #44 and #89) and one lunch meal reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 07/28/2026. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included:During an observation and interview on 07/28/26 at 12:34 PM, the lunch tray was sampled by the Dietary Manager and 5 surveyors. The sample tray consisted of beef steak with a glaze on top, which was hot and tender; the broccoli was lukewarm, overcooked, and bland; and the baked potato was undercooked and lukewarm. The Dietary Manager said the steak with glaze was good and tender; the broccoli could have been warmer, less cooked, and more season added; and the baked potato was not cooked enough and could have been warmer. The Dietary Manager said this failure placed residents at risk of not eating and weight loss. During an observation and interview on 07/28/2026 at 1:03 PM, Resident #89 was in her room sitting on the side of her bed with her lunch tray on her bedside table. Resident #89 had only eaten her steak, and said the food was not good and the potatoes were too hard. During an observation and interview on 07/28/2026 at 1:07 PM, Resident #44 was sitting up in her bed with her lunch tray on her bedside table sitting over her. Resident #44 said her broccoli was overcooked, the potato was not soft enough to eat, and the potato not being well cooked made it difficult to put the fixings on them. Resident #44 said she did not like overcooked food at all. During an interview on 07/29/2026 at 5:48 PM, the DON said she had received complaints about the food from residents at times. The DON said the residents had complaints that included the residents did not like what was on the menu on some days, but the facility had an alternative menu the residents could choose from. The DON said there were times residents complained about taste. The DON said she had a test tray from the kitchen before and it was okay. The DON said her expectation was for the communication to be made to the Dietary Manager and she expected the potatoes and the broccoli to have the correct texture when served to the residents. The DON said the failure placed a risk for wasting food and could potentially cause weight loss. During an interview on 07/29/2026 at 7:04 PM, the Administrator said the food at the facility should be good and spiced according to the taste of the residents. The Administrator said the responsibility was the Dietary Manager's. The Administrator said the failure placed a risk for weight loss. During an interview on 07/29/2026 at 6:46 PM the Administrator said the facility did not have a policy for palatable meals.

Based on observation, interview, and record review, the facility failed to ensure residents were offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 3 residents (Resident #56) reviewed for nutrition. The facility failed to ensure Resident #56 received her physician ordered supplement (magic cup) on 07/28/26 for her lunch meal.This failure could place residents at risk for weight loss or protein deficitsFindings included:Record review of Resident #56's face sheet, dated 07/29/26, reflected Resident #56 was an [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), stroke, malnutrition (a health condition caused by a deficiency, excess, or imbalance in a person's intake of energy and/or nutrients), and muscle weakness. Record review of Resident #56's quarterly MDS assessment, dated 05/18/26, reflected Resident #56 rarely made herself understood, and was rarely understood by others. Resident #56 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident #56 was dependent on ADLs and required maximal assistance with eating. The MDS did not indicate any weight loss. Record review of Resident #56's physician order dated 02/23/26, revealed, Regular diet, pureed texture, nectar consistency, and magic cup twice a day.Record review of Resident #56's comprehensive care plan revised 03/25/26 indicated Resident #56 was at risk of malnutrition. The intervention was for staff to serve diet as ordered. During an observation and interview on 07/28/26 at 1:00 p.m., Resident #56 tray card read magic cup for supplements. Resident #56 did not have a magic cup on her lunch tray. CNA C was assisting Resident #56 with her lunch meal. CNA C looked at Resident #56's tray card and said she did not have a magic cup. She said magic cups were usually given for weight loss. She said the nurse checked the tray and she did not even look at the tray card before assisting Resident #56 with her meal.During an interview on 07/28/26 at 1:09 p.m., LVN D said she checked Resident #56's lunch tray and overlooked the magic cup not being on her tray. She said Resident #56's appetite was good at times and other times not so good. She said Resident #56 should have had her magic cup on her tray to prevent weight loss.During an interview on 07/28/26 at 1:12 p.m., Dietary Aide E said she was responsible for ensuring supplements were on the residents' trays who required them. She said she fixed Resident #56's lunch tray and must have missed putting the magic cup on her tray. She said they usually receive magic cups related to their diet.During a phone interview on 07/29/26 at 6:06 p.m., the dietitian reviewed Resident #56's chart and said she had an appetite stimulant ordered 04/24/26 to help with her appetite. She said Resident #56 was thin and the magic cup helped her maintain her weight.During an interview on 07/29/26 at 5:57 p.m., the DON said she expected all residents who had orders for supplements to receive them. She said the kitchen staff was supposed to place the supplement on the tray, and the nurse was responsible for ensuring it was on the tray before the tray was served to the resident. She said supplements were usually given for extra protein and failure to receive them could potentially cause weight loss.During an interview on 07/29/26 at 7:10 p.m., the Administrator said she expected all residents who had orders for supplements to receive them. She said the dietary staff should place the magic cup on the tray and the nurse should ensure it was on the tray. She said she expected the nurses to read the tray card and if the magic cup was not on the tray, to ask the dietary staff to give them one before the tray was served to the residents. She said residents usually had supplements ordered for extra protein and weight loss.Record review of the facility's policy titled, Supplements, from the Dietary Services Policy & Procedure Manual dated 2012, indicated, We will provide supplements to residents in a safe and sanitary manner. Physician ordered supplements will be prepared and delivered by the Food and Nutrition Department according to facility policies.

Based on observations, interviews, and record reviews, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 6 residents reviewed (Resident #46) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #46's physician ordered sip cup on 07/27/2026 during his lunch meal.This failure could place residents at risk for dehydration, diminished independence, and self-esteem.Findings included: Record review of Resident #46's face sheet dated 07/27/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnose which included major depressive disorder (a common, serious mood disorder defined by persistent sadness, loss of interest in activities, and low energy lasting at least 2 weeks), unspecified intellectual disabilities (delayed motor and language milestones and trouble with problem-solving and logic), and autistic disorder (a lifelong developmental condition affecting social communication, behavior, and sensory processing). Record review of #46's quarterly MDS dated [DATE] indicated he sometimes understood others and sometimes made himself understood. The MDS also indicated he had a BIMS score of 1 which meant he had severely compromised cognition. The MDS also indicated he ate independently. Record review of Resident #46's order summary report dated as of 07/29/2026 indicated he had an order for:1) Regular diet mechanical soft texture, regular consistency, sip cup with a start date of 10/18/2025 and no end date. Record review of Resident #46's comprehensive care plan revised 03/02/2026 indicated he had an ADL self-performance deficit and required supervision for eating and used a sip cup. Record review of Resident #46's meal ticket dated 07/27/2028 indicated he was supposed to have a sippy cup with his meal. During an observation on 07/27/2026 at 12:15 PM, Resident #46 was in the dining room eating his food and had a full glass of tea on his table and no sippy cup. During an observation and interview on 07/27/2026 at 12:35 PM, Resident #46 had a full glass of tea and no sip cup and he was finished eating. Resident #46 said he wanted a drink, but he did not have his sip cup, so he did not drink anything. During an interview on 07/27/2026 at 12:40 PM, the MDS Nurse said he could not remember if he served Resident #46's his lunch tray, but Resident #46 should have had a sip cup for his drink. The MDS Nurse then obtained his sip cup from the kitchen and gave Resident #46 his sip cup filled with tea. Resident #46 drank 2 full sip cups of tea. The MDS nurse said the failure could have caused Resident #46 to be thirsty. During an interview on 07/29/2026 at 6:33 PM, Dietary Aide E said she did not recall not giving Resident #46 his sip cup. Dietary Aide E said she could not even remember if she worked on 07/27/2026 or why Resident #46 was receiving the sip cup on his tray. Dietary Aide E said there was no risk for Resident #46 not having his sip cup at meals. During an interview on 07/29/2026 at 6:40 PM, the Dietary Manager said Dietary Aide E was responsible for ensuring Resident #46 had his sip cup on his tray when meals were served as well as the MDS Nurse and the nurses in the dining room passing out trays. The Dietary Manager said the failure placed Resident #46 at risk of spilling his drink or not drinking at all but she was unsure of the reason for him having the cup. During an interview on 07/29/2026 at 5:53 PM, the DON said if Resident #46 had a sip cup on his lunch ticket it should have been on his tray. The DON said the dietary and nursing staff should have ensured Resident #46 had the sip cup. The DON said the failure placed a risk for him not having anything to drink, but the DON said Resident #46 could ask for drinks. During an interview on 07/29/2026 at 7:06 PM, the Administrator said if Resident #46 needed the assistive device (sip cup) he should have had it on his meal tray. The Administrator said the responsibility was on dietary staff and the nurse who checked the trays. The Administrator said the failure placed a risk of dehydration. Record review of the facility policy revised February 14, 2007, Feeding, Assistive/Complete indicated: Assistive or complete feeding of meals is provided to residents who have decreased appetites or are unable to eat independently because of disabilities, confusion, weakness, or neuromuscular disorders. 10. Assist with feeding as needed: a. Place the napkin or small towel over the chest or tuck under the chin. b. Arrange the dishes on the tray to avoid spilling. c. Arrange the dishes for easy access. Remove and discard the wrappings. d. Cut meat, place straw in glass (unless contraindicated), open and pour fluids from a container into a glass cup. Open salt, sugar, pepper, and margarine and use on food or in fluids as desired or requested by the resident. e. Supply assistive devices such as swivel spoons, built up or long handled utensils, plate guards, non-slip guard on glass, large handled mugs, suction cups on the dishes.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 (Resident #7) reviewed for hospice services. The facility failed to obtain Resident #7's Interdisciplinary Group Meetings since the start of care. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings Included: Record review of face sheet dated 07/29/2026 revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Dementia (severe memory loss and cognitive functioning). Record review of order summary report revealed Resident #7 had an order to admit to hospice on 06/10/2026. Record review of Significant Change MDS dated [DATE] revealed Resident #7 had a change in status requiring a new assessment due to new order for hospice services. MDS assessment revealed had a BIMS score of 03 indicating severe cognitive impairment. Record review of care plan dated 06/16/2026 revealed Resident #7 required hospice services for terminal illness with the intervention for hospice staff will assist the facility in care for Resident #7. Record review of Resident #7 hospice binder on 07/29/2026 revealed Resident #7 did not have any IDG meeting notes in the tab labeled specially for Intradisciplinary Group Meetings since the start of care on 06/10/2026. Interview on 07/29/2026 at 3:37 p.m., the Hospice RN stated she does not bring the IDG meeting notes to the facility and never has been requested for them. The Hospice RN stated that she would bring the IDG meeting notes if the facility requested them. The Hospice RN stated that the IDG meetings consisted of a group of providers that collaborated to create a plan of care, orders, and goals for Resident #7. The Hospice RN stated Resident #7 was at risk of not having coordinated care and continuation of care to the nursing facility. Interview on 07/29/2026 at 4:38 p.m., RN B revealed she was unaware what documents were required to be in the hospice binder for Resident #7. RN B stated she looked in the binder for medication orders to ensure the facility and hospice have the same orders. RN B stated that the hospice binder was to ensure coordination of care, and it was important the required documents were in the binder. RN B stated Resident #7 was at risk of not having continuity of care. Interview on 07/29/2026 at 4:52 p.m., Medical Records stated she was only responsible for the 3074 Physician Certification of Terminal Illness and 3071 The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (Health and Human Services required documents) and she performed audits and uploads them to the electronic system. Medical Records stated she was unaware of what was required in the hospice binders. Medical Records stated she was not sure what the IDG meeting was or the importance of it being in the hospice binder. Interview on 07/29/2026 at 4:55 p.m., the DON revealed Resident #7 was on hospice services since 06/10/2026. The DON stated that she did not have a system for checking the hospice binders to ensure the required documents were placed in each section of Resident #7's hospice binder. The DON stated the hospice binders were used for coordination of care, care plan, orders, and team members to be able to refer to when providing care to Resident #7. The DON stated Resident #7 was at risk of not everyone knowing what the care plans consist of, who to call, medications, and continuing of care. The DON stated she expected the IDG meetings to be printed and placed in the binder every 2 weeks to ensure continuity of care. Interview on 07/29/2026 at 7:00 p.m., the Administrator stated he was not familiar with what documents were required to be placed in the Hospice binder. The Administrator stated the nursing department was responsible for ensuing binders are updated according to policy. The Administrator stated the hospice binders are used each time the hospice comes into the facility and the care providers provide documentation of the care provided. The Administrator stated he would expect IDG meetings to be in the binder. The Administrator stated Resident #7 was at risk of not having coordination of care or change in conditions or orders not addressed. The Administrator stated binders are to ensure the facility and hospice are on the same page with the care residents are to receive. Record review of Hospice Services undated policy revealed the DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071) Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073) Physician Certification of Terminal Illness (#3074) Medicare Election Statement (if dual eligible)Verification that the recipient does not have Medicare Part A Hospice Plan of CareCurrent interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident#4) reviewed for infection control. 1.The facility failed to ensure CNA F did not use dirty linen and performed hand hygiene while providing incontinent care for Resident #4 on 07/28/26. This failure could place residents at risk for cross-contamination and the spread of infection. Findings included: 1.Record review of Resident #4's face sheet, dated 07/29/26, indicated he was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses which included quadriplegia (a medical condition causing partial or total paralysis of all four limbs and the torso, usually resulting from damage to the cervical spinal cord in the neck), and muscle weakness. Record review of Resident #4's admission MDS assessment, dated 06/26/26, indicated Resident #4 usually understood and was usually understood by others. Resident #4's BIMS score was 15, indicating he was cognitively intact. The MDS indicated Resident #4 was dependent on staff's assistance with his ADLs including toileting. The MDS indicated Resident #4 was always incontinent of bowel. Record review of Resident #4's Physician order dated 02/13/24 indicated: May apply barrier cream as needed every shift. Record review of Resident #4's comprehensive care plan, last reviewed 07/20/26, indicated he was incontinent of bowel. The intervention was for staff to provide incontinence care and apply barrier cream after each incontinent episode. During an observation on 07/28/26 at 9:20 a.m., CNA F performed peri care for Resident #4. CNA F cleaned the front and then turned him to clean his buttock. She cleaned his buttock which contained feces, applied barrier cream to his buttock, and then grabbed his clean brief and applied it with the same dirty gloves on. She then grabbed the draw sheet with the same dirty gloves and allowed it to hit the floor and then applied it under Resident #4. She then changed her gloves and performed hand hygiene. CNA F pulled up his covers, gathered equipment, and left the room. During an interview on 07/28/26 at 9:49 a.m., CNA F said she should have changed her gloves after applying the barrier cream and before applying the draw sheet and should not have let the draw sheet touch the floor and then use it. She said she placed Resident #4 at risk for cross contamination. During an interview on 07/29/26 at 5:21 p.m., LVN G she said was Resident #4's nurse. She said she expected staff to wipe the correct way, change gloves, and hand hygiene between dirty to clean. She said they should not use linen that had touched the floor. She said these failures could cause infection control issues related to contamination. During an interview on 07/29/26 at 5:57 p.m., the DON said she expected staff to provide incontinent care appropriatelyShe said they should change their gloves from dirty to clean. She said she did not expect staff to touch clean objects with dirty gloves. She said she did not expect staff to use linen that had touched the floor. The DON said she and the ADON were the overseers of infection control and were responsible for ensuring the staff performed peri care correctly. The DON said check offs for proper incontinent care were completed yearly and as needed. She said failure to properly perform hand hygiene, and the use of dirty linen could place residents at risk of infection and cross contamination. During an interview on 07/29/26 at 7:01 p.m., the Administrator said she expected proper perineal care and hand hygiene to be completed by all staff. She said she expected staff to get new linen if it touched the floor or became contaminated in any way. The Administrator said the nursing administration (DON, ADON) was responsible for ensuring the staff provided proper linen care, perineal care, and hand hygiene. The Administrator said proficiency checks were completed yearly and as needed. The Administrator said these failures created a risk for infection control issues. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, undated, indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. Gloving: Gloves are worn for three important reasons:1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. 2.To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin.3.To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard # 7 Linen and laundry. Hygienic and common-sense storage and processing of clean and soiled linen is recommended.

Based on observation, interview, and record review, the facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for 1 of 7 residents reviewed for dementia care. (Resident #1)The facility failed to ensure CNA A, NA B, and RN C provided appropriate dementia care and services while providing incontinent care for Resident #1 on 7/21/26.This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.Findings included:Record review of Resident #1's face sheet dated 7/21/26 indicated she was [AGE] years old and admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses including dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry), schizoaffective disorder, bipolar type (mental health condition with a combination of schizophrenia [complex chronic brain disorder that impairs a person's ability to think, feel, and perceive reality] symptoms, like hallucinations [sensory experiences where a person sees, hears, smells, tastes, or feels things that do not exist outside their mind] and delusions [false belief that persists despite overwhelming contradictory evidence], with severe mood swings from extreme sadness to excitement), major depressive disorder (persistent sadness), and hypertension (high blood pressure).Record review of Resident #1s quarterly MDS assessment dated [DATE] indicated she was sometimes understood and sometimes understood others. The MDS indicated she had a BIMS of 3, which indicated she had severe cognitive impairment. The MDS indicated Resident #1 had fluctuating inattention and disorganized thinking. The MDS indicated Resident #1 had physical, verbal, and other behavioral symptoms occurring 1-3 days during the look back period. The MDS indicated Resident #1 rejected care 1-3 days during the look back period. The MDS indicated Resident #1 required substantial/maximal assistance for toileting hygiene and partial/moderate assistance with dressing her lower body and toilet transfers. The MDS indicated Resident #1 was independent rolling side to side. The MDS indicated Resident #1 was frequently incontinent of bladder and occasionally incontinent of bowel.Record review of Resident #1's undated care plan indicated the following:Resident #1 had impaired cognitive function/dementia or impaired thought processes with interventions including engaging the resident in simple, structured activities that avoid overly demanding tasks and keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.Resident #1 had demonstrated physical behaviors towards others with interventions including to notify the charge nurse of any physically abusive behaviors, clinical staff and hospice nurse to review medications and changes to medications to decrease her agitation level because she had some recent gradual dose reductions that were not beneficial for the resident, and when the resident becomes agitated, intervene before agitation escalates and if resident's response was aggressive toward staff, staff were to walk away calmly and approach later.Resident had a behavior problem related to refusal of care from staff and cursing them with interventions including to ask her choices and to give her some autonomy (the freedom and ability to make your own choices and govern yourself), caregivers to provide opportunity for positive interaction/attention.Resident #1 resided in the secure care unit related to diagnosis of dementia and memory loss and risk for elopement.Resident #1 was on hospice services as evidenced by terminal illness.Record review of video footage dated 7/21/26 beginning at 10:29 AM, started with Resident #1 lying in bed with her covers at the end of the bed. Resident #1's legs were exposed, her knees were bent and her feet were on the bed. The camera angle was from above the head of the bed and was not able to see Resident #1's face. CNA A entered the room carrying incontinent supplies and then took her foot and pushed the pedal under the bed to unlock the bed. CNA A then grabbed the footboard and pulled the bed away from the wall. CNA A laid the incontinent supplies on the end of the bed and started to crank the bed up to raise the height of the bed with the manual crank at the end of the bed. The bed and Resident #1 could be seen significantly shaking as CNA A manually cranked the bed up. There was no verbal communication from CNA A to let resident know what she was doing. At 10:30 AM, NA B entered the room. CNA A pulled the curtain, and NA B went to Resident #1's left side of the bed and CNA A went to Resident #1's right side of the bed. CNA A then said, {Resident #1's name} we are going to get you situated in this bed, okay. CNA A started moving items from the end of the bed and then started cranking the head of the bed down. Resident #1 could be heard saying something but was unable to understand what was said. CNA A said, do what, ain't nobody {unable to make out} don't do that. CNA A then comes back to beside Resident #1 and started pulling wipes from the container. NA B pulled Resident #1's tab to her brief on her left side and did not tell Resident #1 what he was doing. CNA A then pulled the tab loose to Resident #1's right side of her brief and then said gonna take your brief off as she was already pulling the brief down and pushing between Resident #1's legs. Resident #1 said you're not gonna take my brief off and as CNA A was pushing the brief down between Resident #1's legs, Resident #1 crossed her right leg over her left leg and tried to grab the top of the brief and said again, you're not going to take my brief off. CNA A said okay, we are going to roll this way, to the left as CNA A reached under Resident #1's right side and pushed her toward her left side by her right shoulder and right hip. Resident #1 started to holler out Daddy, Daddy, quit, stop, O Momma, Momma. NA B placed his hands onto her back and hip to hold her on her left side. CNA A continued to pull her brief and under pads out from under the resident as Resident #1 continued to holler Momma, Momma over and over. RN C entered the room at 10:32 AM and said they're just getting you cleaned up baby and Resident #1 said get me cleaned up, that won't help and RN C said no it won't baby and Resident #1 continued to holler Momma, Momma as she tried to take her right hand and grab CNA A's arm and CNA A deflected her hand by putting her elbow between Resident #1's hand and herself. Resident #1 said Get off and then continued to holler Momma, Momma. CNA A continued cleaning Resident #1's bottom with the sheet. RN C walked around closer to the head of the bed and said Ms. {Resident's name}, stop kicking at people as Resident #1 was grabbing at NA A and kicking her feet and hollering Momma, Momma. RN C said, Momma is right here. Resident #1 said I don't want it right now, you son of a bitch. RN C said, they have to get you cleaned up and Resident #1 said you're going to hell as she was seen becoming more agitated with increased grabbing/swinging of her arms, hands, and legs. RN C said, stop hitting, stop hitting. Resident #1 said you stop hitting me as she continued to grab at both CNA A and NA B. CNA A said keep your hands to yourself as she was trying to place draw sheets under the resident. Resident #1 said you're about to kill me, Daddy, get off of me, get off of me, Daddy. RN C said, Ms. {Resident's name} stop yelling, you're fine. Resident #1 said as she was almost crying as she continued to holler Daddy, then said bitch, bitch, bitch as she continued to grab and kick at the staff. Resident #1 then started hollering Momma, Momma, O God as CNA A pushed draw sheets under Resident #1 and then applied a cream to her bottom. Resident #1 said Get out of here you son of a bitch as she was trying to grab NA B. RN C said, Don't hit at people, don't hit at people Ms. {Resident #1's name}, Ms. {Resident #1's name} stop. CNA A then rolled Resident #1 onto her back and had to grab Resident #1's hands multiple times to deflect them as Resident #1 was trying to grab her arm as she was trying to get her brief pulled up between her legs as Resident #1 kicked at them. RN C said, Let her put your under ware on, let her put your under ware on, you're okay, listen to me, quit kicking, quit kicking, quit kicking and Resident #1 said get off of me!. The video ended at 10:34 AM.Record review of video footage of a second video dated 7/21/26 beginning at 10:34 AM was a continuation of the previous video. CNA A finished fastening Resident #1's brief and said to NA B, we're going to take this shirt off as Resident #1 continued to holler Momma, Momma. RN C was at the end of the bed and said Stop, kicking me as CNA A and NA B took off Resident #1's shirt and put a gown on her. Resident #1 yelled Momma, Momma, that why I don't like it and you're gonna die. RN C said yes, eventually, but not today. Resident #1 tried to grab CNA A's face with her right hand and CNA A grabbed her hand and told her to stop. Resident #1 said you stop, God damn it, I just want to get out of here and CNA A said, no ma'am. CNA A then pulled her gown down over her legs and Resident #1 tried to hit/grab CNA A again and she grabbed her hand and put it back down and covered her up. RN C then told Resident #1 they were all done and asked Resident #1 if she wanted some water and she said no. RN C told Resident #1 that they were just trying to clean her up to keep her clean and dry. Resident #1 told RN C you are a lying bitch and RN C said, you can call me whatever you want to, I'm just taking care of you and told her, Goodnight baby. RN C said, thank you for letting us take care of you and Resident #1 said thank you. The video ended at 10:38 AM.During an interview on 7/21/26 at 10:55 AM, Resident #1's family member said Resident #1 had occasional issues with aggressiveness. Resident #1's family member said the facility had done a pretty good job taking care of Resident #1 in the memory care unit. Resident #1's family member said however, she had just watched a video on the camera and there were two staff members, a young black male aide and another, older female black aide providing incontinent care. Resident #1's family member said the older black aide was very rough and held her mom's arms to her chest when she was resistant to care and then used a sheet to wipe between Resident #1's butte cheeks and Resident #1 was raw from having a yeast infection. Resident #1's family member said the nurse, RN C, came in during the care and was trying to comfort Resident #1 during the care. Resident #1's family member said the young male black aide was being very sweet and gentle with Resident #1 during the care. Resident #1's family member said however, when the older black aide came into the room initially, she believed Resident #1 was asleep and the aide just started cranking the bed up, to raise the bed, and it shook the whole bed. Resident #1's family member said she felt that the older aide startled Resident #1 because the aide did not say anything to Resident #1 before she started to crank on the bed. Resident #1's family member said Resident #1 was very upset during the care and felt the whole situation could have been handled better and communicated better to Resident #1.During an interview on 7/21/26 at 2:30 PM, RN C said she had worked at the facility for nine years and normally worked in the memory care unit on the 6 AM to 6 PM shift. RN C said she did not see the first part of the care provided to Resident #1 the morning of 7/21/26, but she was called into the room (located next to the nurse's station) to assist CNA A and NA B while they were trying to perform incontinent care. RN C said Resident #1 was kicking and hitting at the staff. RN C said Resident #1 was mad, but they were just trying to change her. RN C said Resident #1 could get on a rage at times.During an interview on 7/21/26 at 2:44 PM, NA B said he had worked at the facility for three weeks and 7/21/26 was only his second day in the memory care unit. NA B said he had completed the nurse aide program and was working on his clinical portion and was not a certified aide yet. NA B said he was still learning how to care for the residents with dementia and was training with CNA A. NA B said he assisted CNA A provide incontinent care for Resident #1 the morning of 7/21/26. NA B said Resident #1 was trying to hit and kick them and they were just trying to not get hit while CNA A was providing incontinent care. NA B said he just tried to assist in turning and holding Resident #1 while CNA A provided the actual care. NA B said he had received training on how to care for residents with dementia. NA B was asked what he should do if a resident was resistant to care or said stop/quit during care and he said he did not really know how to answer it because he was still training.During an observation and interview on 7/21/26 at 3:05 PM, Resident #1 was lying in bed with a family member at bedside. Resident #1 was pleasantly confused but said she was doing just fine. Resident #1 did not remember the incontinent care incident from the morning of 7/21/26. Resident #1's family member said she came to the facility today (7/21/26) and showed the video footage of the care provided to Resident #1 on the morning of 7/21/26 to the ADM. Resident #1's family member said the ADM had sent the older aide (CNA A) home that had performed the actual care and did not communicate with Resident #1 prior to initiating care. Resident #1's family member said if the staff had communicated with Resident #1 prior to cranking the bed up, which startled and scared Resident #1, Resident #1 may had not been so upset during the care being provided. The family member said Resident #1 had dementia and needed to have things explained to her prior to just doing something to her.During an interview on 7/21/26 at 3:40 PM, the ADM said Resident #1's family member had come in this afternoon (7/21/26) and showed him the video footage from the morning of 7/21/26. The ADM said he agreed the care provided was not how he would have wanted to be cared for. The ADM said he did not feel the staff was really abusive but was rough. The ADM said when the resident was resistant to care, hitting and kicking, the staff should have stopped and came back to give her time to calm down. The ADM said the staff member (CNA A) should have given Resident #1 time to wake up and not startled her with the cranking of the bed to raise it. The ADM said he had suspended CNA A, pending his investigation. The ADM said the Social Worker performed a trauma screening after being informed of the incident the afternoon of 7/21/26 and Resident #1 did not remember anything about the incident. The ADM said they did a full skin assessment and it did not reveal anything new.During an attempted interview on 7/21/26 at 3:59 PM, CNA A was called but there was no answer and a detailed voicemail was left requesting a return call. CNA A was sent a detailed text message on 7/21/26 at 3.59 PM requesting a return call. CNA A had been sent home pending the results of the investigation on 7/21/26 and did not return call or text message prior to exiting the facility on 07/21/2026.During an interview on 7/21/26 at 4:50 PM, RN C said she was trying to talk to Resident #1 and calm her down during incontinent care the morning of 7/21/26. RN C said she had received training on caring for residents with dementia. RN C said they normally stopped care, when a resident was resistant or refusing care and came back later and tried again. RN C said she did not tell CNA A to stop care because Resident #1 had not been changed in a while and she was wet. RN C said that residents did have the right to resist and refuse care. RN C said the staff probably should have stopped providing care and came back and tried again later and that was normally what they did. RN C said it probably scared Resident #1 when the staff did not tell Resident #1 what they were going to do prior to cranking the bed up and when she was resistant to care and they did not stop care. RN C said she felt awful and did not realize it at the time it was happening, but she should have told the staff to stop care and had them come back later. RN C said she made a mistake and should have told the staff to stop care and tried again after Resident #1 had calmed down.During an interview on 7/21/26 at 5:20 PM, the ADON said if a resident with dementia or any resident was resisting or refusing care, staff should stop care if resisting, try re-approaching later or try another staff member, and if still resisting, then the nurse should reach out to the physician. The ADON said often times when a resident with dementia was resistant to care it was because of pain. The ADON said she had reviewed the video footage that morning of CNA A providing incontinent care to Resident #1, and it was disgusting. The ADON said the whole situation should had been stopped long before when the resident was yelling, hitting, and kicking at the staff. The ADON said CNA A had been sent home as soon as they were informed of the incident on 7/21/26, pending the results of the investigation. The ADON said that was not how they provided care for dementia residents at their facility. The ADON said Resident #1 was probably made to feel scared and helpless when staff did not explain what they were going to do, before they did it, and continued to provide care while she was resisting care.During an interview on 7/21/26 at 5:26 PM, the ADM stated the incident with Resident #1 the morning of 7/21/26, probably caused the resident to be terrified when the staff came in and did not talk to her and just started cranking the end of the bed and then did not stop care when she resisted and was kicking and hitting at the staff. The ADM said Resident #1 probably did not know what was happening. The ADM said he would expect the staff to follow the facility's policies and procedures related to the care of residents with dementia. He said CNA A, CNA B and RN C had been in-serviced on caring for residents with dementia prior to the 7/21/26 incident and they were currently re-educating all staff.Record review of CNA A's electronic course training log indicated she had completed the courses titled Dementia for Nursing facilities on 4/09/26, Person-centered Behavioral Management, Behavioral Management Techniques, Helping a Person with Dementia and What is Dementia: Etiology and Treatment that were marked with a status of completed but there were no dates of completion.Record review of CNA B's electronic course training log indicated he had completed the courses titled Dementia: Types and Causes, Behavioral Health: Dementia, Behavioral Management Techniques, and What is Dementia: Etiology and Treatment on 6/29/26.Record review of RN C's electronic course training log indicated she had completed the courses titled Dementia Care in Nursing Facilities on 3/07/26, Behavior Management Techniques on 9/06/25, Helping a Person with Dementia on 9/06/25 and What is Dementia: Etiology and Treatment on 9/05/25.Record review of the facility's undated policy titled Dementia Policy, indicated . 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 thee and other symptoms . behavioral or psychological symptoms are often related to the brain disease in dementia; however, behavior and other symptoms may also be caused or exacerbated by environmental triggers . behavior often represents a person's attempt to communicate an unmet need, discomfort or thoughts that they can no longer articulate . Caring for a Resident with Dementia . fundamental principles of care for a person with dementia include an interdisciplinary team approach that focuses holistically on the needs of the resident as well as the needs of the other residents . it is important for the facility to have systems and procedures in place to assure that assessments were timely and accurate; interventions were described, consistently implemented, monitored, and revised as appropriate in accordance with current standards of practice . Individualized Approaches and Treatment . this step implements the care plan interventions to address the needs of a resident with dementia . it addresses the causes and consequences of the resident's behavior and staff communication and interactions with residents and families to try to prevent potentially distressing behaviors or symptoms . Staffing and Staff Training . the nursing home must provide staff both in terms of quantity and quality to meet the needs of the residents as determined by the resident assessments and individual plans of care . the principles for quality include, but are not limited to, the facility ensuring that nursing assistants were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments, and as described in the plan of care .

Based on interview and record review, the facility failed to provide the necessary care and services in the area of hygiene, grooming, and incontinent care for 1 of 16 residents (Resident #1) reviewed for activities of daily living. The facility failed to ensure Resident #1 was provided with incontinent care every two hours as recommended for Resident #1, which resulted in bed linens being saturated with urine. This failure could result in pressure injuries, infection, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 03/04/2026 revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses which included cerebral infarction (occurs when an artery blockage cuts off blood flow and oxygen to the brain), chronic obstructive pulmonary disease (a lung disease that makes breathing difficult), dysphagia (difficulty swallowing), diabetes mellitus type 2 (a chronic metabolic disorder where the body fails to produce enough insulin resulting in high blood glucose), bipolar disorder (a mental health condition alternating between intense highs and lows), heart failure (a condition where the heart muscle cannot pump blood efficiently), hyperlipidemia (high cholesterol), chronic kidney disease stage 3(moderate kidney damage) and seizures (uncontrolled bursts of electrical activity in the brain that cause temporary changes in consciousness, behavior, or muscle movement). Record review of Resident #1's quarterly MDS dated [DATE] revealed no hearing, vision or communication deficits and a BIMS score of 15 indicating intact cognition. Further review of the MDS revealed Resident #1 had upper and lower extremity range of motion impairment, required the use of a wheelchair for mobility, was independent in eating, required maximum assistance in upper body dressing, bathing and was dependent in peri-care / toilet hygiene, bed mobility, transfers and lower body dressing. Record review of Resident #1's care plan revealed a focus area indicating resident received diuretic therapy (involves using medications to increase urine output), was incontinent of bowel, had a potential for impairment to skin integrity related to yeast infection of the groin, had an ADL self-care deficit for bed mobility and toilet use, and had bladder incontinence and was at risk for skin breakdown. Record review of Resident #1's physicians orders dated 03/04/2026 revealed an order for Nystatin External Powder 100000 unit / gram (topical) dated 10/22/2025 apply to affected area topically every 12 hours as needed for yeast or redness, cleanse with normal saline or soap and water, pat dry and apply powder and an order for Nystatin External Cream 100000 units / gram (topical) dated 03/01/2026 apply to vaginal/perineal area topically every shift for yeast for 7 days with a stop date of 03/08/2026. Record review of resident's skin assessment dated [DATE] & 02/25/2025 revealed resident had no open areas but continued with treatment to yeast infection to abdominal folds. Record review of nurse aid tasks for 02/25/2026 revealed incontinent care was checked off for each shift but did not indicate the number of times per shift that peri-care was provided to Resident #1. During an interview and observation of Resident #1 on 03/04/2026 at 8:39 a.m., resident stated she was soiled with urine and was waiting to be changed. Resident #1 allowed surveyor to visualize brief and bed pad, slight urine odor noted, brief did not appear to be saturated at this time and was the appropriate size. Resident #1 stated she believes that staff are coming in her room and turning off the light, however, could not identify a staff member who had done this this morning or on 02/25/2026. This surveyor noted that Resident #1's call light was not on during this interview. Resident #1 stated that on 02/25/2026, she was left in her brief for over five hours which resulted in her bed linens to be saturated with urine. Resident #1 stated she did not have any skin breakdown. During a phone interview with the Ombudsman on 03/04/2026 at 10:39 a.m., the Ombudsman stated that she visited Resident #1 on 02/25/26 at approximately 11:30 a.m. and found resident crying and soaking wet. The Ombudsman stated she allowed Resident #1 to use her personal phone to contact the Texas Health & Human Services hotline. The Ombudsman stated that she notified the ADON and observed aides enter resident's room to provide peri-care while she was speaking with the ADON. During an interview on 03/04/2026 at 3:40 p.m., CNA A stated Resident #1 utilized XXL briefs and that the briefs are kept in her room. CNA A stated that she was not aware of a time when Resident #1 was soaked or soiled due to not being changed. CNA A stated that Resident #1 will call for assistance as needed and sometimes she will say, I did not want to bother you, but she had never found resident soaked in her bed. During an interview on 03/04/2026 at 4:06 p.m., Hospitality Aide B stated she had worked at the facility over 1 1/2 months and that she had worked multiple times on 100 Hall with Resident #1. Hospitality Aide B stated that Resident #1 will put on the call light when she needs to be changed and that she uses the largest brief. Hospitality Aide B stated that she did not recall a time when Resident #1 was soiled or excessively wet that would indicate she had not been changed. During an interview on 03/04/2026 at 4;14 p.m., Hospitality Aide C stated that she has worked at the facility for approximately 2 months and stated she was aware that Resident #1 utilizes the largest brief size and her briefs were kept in her closet. Hospitality Aide C stated that she had never observed Resident #1 soaked when she called for incontinent care. During an interview on 03/04/2026 at 4:30 p.m., LVN D stated she did not recall a specific date or event when Resident #1 was found soaked with urine due to not being changed. Stated at times Resident #1 would refuse toileting care in the nighttime due to preference to sleep, but during the day she usually would put on the call light as needed. During an interview on 03/04/2026 at 4:55 p.m., ADON LVN E stated that Resident #1 had facility provided briefs that were XXL and kept in her room, and she wound never run out of briefs. LVN E stated that Resident #1 would utilize the call light as needed and during her shift, she had not been left unattended. The ADON LVN E stated that she recalled the Ombudsman identified concern regarding Resident #1 and while they were speaking in the hallway, the nurse aides entered her room to provide care. During an interview on 03/04/2026 a 5:40 p.m., CNA D revealed that she worked on 100 hall on 02/25/2026 where Resident #1 resided and was familiar with her incontinent care needs. The CNA D revealed she was rushed throughout her shift but stated she had no concerns about getting her tasks completed. CNA D stated that Resident #1 will put on the call light when she needed assistance and although she could not recall what times or how often she checked on Resident #1, she does feel she provided the necessary care on her shift. During an interview on 03/04/2026 at 5:50 p.m., the DON stated that she was not notified Resident #1 had been left in her bed without toileting assistance. The DON stated that Resident #1 utilized her call light without difficulty and was not always accepting of staff interactions. The DON stated she expected nursing staff to round at a minimum every two hours to ensure residents incontinent care needs are being met appropriately. The DON stated she would monitor effectiveness of this by reviewing skin care concerns and trends for infection. The DON stated she was ultimately responsible to ensure residents are clean and incontinent care needs are met. During an interview on 03/04/2026 at 5:50 p.m., the Administrator stated that he expected the nursing staff to provide incontinent care as needed for all residents. The Administrator stated that failure to provide incontinent care could result in increased skin breakdown and increased infections. The Administrator stated that the DON is responsible for all nursing care and he was ultimately responsible to ensure the care if provided appropriately. Review of facility incontinent care policy or activities of daily living policy did not occur prior to survey exit. According to State Operations Manual 483.24(b) Activities of daily living. the facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (b)(3) elimination-toileting.

Based on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to ensure CNA A treated Resident #1 respectfully when he required assistance with his TV, and she failed to address him prior to exiting his room on 11/11/2025. This failure could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life. Findings included:Record review of Resident #1's face sheet dated 11/12/2025 indicated he was a [AGE] year-old male initially admitted to the facility 12/31/2021 and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and anxiety disorder. Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and was understood by others. The MDS assessment indicated Resident #1's hearing was adequate. The MDS assessment indicated Resident #1 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #1 required supervision or touching assistance with eating and substantial/maximal assistance with toileting hygiene. Record review of Resident #1's care plan reviewed 10/31/2025 indicated he was dependent on staff for meeting emotional, intellectual, physical, and social needs, and enjoyed relaxing and watching television. Resident #1's care plan indicated he had a TV and TV remote in his room to provide daily choice of programs. Resident #1's care plan indicated he had impaired visual function, and a communication problem to anticipate and meet his needs. Resident #1's care plan indicated he had a hearing deficit to not cut off or interject when the resident was speaking maintain eye contact while speaking to resident, and to speak in a clear voice and face him when speaking to the resident. During an interview and observation on 11/11/25 at 9:12 AM, Resident #1 said the staff were rude to him. Resident #1 said he had difficulty hearing, but he overhead the staff talking bad about him. Resident #1 said the staff said he was crazy and made the comments don't listen to him because he is crazy. Resident #1 said he had reported it to the nurses and everyone knew. Resident #1 was unable to provide names of the staff. Resident #1 said he was not able to work the remote to his TV because he could not see. Resident #1 requested for his TV volume to be increased, and CNA A came to assist. CNA A walked into the room and told the surveyors in a decreased voice he usually does not want his TV on its because y'all are in here. Surveyor asked CNA A to please assist Resident #1 with his TV because he could not hear it. Surveyor informed Resident #1 CNA A to assist him and stepped out of the room. Surveyor walked out of the room into the hallway. Resident #1's door was open, CNA A was observed with her back to Resident #1, facing the TV, pointing the remote at the TV. When she said, I have to get batteries, and walked out of the room. As she walked out of the room Resident #1 was heard saying What?. CNA A continued to exit the room. During an interview on 11/11/2025 at 1:59 PM, CNA A said Resident #1 had visual impairment and was hard of hearing. CNA A said there was no problem with her making the comment that Resident #1 only wanted the TV on because the surveyors were in his room because he could not hear her. CNA A said there were no dignity issues associated with the way she treated Resident #1 or with her walking away from him without explaining why she was leaving the room when he questioned her. CNA A said she did not talk bad about any of the residents, and she had never said Resident #1 was crazy.,During an interview on 11/12/2025 at 12:38 PM, the DON said she expected the staff to explain to the residents what they were doing. The DON said she had not received any complaints about CNA A. The DON said she did not want any of the staff to speak negatively about the residents. The DON said CNA A walking away from Resident #1 could make him feel confused about the situation. During an interview on 11/12/2025 at 1:05 PM, the Administrator said he expected the staff to explain to the residents what they were doing and prior to leaving the room ensure the residents' needs were met. The Administrator said everyone was responsible for treating the residents with dignity and respect. The Administrator said speaking about the residents in front of them, even if they were not able to hear, and walking away from them without explaining could make them feel bad. Record review of the facility's undated policy titled, Resident Rights, indicated, 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. Respect and dignity - The resident has a right to be treated with respect and dignity, including. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's Qulipta (medication used to treat migraines) was administered as ordered on 10/31/2025, 11/01/2025, and 11/02/2025. This failure could place the residents at risk of not having medications available for use and medications errors. Findings included: Record review of Resident #2's face sheet dated 11/12/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body) and migraine. Record review of Resident #2's Quarterly MDS assessment dated [DATE], indicated he was usually understood and usually understood others. Record review of Resident #2's MDS assessment indicated he had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #2 received scheduled and PRN pain medication. Record review of Resident #2's care plan reviewed 10/21/2025 indicated he had a potential for uncontrolled pain related to migraines, immobility, and contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement). Record review of Resident #2's Order Summary Report dated 11/12/2025 indicated Qulipta 60 mg give 1 tablet via g-tube one time a day for migraines with a start date of 08/22/2024. Record review of Resident #2's October 2025 MAR indicated Qulipta 60 mg give 1 tablet via g-tube one time a day was not administered on 10/31/2025. Record review of Resident #2's November 2025 MAR indicated Qulipta 60 mg give 1 tablet via g-tube one time a day was not administered on 11/01/2025 and 11/02/2025. During an interview on 11/11/2025 at 9:44 AM, Resident #2 said he did not receive his headache medication twice. Resident #2 said the nurses told him they were out of his medication. Resident #2 said it was about 2 weeks ago. During an interview on 11/11/2025 at 4:19 PM, LVN B said at the beginning of November 2025 she had not administered Resident #2's Qulipta. She said she was told by LVN C that the medication had been ordered from the pharmacy but had not been delivered and she was not able to administer it. LVN B said she did not know when it was ordered. LVN B said she did not call the pharmacy because she was still training when this happened. LVN B said she had not notified the doctor that Resident #2's Qulipta had not been administered. LVN B said she was training with LVN C, and LVN C notified the doctor. LVN B said it was important for the residents to receive their medications as ordered by the physician for their health and for their mental and physical well-being. During an interview on 11/11/2025 at 9:21 PM, LVN C said Resident #2's Qulipta ran out at the beginning of November 2025, and he did not receive it. LVN C said she was unsure how many doses he missed, but they were waiting on the pharmacy to deliver the medication. LVN C said when a resident did not have a medication, they should contact the pharmacy and notify the doctor. LVN C said she did not contact the pharmacy to see why his Qulipta was not delivered because she was not the only nurse who had not administered the medication. LVN C said she did not notify the doctor about Resident #2's missed doses of Qulipta. LVN C said not administering Resident #2's Qulipta could result in him having headaches. During an interview on 11/12/2025 at 9:14 AM, the Pharmacist said a refill was ordered for Resident #2's Qulipta on 10/31/2025 and was delivered to the facility on [DATE]. The Pharmacist said the facility had not reached out to get the medication delivered sooner. The Pharmacist said if the facility had contacted them and requested a quicker delivery it could have been done. During an interview on 11/12/2025 at 12:24 PM, the DON said the nurses were supposed to call the pharmacy prior to the residents' medications running out. The DON said if a medication was not administered the physician should be contacted. The DON said she was not aware Resident #2's Qulipta was not administered. The DON said the nurses should have contacted her to notify her of the doses of the missed medication, but they did not. The DON said not administering medications as ordered by the physician could result in a negative outcome. During an interview on 11/12/2025 at 12:50 PM, the Administrator said if a medication was not in the building, he expected the nurses to contact the pharmacy and get the medication delivered immediately. The Administrator said it was the nurse's responsibility to ensure medications were administered as ordered, and his expectations were if they did not, they should notify the ADON and DON. The Administrator said he was not medical; therefore, he was not aware of the risks associated with not administering medications as ordered. During an attempted phone interview on 11/12/2025 at 1:09 PM, LVN D did not answer the phone. Record review of the facility's policy, Medication Administration and General Guideline v3-2025, indicated, Medications are administered as prescribed.Medications are administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents (Resident #17 and Resident #54) reviewed for medication administration accuracy. 1. The facility failed to ensure Resident #17 received his blood sugar checks or insulin for 21 out of 31 days during May 2025. 2.The facility failed to ensure Resident #54 received his Metoprolol (used to treat heart condition, lowers blood pressure, reducing the risk of strokes and heart attacks) on 05/30/2025 at 4:00 p.m. These failures could place residents at risk of not receiving the therapeutic effect of the medication. The findings included: 1.Record review of Resident #17's face sheet dated 06/04/25, indicated a [AGE] year-old male who admitted [DATE] and readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (also known as diabetes, a chronic disease that occurs when the body has high blood sugar levels), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and high blood pressure. Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated Resident #17 was usually able to make himself understood and understood others. The MDS assessment indicated Resident #17 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #17 had received insulin 7 days out of the 7-day look-back period. The MDS assessment indicated Resident #17 had received a hypoglycemic medication within the last 7 days of the look-back period. Record review of Resident #17's comprehensive care plan, revised on 05/23/25, indicated Resident #17 had Diabetes Mellitus. The care plan interventions were for staff to give medication as ordered by the doctor. Record review of Resident #17's order summary report dated 03/15/25 indicated Resident #17 had an order for the following: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Lispro), Inject as per the sliding scale: if 0 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units. Call the physician if above 400, subcutaneously, before meals and at bedtime, related to type 2 diabetes mellitus. Record review of Resident #17's order summary report dated 06/03/25, after surveyor intervention, indicated Resident #17 had an order for the following: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Lispro), Inject as per the sliding scale: if 0 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units. Call the physician if above 400, subcutaneously, two times a day (7:00 am and 4:00 pm), related to type 2 diabetes mellitus. Record review of the MAR dated 05/01/25 through 05/31/25 revealed Resident #17's blood sugar was not checked at 11:00 am on the following days: 05/01/25, 05/02/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/11/25, 05/12/25, 05/13/25, 05/15/25, 05/16/25, 05/19/25, 05/20/25, 05/21/25, 05/23/25, 05/25/25, 05/27/25, 05/28/25, 05/29/25. Record review of the MAR revealed the nurses had placed a number 3 under their initial, which indicated Resident #17 was away from the facility. During a phone interview on 06/02/25 at 2:21 p.m., the case manager said she worked at the adult habilitation center, where they specialize in mental health or developmental disability diagnosis. She said Resident #17 came to their facility Monday through Friday from 9 am until 2 pm. She said they were unable to give any medication to any resident while at their facility. She said the facility the resident (s) resided in was responsible for administering their residents' medication if required. During an interview on 06/03/25 at 9:20 a.m., LVN D said she was the nurse for Resident #17. She said on the days she worked, and Resident #17 was not in the facility because he was at the adult habilitation center, she would put a 3 on his medication administration records for his 11:00 am blood sugar check/insulin. She said the 3, indicating he was not in the facility for his 11:00 am blood sugar check or insulin if required. She said she did not notify the physician because she thought the physician was aware he missed the 11:00 am blood sugar check or insulin. During a phone interview on 06/03/25 at 10:22 a.m., the Medical Director said he was unaware Resident #17 was not receiving his blood sugar checks or medication while at the adult habilitation center. He said the facility notified him today (06/03/25), and he made some medication changes. He said Resident #17 was non-compliant with following his diabetes management, but missing his medication could cause his blood sugar levels to be higher and require more insulin. During an interview on 06/03/25 at 4:09 p.m., Resident #17 said he went to the adult habilitation center Monday through Friday. He said that while he was at the center, he did not receive his 11:00 am blood sugar check or insulin. He said he did receive his blood sugar checks and insulin on the weekend while he was at the facility. During an interview on 06/04/24 at 12:53 p.m., LVN A said she was one of Resident #17's primary nurses. She said Resident #17 was at the adult habilitation center Monday through Friday. She said she would put a 3, which meant not given, on his medication administration record because he was not in the facility. She said she was unaware that the adult habilitation center did not check to monitor his blood sugars or give him medication as ordered. She said without his medication, it could cause him to go into diabetic ketoacidosis (a serious complication of diabetes). During an interview on 06/04/25 at 2:00 p.m., the Regional Nurse Consultant said she expected medication to be given as ordered. She said she was aware the adult habilitation center did not give medication, but did not realize Resident #17 was not receiving his 11:00 am blood sugar checks or insulin medication. She said the facility was responsible for giving the medication as ordered. She said Resident #17 could have had a negative outcome with his blood sugars being either too high or too low. During an interview on 06/04/25 at 2:27 p.m., the Administrator said he expected staff to follow the physician's orders. He said the nurses should have ensured Resident #17 received his blood sugars or insulin as ordered. He said the DON was responsible for ensuring medication was being given. The Administrator said failure to check blood sugars could impact their blood sugar levels by being too low or too high. 47612 2.Record review of Resident #54's face sheet dated 06/03/2025, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included dysphagia (difficulty swallowing), gastrostomy hemorrhage (bleeding associated with a gastrostomy, which was a surgical procedure creating an opening in the abdomen to insert a feeding tube into the stomach), muscle wasting and atrophy (loss of muscle mass). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #54's speech was unclear, but he was able to make himself understood, and understood others. The MDS assessment indicated Resident #54's had a BIMS score of 10 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #54 had a feeding tube. Record review of Resident #54's comprehensive care plan revised dated 04/15/2025, indicated he had hypertension with interventions to give anti-hypertensive medication as ordered. Record review of Resident #54's order summary report dated 05/06/25, indicated he had the following orders, Metoprolol 25 mg give 1 tablet via gastrostomy tube twice a day 8:00 a.m. and 4:00 p.m. with start date 02/14/2024. During an interview on 06/02/2025 at 3:16 p.m., Resident #54 stated he did not receive his 4:00 p.m. medication on 05/30/2025. Resident #54 stated he felt like the nurse did not give him because he had spoken with the state surveyor earlier that day. During an interview on 06/04/2025 at 12:00 p.m., RN K stated it was her responsibility to administer Resident #54's medications on time. RN K stated Resident # 54's medications were important to ensure he received the treatment he needed. RN K stated the risk to Resident #54 could leave his condition untreated. During an interview on 06/04/2025 at 1:15 p.m., the Corporate Nurse stated she expected the medications to be administered as ordered by the physician. The Corporate Nurse stated the nurse was responsible for ensuring this was done. The Corporate Nurse stated the failure to provide the medications as ordered could result in a change of condition. The Corporate Nurse stated she would monitor by watching a medication pass. During an interview on 06/04/2025 at 1:30 p.m., the Administrator stated his expectations were for nursing staff to follow physician orders The Administrator stated the nurse was responsible for ensuring the medications were being administered as ordered. The Administrator stated it was important for compliance and resident safety. The Administrator stated he was not clinical, so he was unsure of the risk. The Administrator stated he would monitor by direct observation and in-service. Record review of the facility's policy titled, Medication Orders, from Pharmacare USA V3-2025, indicated, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Record review of the facility's policy titled, Medication Administration and General Guidelines, from Pharmacare USA V3-2025, indicated, Policy: Medications are administered as prescribed, by State Regulations, using good nursing principles and practices and only by persons legally authorized to do so. #17. 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. If an electronic medical record is being utilized than the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials.

Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 20 residents (Resident #129 and Resident #130) and 1 of 7 medication carts (400 hall Nurse Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure RN C secured the 400 hall Nurse Medication Cart, when she went in Resident #47's room to obtain his blood sugar on 06/02/25. 2. The facility did not ensure Resident #129's inhaler (a device that delivers medication directly into the lungs by inhaling it) was not left on her dresser. 3. The facility did not ensure Resident #130's nystatin cream (antifungal medication) was not left on her bedside table. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: 1. During an observation and interview on 06/02/25 at 11:41 AM, RN C entered Resident #47's room to obtain his blood sugar. RN C left the nurse's medication cart unlocked. RN C proceeded to obtain Resident #47's blood sugar. RN C said she forgot to lock the cart because was nervous. RN C said the nurse cart should always be locked when leaving it unattended. RN C said she was responsible for ensuring the cart was locked. RN C said failure to lock the cart was a safety concern and a resident could have walked by and gotten into the cart. During an interview on 06/04/25 at 11:42 AM, the RNC said she expected medication carts to be to be locked when leaving unattended. She said failure to properly lock the medication cart could leave other residents at risk for getting into the cart. The RNC said the nurse or medication aide was responsible for ensuring medication carts were kept locked when leaving unattended. During an interview on 06/04/25 at 11:46 PM, the Administrator said he expected medications carts to be to be locked when leaving unattended. He said by not properly locking the medications carts, residents could access the cart. The Administrator said the nurse or medication aide were responsible for ensuring medication carts were kept locked with leaving unattended. 43047 2. Record review of Resident #129's face sheet, dated 06/04/25, reflected Resident #129 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and asthma (chronic condition that affects the airways in the lungs). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #129's admission MDS had not been completed yet. Record review of Resident #129's comprehensive care plan initiated on 05/23/25 reflected Resident #129 had emphysema (long term lung condition that causes shortness of breath) and COPD. The care plan interventions included give aerosol (spray) or bronchodilators (inhaler) as ordered and monitor/document side effects and effectiveness. Record review of the order summary report dated 06/02/25 reflected an active physician order for Albuterol Sulfate HFA Inhalation Aerosol Solution (medication used to treat or prevent bronchospasm (muscles that line bronchi (airway in your lungs) tighten or narrowing of the airway in the lungs) 90 mcg/act: 2 puff inhales orally one time a day for COPD with a start date 05/24/25. During an interview and observation on 06/02/25 at 11:12 a.m., Resident #129 was lying in bed. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. Resident #129 stated she did 2-3 puffs as needed and it really depended on how bad she felt. Resident #129 stated she brought it from home. During an interview and observation on 06/02/25 at 11:48 a.m., with MA G revealed Resident #129's inhaler was located on the nurse's medication cart. MA G stated the medication was administered by a nurse one time a day, every day. During an observation on 06/03/25 at 8:02 a.m., Resident #129 was eating her breakfast. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. During an observation and interview on 06/04/25 at 12:33 p.m., Resident #129 was sitting on her bed. An inhaler that was labeled Albuterol Sulfate HFA Inhalation Aerosol was on her dresser. Resident #129 stated she told someone that it was her inhaler, and she did not use the one that was in the nurse's medication cart, when asked if she had let the facility know that she had one her dresser. Resident #129 was unable to give the staff name that she told. 3. Record review of Resident #130's face sheet, dated 06/04/25, reflected Resident #130 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included gastroenteritis (stomach virus) and colitis (inflammation of the colon). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #130's admission MDS had not been completed yet. Record review of Resident #130's comprehensive care plan did not address nystatin cream. Record review of Resident #130's order summary report dated 06/02/25 reflected there was not an order for nystatin cream in the summary. During an observation and interview on 06/02/25 at 11:01 a.m., Resident #130 was lying in bed. A tube that was labeled nystatin cream was on her bedside table. Resident #130 stated she used it because her private area itched. Resident #130 stated her husband brought the medication to her. During an observation and interview on 06/03/25 at 8:15 a.m., Resident #130 was lying in bed. Resident #130 stated her husband took the medication home on 06/02/25. During an interview beginning on 06/04/25 at 12:37 p.m., LVN A stated Residents #129 and #130 had not been evaluated for self-administration of medications. LVN A stated if a resident was able to self-administer, he/she must be assessed for competence. LVN A stated she saw Resident #130's nystatin cream over the weekend and told her she was not allowed to keep the cream in her room. LVN A stated Resident #130 told her that her husband would take the medication home. LVN A stated she was unaware Resident #129 had an inhaler on her dresser. LVN A stated medications should be stored on the medication cart. LVN A stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated her expectations were that medications were locked in the medication cart and administered by the nurse or MA. The Regional Compliance Nurse stated to self-administrate, an assessment for self-administration must be completed and an order obtained from the MD. The Regional Compliance Nurse stated the nursing administration, which included the DON and ADONs, were responsible for monitoring and overseeing medications at bedside by daily facility rounds. The Regional Compliance Nurse stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated medications should not be left at bedside. The Administrator stated medications should be locked and secured and administered by the nurse or MA. The Administrator stated the charge nurse should be ensuring medications were not left at bedside. The Administrator stated the DON and ADONs were responsible for monitoring and overseeing medication storage by daily rounds. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the facility's policy undated policy titled Storage of Medication indicated . Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .2 . Medications rooms, carts and medication supplies are locked and attended by persons with authorized access . Record review of an undated facility policy titled Self-Administration of Medications by Residents Policy, indicated . 2. If the resident desires to self-administer medications as assessment is conduced by the IDT of the resident's cognitive, physician, and visual ability to carry out the responsibility . 6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage, and then give unauthorized medications to the charge nurse for return to the family or responsible party .

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #76, Resident #54, and Resident #131) reviewed for infection control. 1.The facility failed to ensure CNA L performed hand hygiene while providing incontinent care for Resident #76 on 06/02/25. 2. The facility failed to ensure LVN D applied a gown when she administered an IV medication to Resident #131 on 06/03/25. 3. The facility failed to ensure LVN E applied a gown when she administered medications via a gastrostomy tube (feeding tube) to Resident #54 on 06/03/25. 4.The facility failed to ensure CNA L and CNA M applied a gown when they administered care to Resident #54 on 05/30/2025. These failures could place any resident at the facility at risk for cross-contamination and the spread of infection. Finding included: 1.Record review of Resident #76's face sheet, dated 06/04/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), muscle weakness, and Congestive heart failure, or heart failure, is a long-term condition in which your heart can't pump blood well enough to meet your body's needs. Record review of Resident #76's quarterly MDS assessment, dated 04/11/25, indicated Resident #76 understood and was understood by others. Resident #76's BIMS score was 08, which indicated her cognition was moderately impaired. The MDS indicated Resident #76 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was frequently incontinent of bladder. Record review of Resident #76's comprehensive care plan revised on 11/07/24, indicated Resident #76 was incontinent of bladder. The care plan interventions were for staff to provide incontinent care at least every 2 hours and apply a moisture barrier after each episode. During an observation on 06/02/25 at 11:40 a.m., CNA L provided incontinent care for Resident #76. She wiped her front area and then her backside without changing her gloves or performing hand hygiene. She then grabbed a clean brief, applied it, pulled down her gown, and assisted Resident #76 to her wheelchair with the same dirty gloves still on. CNA L then removed her gloves, gathered her equipment, washed her hands, and left the room. During an interview on 06/02/25 12:03 p.m., CNA L said she did not realize she did not perform hand hygiene or change her gloves after wiping Resident #76's front, then wiping her back and touching the clean brief and her gown with dirty gloves. S. The Regional Nurse Consultant said they went over incontinence care and hand washing upon hire, annually, and as needed. She said nurse management oversaw infection control and cross-contamination. She said staff should change gloves and practice hand hygiene to prevent infection and cross-contamination. During an interview on 06/04/25 at 12:17 p.m., the Administrator said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care and infection control. He said improper hand hygiene could place residents at risk for cross-contamination.he said she knew, that without hand hygiene or removing dirty gloves, she could cause cross-contamination. During an interview on 06/04/25 at 11:44 a.m., LVN A said she was Resident #76's nurse. She said she expected the CNAs to perform incontinent care the correct way. She said she expected them to change their gloves between clean and dirty to prevent cross-contamination. During an interview on 06/04/25 at 2:00 p.m., the Regional Nurse Consultant said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes Record review of CNA L's proficiency on incontinent care and handwashing was dated 05/26/25. 46928 2. Record review of Resident #131's face sheet dated 06/03/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) and cellulitis (bacterial infection involving the inner layers of the skin) of the right lower limb. Record review of Resident #131's admission MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #131 had received IV antibiotics within the last 14 days of the look back period. Record review of Resident #131's comprehensive care plan dated 05/21/25, indicated Resident #131 was on enhanced barrier precautions with the interventions for gloves and gown should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, bathing, or high-contact activity. Record review of Resident #131's order summary report dated 06/03/25, indicated he had the following orders: o Flush IV line with 10 mls of normal saline before and after medication with an order start date of 05/21/25. o Flush IV with 10 ml normal saline q shift with an order start date of 05/21/25. o Vancomycin 1 GM give 1 GM intravenously two times a day for wound with a start date of 05/29/25. During an observation and interview on 06/03/25 at 8:09 AM, LVN C entered Resident #131's room to administer vancomycin 1 GM IV via his PICC (a thin flexible tube that is inserted into a vein in the upper arm for IV antibiotics or IV medications) line. LVN C performed hand hygiene, applied gloves, flushed Resident #131's PICC line with 10 ml of normal saline and set the IV at 200 mls/hour to administer the vancomycin medication. LVN C did not apply a gown before she administered Resident #131's medication. LVN C removed her gloves and performed hand hygiene. Resident #131 had a 3-drawer plastic bin, with PPE, inside his room to the left side of the door and EBP signage on his door. LVN C said she missed applying the gown because she was very nervous. LVN C said she should have applied the gown to protect Resident #131 from bacteria. LVN C said she was responsible for ensuring proper PPE was worn. During an interview on 06/04/25 at 11:42 AM, the RNC said she expected proper PPE to be worn when caring for a device or if the staff was providing close personal care to residents on EBP. The RNC said PPE should have been worn when providing IV and peg-tube medications. The RNC said failure to apply proper PPE placed the residents at risk for infection. The RNC said the person caring for the device was responsible for ensuring EBP precautions were followed. During an interview on 06/04/25 at 11:46 AM, the Administrator said he expected EBP precautions to be followed as per the facility's policy and when it was required. The Administrator said PPE should be worn when providing IV medications or when providing medications through a peg-tube to protect the resident from any infections. The Administrator said the staff taking care of the resident was responsible for ensuring proper PPE was worn. During an interview on 06/04/25 at 3:13 PM, the ADON H, said she was the Infection Preventionist. ADON H said she expected the staff to follow the EBP protocol. She said if a nurse was providing medications through an IV or peg tube, PPE should be worn. She said failure to apply proper PPE placed the residents at risk for exposure to bacteria. ADON H said the nurse was responsible for ensuring proper PPE was worn. 47612 Resident #54 Record review of Resident #54's face sheet dated 06/04/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis that affects all limbs and body from the neck down) and dysphagia (difficulty swallowing). Record review of Resident #54's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. Resident #54 had a BIMS score of 10 which indicated his cognition was moderately impaired. Resident #54 was dependent on staff with all ADLs. The MDS assessment indicated Resident #54 had a feeding tube. Record review of Resident #54's comprehensive care plan dated 04/03/24, indicated Resident #54 was on enhanced barrier precautions with the interventions for gloves and gown to be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, bathing, or high-contact activity. 3. Record review of Resident #54's order summary report date 06/03/25, indicated Resident #54 had the following orders: o Enteral Feed Order flush tube with 60 ML water before and after medication and feedings with an order start date of 02/13/24. o Hydroxyzine 50 mg give one tablet via peg tube (tube inserted in the stomach for nutrition or medications) three times a day for itching with an order start date of 03/03/25. o Clonazepam 0.5 mg give one tablet via peg tube three times a day related to anxiety with an order start date of 09/26/24. o Lyrica 100 mg give one capsule via peg tube four times a day for pain with a start date of 03/25/25. o Zofran 4 mg give one tablet via g-tube 3 times a day for nausea/vomiting with a start date of 11/18/24. o Tylenol 325 mg give 2 tablets via g-tube every 6 hours as needed for pain with a start date of 02/13/24. During an observation and interview on 06/03/25 at 11:00 AM, LVN E prepared Resident #54's medications. LVN E obtained the following medications: 1 capsule of Lyrica 100mg, 1 tablet of clonazepam 0.5mg, 1 tablet of ondansetron 4 mg, 1 tablet of hydroxyzine 50 mg, and 2 tablets of Tylenol 325 mg. LVN E entered Resident #54's room to administer his routine medications via his peg tube. LVN E performed hand hygiene, applied gloves, administered all medications via his peg tube, removed her gloves and washed her hands. LVN E failed to apply a gown. Resident #54 had a 3-drawer plastic bin, with PPE, inside his room to the left side of the door and an EBP signage on his door. LVN E said Resident #54 was on EBP precautions which indicated gown and gloves were required when providing direct patient care. LVN E said she forgot to apply her PPE because the state surveyor made her nervous. LVN E said failure to apply proper PPE placed the resident at risk for bacteria. LVN E said she was responsible for ensuring EBP precautions were followed. 4. During a video observation dated 05/30/2025, on 06/03/2025 at 11:00 a.m., CNA L and CNA M were observed coming into Resident#54's room to provide care, applied their gloves, bathed resident's face, chest, and abdomen without applying a gown. During an interview attempt on 06/03/2025 at 11:42 a.m., surveyor attempted to contact CNA M by phone and left voicemail to return call. During an interview on 06/03/2025 at 2:44 p.m. CNA L stated she had worked for the facility for 3 days prior to giving Resident #54 care on 05/30/2025. CNA L stated she had been trained on when to apply PPE. CNA L stated it was important to wear PPE because you did not want to contaminate Resident #54's catheter and a feeding tube. CNA L stated the risk to Resident #54 was infection. During an interview on 06/04/2025 at 1:15 p.m., the Corporate Nurse stated she expected proper PPE to be worn when providing close personal care to residents on EBP. The Corporate Nurse stated it was the nursing staff's responsibility to wear PPE when providing personal care. The Corporate Nurse stated it was important to wear PPE for infection control. The Corporate Nurse stated she would monitor by in-service and entering Resident rooms to make sure staff was properly donning PPE. During an interview on 06/04/2025 at 1:30 p.m., the Administrator stated his expectations were for the staff to don and doff PPE correctly. The Administrator stated it was important to wear PPE to ensure no cross contamination. The Administrator stated it was the individual staff members responsibility to wear PPE correctly. The Administrator stated he was not clinical, so he was unsure of the risk. The Administrator stated he would monitor by direct observation and in-service. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, section AD 03-08, indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. Record review of the facility's undated policy Enhanced Barrier Precautions, indicated .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomy .

Based on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 20 residents (Resident #68) reviewed for resident rights. The facility failed to ensure Resident #68's representative was invited to participate in the development and review of Resident #68's care plan. This failure could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: Record review of Resident #68's face sheet dated 06/04/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss), muscle weakness, and anxiety. Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. Resident #68 had short/long term memory problems and her cognition was severely impaired. Record review of Resident #68's comprehensive care plan dated 04/02/24, indicated Resident #68 had impaired cognitive function, impaired thought processes and communication related to dementia. The care plan interventions included to communicate with the resident/family regarding resident's capabilities and needs. Record review of Resident #68's EMR on 06/04/25, did not reveal a care plan conference had been completed or uploaded. During an interview on 06/02/25 at 10:50 AM, Resident #68's representative said she had not been invited to a care plan meeting since Resident #68 admitted to the facility February of last year (2024). She said she would like to be invited to the care plan meetings so she would be aware of what was going on with Resident #68's care. During an interview on 06/04/25 at 09:26 AM, the SW reviewed Resident #68's EMR and said she did not see where a care plan meeting had been completed. The SW said a care plan meeting was to be completed quarterly and as needed. The SW said a care plan meeting was conducted to update the resident's family and to see if they had any issues or concerns. The SW said the MDS Coordinator and herself were responsible for ensuring the care plan meetings were being completed. She said she was unsure of how Resident #68's care plan meetings were missed. She said from what she could tell, Resident #68 had not had a care plan meeting since she admitted to the facility. During an interview on 06/04/25 at 11:42 AM, the RNC said the care plan meetings should be held at least quarterly. She said the care plan meetings were held to ensure the families were being updated with the current plan of care. The RNC said the SW was responsible for ensuring the care plan meetings were being conducted as required. During an interview on 06/04/25 at 11:46 AM, the Administrator said he expected the care plan meetings to be to be held at least quarterly. He said the care plan meetings were held with the resident and family to ensure the plan of care was best suited for the resident. The Administrator said the SW was responsible for ensuring the care plan meetings were being conducted. During an interview on 06/04/25 at 12:08 PM, MDS Coordinator B said the SW was responsible for setting up the care plan meeting. Record review of the facility's undated policy Comprehensive Care Planning, indicated .The facility will provide the resident and resident representative, if applicable, with advance notice of care planning conferences to enable resident/resident representative participation. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing .

Based on interviews, observations, and record review the facility failed to ensure residents were free from abuse for 1 of 20 residents (Resident #47) reviewed for resident abuse. The facility did not ensure Resident #47 was free from abuse when Resident #4 hit Resident #47 in the head. The noncompliance was identified as PNC. The past noncompliance began on 04/21/25 and ended on 04/24/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Resident #47 Record review of Resident #47's face sheet, dated 06/04/25, reflected Resident #47 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain chemical imbalance in the blood), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment, dated 03/05/24, reflected Resident #47 made himself understood and understood others. The MDS assessment did not address Resident #47's BIMS score. The staff assessment reflected Resident #47 had short- and long-term memory problem. The MDS reflected Resident #47 had no behaviors or refusal of care during the look-back period. Record review of Resident #47's comprehensive care plan revised 01/10/23 reflected Resident #47 had behavior problem including cursing, talking to self, physical aggression toward staff during care, and history of grabbing and/or verbal threats to others. The care plan interventions included anticipate/meet the resident's needs and monitor behavior episodes and attempts to determine underlying cause. Resident #4 Record review of Resident #4's face sheet, reflected Resident #4 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental health condition characterized by significant mood swings), schizophrenia (a condition that can make you feel detached from reality and can affect our mood), delusions (unshakable belief in something that is not true) disorder, and anxiety disorder. Record review of Resident #4's annual MDS, dated [DATE], reflected Resident #4 made herself understood and usually understood others. Resident #4's BIMS score was 14, which indicated his cognition was intact. The MDS reflected Resident #4 had no behaviors or refusal of care during the look-back period. Record review of Resident #4's comprehensive care plan initiated on 04/21/25 reflected Resident #4 had potential to demonstrate physical behaviors and poor impulse control. The care plan interventions included analyze of key times, places, circumstances, triggers, what de-escalates behavior and document. The interventions also included if the resident had physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. Record review of the facility's PIR dated 04/24/25 with an incident category of abuse was signed by the Administrator on 04/24/25. The PIR reflected CNA N reported that Resident #4 hit Resident #47 in the head while in the dining room. The PIR included a witnessed statement by CNA N that reflected she witnessed Resident #4 hitting Resident #47 in the head while taking a tray to the kitchen. The witnessed statement reflected CNA N immediately reported the incident to the charge nurse. The PIR included a witnessed statement by MDS Coordinator B as he was walking from Hall 1 to nursing station when Resident #4 yelled out Hey get off my foot, MDS Coordinator B stated he noted Resident #4 sitting in her wheelchair in day room and noted her pushing Resident #47's wheelchair away from her stating he ran over her foot. The witnessed statement written by Social Services reflected Resident #4 stated he (pointing at Resident #47) run over her foot, so she hit him. The PIR included a skin assessment for Residents #4 and #47 completed 04/21/25 reflected no new skin issues, psychiatric assessment for Resident #4 completed 04/21/25, social service notes for Residents #4 and #47 completed 04/21/25 reflected no s/s of distress and no new orders, trauma informed PRN assessment for Resident #47 completed 4/21/25 reflected negative for any new findings, Q15 minute monitoring log for Resident #4 with (start date 04/21/25, end date 04/22/25) reflected no new behaviors noted, resident safe surveys with no areas of concerns dated for 04/21/25, staff/resident and resident to resident monitoring completed 05/23/25 reflected no new behaviors noted. The PIR reflected staff was in-serviced promptly on abuse and neglect including resident to resident completed 04/21/25 reflected who the abuse coordinator was, how to contact the abuse coordinator and when to notify the abuse coordinator. During an observation and attempted interview on 06/02/25 at 12:01 p.m., Resident #47 was sitting in his wheelchair next to the bed. Resident #47 was non-interview able. During an observation and interview on 06/02/25 at 2:38 p.m., Resident #4 was lying in bed. Resident #4 stated, I haven't hit nobody when asked if she remembered the incident between her and Resident #47. Resident #4 stated, I don't remember him running over my foot. During an interview on 06/02/25 at 2:45 p.m., CNA N stated Resident #4 and Resident #47 was sitting in the day room when Resident #47 run over Resident #4 foot with his wheelchair. CNA N stated she was taking a tray into the dining room from lunch when she heard Resident #4 and Resident #47 arguing and by the time she laid the tray down to intervene that was when Resident #4 hit Resident #47 on his head which was loud enough that everyone heard it. CNA N stated she did not see the part when Resident #47 run over Resident #4 foot. CNA N stated she intervened immediately by separating the residents and notifying LVN O. An attempted telephone interview on 06/04/25 at 1:48 p.m. with LVN O, was unsuccessful. During interviews on 06/02/25 beginning at 10:00 a.m., - with 10 residents (#4, #47, #68, #54, #132, #17, #129, #130, #76, #131) regarding abuse and neglect with a focus presented on resident-to-resident physical abuse reflected they all denied abuse. During staff interviews beginning on 06/02/25 at 10:00 a.m. and ending 06/04/25 at 3:13 p.m.,- with LVN (A, D, E, O), RN (C, K), CNA (L, M, N, P, R, T), MA G, MDS Coordinator (B, F), Laundry Aide S, Human Resources, Dietary Manager, ADON revealed they were in serviced 04/21/25 on abuse/neglect including resident to resident and were able to define abuse, when to report, and whom to report it to. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated she was aware of the abuse allegation between Residents #4 and #47 and was told by the DON that the residents were separated immediately, skin assessments were completed to make sure there were no harm, safe surveys were completed to make sure everyone was ok, and trauma assessments were completed to ensure that no one had a negative psychosocial outcome from it. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated he was the abuse coordinator for the facility. The Administrator stated he was aware of the incident between Residents #4 and #47. The Administrator stated the victims did not have any changes in behavior since the incident. The Administrator stated abuse was monitored daily during rounds by visiting with residents and directly observing the residents and facility. The Administrator stated once he was learned of any allegations he reported accordingly, investigate, and ensure all residents were protected. Record review of the facility's policy titled Abuse/Neglect revised 03/29/18 reflected . the resident has the right to be free from abuse . Residents should not be subjected to abuse by anyone, including, but not limited to . other residents .

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 20 residents (Resident #4) reviewed for MDS assessment accuracy. The facility did not ensure Resident #4's MDS assessment was accurately coded for PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability). This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #4's face sheet, reflected Resident #4 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental health condition characterized by significant mood swings), schizophrenia (a condition that can make you feel detached from reality and can affect our mood), delusions (unshakable belief in something that is not true) disorder, and anxiety disorder. Record review of Resident #4's annual MDS assessment, dated 05/02/25, reflected in Section A1500 (PASRR) asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. Resident #4 made herself understood and usually understood others. Resident #4's BIMS score was 14, which indicated his cognition was intact. Record review of Resident #4's comprehensive care plan revised on 10/03/24 reflected Resident #4 had a diagnosis of ID and was PASRR positive. The care plan interventions included Resident #4 was receiving habilitation coordination and independent living skills trainings. During an interview on 06/04/25 at 1:14 p.m., MDS Coordinator B stated MDS Coordinator F was responsible for Resident #4's MDS annual MDS. MDS Coordinator B stated if the resident was PASRR positive yes should have been marked that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and mental illness/ID should have been checked. MDS Coordinator B stated MDS Coordinator F was out today due to personal reasons. MDS Coordinator B stated it was important to ensure the MDS was accurate so services will be evaluated and given. During an interview on 06/04/25 at 1:37 p.m., the Regional Reimbursement Specialist stated he expected yes to be marked that the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and mental illness/ID should have been checked. The Regional Reimbursement Specialist stated he expected the Administrator to be responsible for monitoring and overseeing MDS accuracy. The Regional Reimbursement Specialist stated it was important for MDS accuracy to reflect the resident's status. During an interview on 06/04/25 at 1:55 p.m., the Regional Compliance Nurse stated there was not a policy and procedure regarding MDS assessment accuracy. The Regional Compliance Nurse stated the facility followed the RAI manual. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated he expected the MDS to be marked correctly because Resident #4 was PASRR positive. The Administrator stated he monitored accuracy by random as needed audits/spot checks. The Administrator was unable to recall his last audit. The Administrator stated it was important to ensure MDS accuracy to ensure the residents received the necessary services.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 1 of 2 residents reviewed for nutritional status (Resident #54). The facility failed to ensure Resident #54's enteral feeding (a form of nutrition that was delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 05/30/2025. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #54's face sheet dated 06/03/2025, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included dysphagia (difficulty swallowing), gastrostomy hemorrhage (bleeding associated with a gastrostomy, which was a surgical procedure creating an opening in the abdomen to insert a feeding tube into the stomach), muscle wasting and atrophy (loss of muscle mass). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #54's speech was unclear, but he was able to make himself understood, and understood others. The MDS assessment indicated Resident #54's had a BIMS score of 10 which indicated his cognition was moderately impaired. The MDS assessment did not indicate Resident #54 had a weight loss or weight gain of 5% or more in the last month or 10% or more in the last 6 months. The MDS assessment indicated Resident #54 had a feeding tube. Record review of Resident #54's comprehensive care plan revised dated 04/15/2025, indicated he had required the use of a feeding tube and was at risk for aspirations (accidentally inhaling food, liquid, or other material into the lungs instead of the digestive system), weight loss, and dehydration. The care plan interventions included to administer tube feeding as ordered. Record review of Resident #54's order summary report dated 05/06/25, indicated he had the following orders, Enteral feed order: Nutren 2.0 250cc via peg tube with 60 cc peg flush before and after feeding with a start date 02/14/2024. During an interview on 06/02/2025 at 3:16 p.m., Resident #54 stated he did not receive his 4:00 p.m. feeding on 05/30/2025. Resident #54 stated he felt like the nurse did not give it to him because he had spoken with the state surveyor earlier that day. During an interview on 06/04/2025 at 12:00 p.m., RN K stated it was her responsibility to administer Resident #54 feedings on time. RN K stated Resident # 54's feeding was important to provide the nutrients he needed. RN K stated the risk to Resident #54 would be weight loss and skin breakdown. During an interview on 06/04/2025 at 1:15 p.m., the Corporate Nurse stated she expected the enteral feedings to be administered as ordered. The Corporate Nurse stated the nurse was responsible for ensuring this was done. The Corporate Nurse stated failure to provide the enteral feedings as ordered could cause Resident #54 to have weight loss. The Corporate Nurse stated she would monitor by watching a portion of enteral feeding, medication pass, and checking weights. During an interview on 06/04/2025 at 1:30 p.m., the Administrator stated his expectations were for nursing staff to follow physician orders The Administrator stated the nurse was responsible for ensuring the feedings were being administered as ordered. The Administrator stated failure to provide the enteral feedings as ordered could cause Resident #54 to have weight loss. Record review of the facility's undated policy titled Resident Weight , The nursing service department was responsible for all feeding equipment and the administration of tube feedings

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 12 residents (Resident #132) reviewed for oxygen therapy. The facility failed to ensure Resident #132 had a physician's order in her chart for oxygen. This failure could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings Included: Record review of Resident #132's face sheet, dated 06/04/25, reflected Resident #132 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #132's admission MDS had not been completed yet. Record review of Resident #132's comprehensive care plan initiated on 05/24/25 reflected Resident #132 received oxygen therapy. The care plan interventions give medications as ordered by physician, monitor for s/sx of respiratory distress and report to MD PRN. The care plan did not address how many liters Resident #132 should be at. Record review of Resident #132's physician order summary report, dated 06/03/25, reflected there was not an order for oxygen in the summary. During an observation and interview on 06/02/25 at 11:08 a.m., Resident #132 was lying in bed wearing oxygen via nasal cannula. Resident #132's five-liter oxygen concentrator was set on 2 lpm. Resident #132 stated she wore oxygen all the time due to COPD. During an observation on 06/03/25 at 4:22 p.m., Resident #132 was wearing oxygen via nasal cannula while sitting on a bedside commode. Resident #132's five-liter oxygen concentrator was set on 2 lpm. During an interview beginning on 06/04/25 at 12:37 p.m., LVN A stated she was Resident #132's 6am-6pm charge nurse. LVN A stated Resident #132 had been wearing oxygen since admission. After reviewing Resident #132's electronic medical records, LVN A stated Resident #132 did not have an order for oxygen. LVN A stated she was unaware Resident #132 did not have an order for oxygen until the state surveyor intervention. LVN A stated all nurses were responsible for checking the orders in PCC to ensure there was an order for oxygen. LVN A stated it was important to ensure oxygen orders were placed in Resident #132's electronic medical records because if the resident did not need oxygen, she could come dependent on the oxygen or if the oxygen was taken away because there was no order, Resident #132 could become hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions). An attempted telephone interview on 06/04/25 at 1:28 p.m. with RN C, the nurse that admitted Resident #132, was unsuccessful. During an interview on 06/04/25 at 2:27 p.m., the Regional Compliance Nurse stated she expected Resident #132 to have an order for oxygen upon admission. The Regional Compliance Nurse stated the charge nurse that admitted Resident #132 should have entered the order upon admission. The Regional Compliance Nurse stated the nursing administration, which included the DON/ADONs, were responsible for monitoring and overseeing by checking orders upon admission to ensure accuracy. The Regional Compliance Nurse stated it was important to ensure oxygen orders were place in PCC to communicate with all nurses that resident needs oxygen. During an interview on 06/04/25 at 2:39 p.m., the Administrator stated if the resident was receiving oxygen she should have had an order. The Administrator stated the admission was responsible for ensuring an order was placed in PCC. The Administrator stated the DON and ADONs were responsible for monitoring and overseeing by reviewing the admission order after a new admission. The Administrator stated it was important to ensure an oxygen order was place in PCC for resident safety. Record review of an undated facility policy titled, Oxygen Administration, indicated, the amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician .

Based on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 4 of 5 residents (Resident #5, Resident #7, Resident #10, and Resident #58) reviewed for resident rights. The facility failed to ensure CNA A treated Resident #5, Resident #7, Resident #10, and Resident #58 respectfully when she failed to speak to them while providing care. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 01/08/2025 indicated Resident #5 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #5 was able to make herself understood and understood others. The MDS assessment indicated Resident #5 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #5 required supervision or touching assistance with personal and toileting hygiene and lower body dressing, and partial to moderate assistance with showering/bathing self and putting on taking off footwear. Record review of Resident #5's care plan last reviewed 01/05/2025 indicated she had an impaired cognitive function that varies. Resident #5's care plan indicated interventions to use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions, the resident understands consistent, simple, directive sentences, provide the resident with necessary cues stop and return if agitated, and cue, reorient and supervise as needed. 2. Record review of Resident #7's face sheet dated 01/08/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbance (deterioration of memory, language, and other thinking abilities). Record review of Resident #7's Quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #7 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #7 was independent with eating, oral hygiene, toileting hygiene, required set-up or clean-up assistance with dressing, and supervision or touching assistance with showering/bathing, putting on/taking off footwear, and personal hygiene. Record review of Resident #7's care plan last reviewed 12/17/2024 indicated she had a limited physical mobility related to poor balance to provide supportive care, and assistance with mobility as needed. 3. Record review of Resident #10's face sheet dated 01/08/2025 indicated she was an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #10's Quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #10's BIMS was a 14, which indicated her cognition was intact. The MDS assessment indicated Resident #10 required partial/moderate assistance for toileting hygiene, showering/bathing self, dressing, and personal hygiene. Record review of Resident #10's care plan last reviewed 10/31/2024 indicated she had a behavior problem of excessive use of call light unknowingly at times without need due to numbness to left hand and tremors in right hand. Interventions included explain all procedures to her before starting and allow her to adjust to changes, assist her to develop more appropriate methods of coping and interacting, and anticipate and meet resident's needs. 4. Record review of Resident #58's face sheet dated 01/08/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of Resident #58's Comprehensive MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. Resident #58's BIMS score was 13, which indicated his cognition was intact. The MDS assessment indicated Resident #58 required substantial to maximal assistance with toileting, dressing, showering/bathing self, and personal hygiene. Record review of Resident #58's care plan last reviewed 10/31/2024 indicated he had impaired cognitive function or impaired thought processes. Interventions included to use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions-turn off TV, radio, close door, the resident understands consistent, simple, directive sentences, provide the resident with necessary cues, stop and return if agitated. During a resident group meeting starting on 01/06/2025 at 11:04 AM, Resident #5, Resident #7, Resident #10, and Resident #58 said CNA A did not treat them with dignity and respect, and she was rude to them. Resident #58 said CNA A had been working every day without a day off and she was not a people person. Resident #58 said CNA A did not treat anyone with respect. Resident #58 said CNA A was usually the only one on his hall and I think she takes it out on us because she is the only one working that hall. Resident #58 said CNA A did not speak when she was providing care. Resident #58 said he had reported CNA A to the nurses 2-3 times before and they never do anything. Resident #7 said CNA A did not treat her respectfully and ignored her because CNA A did not speak to Resident #7 when Resident #7 spoke to CNA A. Resident #7 said one day CNA A was sitting at the nurses' station on the computer and Resident #7 asked her something and she did not respond. Resident #10 said CNA A was rude to her because she overheard CNA A refer to her as the white person, and CNA A did not speak to her while providing care. Resident #10 said she had not reported it because they won't do anything. Resident #5 said CNA A was rude to her because she did not speak to her while providing care. Resident #5, Resident #7, Resident #10, and Resident #58 said they were not afraid of CNA A, but they felt disrespected by CNA A. During an interview on 01/07/2025 at 1:16 PM, CNA A said she was coming up on one year for her employment at the facility. CNA A said she had not had any issues with Resident #5, Resident #7, Resident #10, or Resident #58. CNA A said when she provided care to the residents she went in their room and asked them what they needed and did it for them. CNA A said she explained to the residents what she was doing while providing care to them. CNA A said she had not ignored any residents, and when they spoke to her, she spoke back to them. CNA A said she had never refused to provide care to any residents. CNA A said she had not been working every day and worked per her rotation. CNA A said it was important to treat the residents with dignity and respect for good customer service, to do as they needed because it was her job to make sure they were okay. CNA A said if the residents were not treated with dignity and respect, they could feel neglected and abused, and it would affect them if they did not get their needs met. During an interview on 01/07/2025 at 9:26 PM, CNA B said she worked the night shift with CNA A. CNA B said Resident # 10 had told her CNA A would not speak back to Resident #10 when spoken to. CNA B said she had not reported Resident #10 telling her CNA A would not speak to her to anyone. CNA B said she told CNA A she might want to speak to Resident #10. CNA B said she had not heard CNA A refer to Resident #10 as the white lady. CNA B said no other residents reported any issues with CNA A. During an interview on 01/08/2025 at 12:14 PM, the DON said in the past, there was an incident between Resident #7 and CNA A. Resident #7 reported CNA A was rude to her because she would not talk while providing care. The DON said a customer service in-service was completed with CNA A. The DON said there were not other complaints about CNA A. The DON said she had not observed any issue with CNA A's care towards the residents. The DON said she expected the staff to treat the residents respectfully, talk to the residents while they were providing care, and let them know what they were doing. During an interview on 01/08/2025 at 12:48 PM, the Administrator said to his knowledge CNA A did not have any inappropriate behaviors towards residents. The Administrator said he expected for every resident to be treated with respect and customer service was a big deal. The Administrator said if residents were not treated with dignity and respect it could impact their emotional well-being. Record review of a Resident Grievance received 08/06/2024 indicated Resident #7 reported in resident council that the night aide (CNA A) was rude because she would not talk to her when she was providing care. Resolved date 08/06/2024. The DON was assigned to take action, and the corrective action taken to prevent recurrence was employee to receive counseling. Signed by the Administrator 08/06/2024. Record review of CNA A's employee file indicated an In-Service Training Topic Customer Service dated 08/06/2024 provided by the DON signed by multiple staff, including CNA A. Record review of the facility's policy titled, Resident Rights, revised 11/28/2016, 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 right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care .The resident has a right to be treated with respect and dignity, including .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and failed to demonstrate their response and rationale for such response for 6 of 6 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns about call light response times collected at the resident council meetings on 07/15/2024, 08/22/2024, and 09/20/2024. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 07/15/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 08/22/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 09/20/2024 indicated the call lights were not being answered timely. Record review of the grievances from July 2024-January 2025 did not indicate grievances to address the efforts to resolve the resident councils' concerns. During a confidential group interview with 6 residents on 01/06/2025 starting at 11:04 AM, the resident group said call lights were not answered timely. The resident group said they had mentioned it in the resident council meetings and to staff members and nobody had gotten back to them with any resolution. During an interview on 01/07/2025 at 7:17 PM, RN D said occasionally the residents complained about the call lights not being answered timely. RN D said he reported it to the ADONs and was not provided a resolution. RN D said he tried to help the CNAs the best he could. RN D said it was important for the call lights to be answered timely because it was the residents' home, and they should have their needs met in a timely manner. During an interview on 01/08/2025 at 10:22 AM, ADON E said none of the residents had reported to her the call lights not being answered timely. ADON E said none of the staff had reported to her the call lights were not being answered timely. During an interview on 01/08/2025 at 12:14 PM, the DON said the staff had not reported issues with answering the call lights timely. The DON said none of the residents had reported to her that the call lights were not answered timely. During an interview on 01/08/2025 at 12:48 PM, the Administrator said when there were grievances in resident council, they started off with staff education, and then they followed up at the next resident council meeting. The Administrator said after the resident council he completed grievances if there were multiple concerns. The Administrator said he would look for grievances completed for the resident council and provide them (none were provided upon exit of the facility). The Administrator said he was aware of the call lights not being answered timely and it was an ongoing issue. The Administrator said it was important to address the issues that the resident council voices to do the best to meet the residents' needs. Record review of the facility's policy titled, Grievances, revised 11/02/2016, indicated, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. 1. The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations. 2. The grievance official of this facility is the administrator or their designee. 3. The grievance official will: o Oversee the grievance process o Receive and track grievances to their conclusion o Lead any necessary investigations by the facility o Maintain the confidentiality of all information associated with grievances o Issue written grievance decisions to the resident .

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 9 of 24 residents (Residents #9, #4, #41, #36, #44, #57, #130, #180, and #179 and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff to ensure adequate supervision and to prevent accidents involving Resident #44, who was physically assaulted on [DATE], Resident #4, had an unwitnessed fall on [DATE], Resident #4 was left unsupervised in the bathroom on [DATE] and self-transferred from the toilet to the wheelchair, Resident 180, sustained an unwitnessed fall with injury on [DATE] and expired on [DATE], and Resident #130 suffered unwitnessed falls on [DATE] and [DATE] in his room while only one CNA was available on the secured unit. The facility failed to provide sufficient nursing staff to ensure Resident #44, Resident #41, Resident #57, Resident #179, Resident #36, and Resident #9 did not receive their medications 1 to 6 hours late. The facility failed to ensure LVN D was able to complete her required nursing tasks timely allowing LVN D to work 24 hours on [DATE] - [DATE]. The facility failed to ensure LVN C was able to complete her required nursing tasks timely allowing LVN C to work 4 hours and 55 minutes over her scheduled shift. The facility failed to provide sufficient nursing staff to ensure ADON E did not remain on shift for over 24 hours on [DATE]-[DATE] due to excessive call offs. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:50 PM. The IJ template was provided to the facility Administrator on [DATE] at 3:39 PM. While the IJ was removed on [DATE] at 3:44 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures place residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered ,d+[DATE] days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated [DATE] and updated on [DATE] indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of the Consolidated Physician's orders dated February 2024 indicated Resident #44 was ordered Cephalexin 500 milligrams three times daily for a urinary tract infection. Record review of a Medication Administration Record dated February 2024 indicated Resident #44's Cephalexin was ordered for administration on [DATE] at 8:00 p.m., the medication administration record indicated Resident #44 received her antibiotic therapy Cephalexin at 2:51 a.m. on [DATE]. Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an observation and interview on [DATE] at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2. Record review of a face sheet dated [DATE] indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of the Consolidated Physician's orders dated February 2024 Resident #41 was ordered Medpass 2.0 (supplement for weight loss) four times daily for protein-calorie malnutrition. Record review of the Medication Administration Audit Report Resident #41 was scheduled to receive the Medpass 2.0 supplement at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Resident #41 received the ordered Medpass 2.0 on [DATE] at 12:56 a.m. and on [DATE] at 10:15 p.m. Record review of a progress note dated [DATE] at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell . LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated [DATE] at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell . LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #41was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on [DATE] at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on [DATE] there was no remarks indicating anything in regarding Resident #41. During an observation on [DATE] at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on [DATE] at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room , and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on [DATE] at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on [DATE] at 11:46 a.m., the DON said on [DATE] CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on [DATE] at 11:51 a.m., LVN D said she was called to the unit on [DATE] at 6:30 p.m. by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on [DATE]. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell . LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 and Resident #55 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. LVN D said she was late with administering the medications due to being called to the secured unit during the medication administering time. During an interview on [DATE] at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. During an interview on [DATE] at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed by the nurse on duty at the time of the incident. 3. Record review of a face sheet dated [DATE] indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't call fall sign at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an Admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had ,d+[DATE] falls in the past, required assistance with elimination, and took ,d+[DATE] medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated [DATE] at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated [DATE] at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated [DATE] at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took ,d+[DATE] medications which could cause falls. Record review of a Fall Nurses Note dated [DATE] at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated [DATE] at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on [DATE] at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA C was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on [DATE] at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. Record review of an incident report dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 4. Record review of a face sheet dated [DATE] indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Record review of the Comprehensive Care Plan dated [DATE] and revised on [DATE] indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on [DATE] and [DATE]. Record review of an incident report dated [DATE] at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of a fall risk assessment completed by LVN C on [DATE] indicated Resident #130 was always disoriented. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated [DATE] - [DATE] indicated on [DATE] Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on [DATE] and on the morning of [DATE]. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of an incident report dated [DATE] at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated [DATE] at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated [DATE] at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on [DATE] indicated Resident #130 fell and was sent to the local emergency room . The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facility. Record review from the hospital orthopedist report dated [DATE] indicated Resident #130 had fallen over the last couple of weeks at least ,d+[DATE] times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated [DATE] indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated [DATE] indicated right femoral neck fracture. Record review of a progress note dated [DATE] at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated [DATE] indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated [DATE] at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated [DATE] at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. Record review of a Daily Census form dated [DATE] indicated on Hall 400 resided 24 residents and on the secured unit there were 15 residents. During an interview on [DATE] at 11:51 p.m., LVN D said she worked the 6:00 p.m. - 6:00 a.m. shift as the nurse for the secured unit and Hall 400. LVN D said her job duties on this shift was to pass the assigned residents their medications, provide nursing care, and assist with nurse aide care as needed. LVN D said on this night she had Resident #44 was assaulted by Resident #41 in the room of Resident #55. LVN D said she had to stop the tasks she was completing to assess the situation, send Resident #44 to the local emergency room , place Resident #41 on 1:1 oversight, and then complete all the tasks this associated with this incident. LVN D said CNA A was alone in the unit when Resident #41 assaulted Resident #44 according to Resident #55's statement. LVN D said CNA A tried to separate Resident #41 and Resident #55 but Resident #41 was too aggressive. During an observation and interview on [DATE] at 6:15 p.m., LVN D was at the nursing desk when she said she had a bit more to complete on the tasks from her shift before leaving. LVN D said she had been at the facility now 24 hours. During an interview on [DATE] at 8:48 a.m., LVN C said she was not able to physically able to visualize Resident #41 but relied on the CNA to do 1:1 with Resident #41. LVN C said due to having only ,d+[DATE] CNAs on the 6:00 p.m. to 6:00 a.m. shift she was unable to complete her resident care tasks including administration of medications timely according to the orders. LVN C said she had many times informed the nursing management she would have to invoke Safe Harbor to ensure resident safety. LVN C said only when she would tell management she would invoke Safe Harbor would she get extra help to pass medications at least to the assigned Hall 400. LVN C said she had also notified the Medical Director of the nursing duties she was unable to complete timely. LVN C said in the secured unit the CNA was most often working alone and she would assist as she could. LVN C said CNA K was in a room with another resident when Resident #44 fell . During an interview on [DATE] at 10:55 a.m., LVN C said she had not completed all the tasks from her shift regarding resident care but was told by nursing management she had to leave because she was scheduled for her next shift at 6:00 p.m. Record review of the Schedule Sheet dated [DATE] indicated the census was 81 and the facility had scheduled: 6:00 a.m. - 6:00 p.m.: 2 student nurse aides, and 3 CNAs with one a no call no show status; 2 RNs and 1 LVN 6:00 p.m. - 6:00 a.m.: 2 CNAs and 1 student nurse aide who called off; and 1 RN and 1 LVN 6:00 a.m. - 2:00 p.m. 1 MA was scheduled 2:00 p.m. - 10:00 p.m. 1 CNA who called off. 10:00 p.m. - 6:00 a.m. 1 CNA Record review of the Employee Punch Report dated [DATE] - [DATE] indicated: LVN YY, RN U, LVN EEE, and LVN RRR worked 6:00 a.m. - 6:00 p.m. shift on [DATE]. LVN D and RN DD worked 6:00 p.m. -6:00 a.m. shift, on [DATE]. ADON E worked 7:47 p.m. - 11:11 p.m. on [DATE]. ADON WW worked 7:19 p.m. - 11:17 p.m. on [DATE]. CNA Y, CNA GGG, SNAs RR and PPP worked 6:00 a.m. - 6:00 p.m. shift on [DATE]. CNA SSS worked 6:00 p.m. - 6:00 a.m. shift on [DATE]. CNA H worked 5:00 a.m. - 5:00 p.m. shift on [DATE]. CNA K worked 10:00 p.m. - 6:00 p.m. shift on [DATE]. CNA A worked 6:00 p.m. - 9:00 p.m. shift on [DATE]. Record review of the Budgeted PPD on the facility assessment indicated, (based on a census of 77) 0.41 was required, which is equivalent to 31.57 hours (for CNAs) of budgeted time was unused. This indicated there was a shortage of approximately 3 CNAs on [DATE] when the incident with Resident #41 and Resident #44 occurred. During an interview on [DATE] at 8:28 AM, ADON WW stated she was at the facility working on [DATE]. ADON WW said she went to work at 5:23 AM and stayed until 1 PM then returned to the facility and worked from 7 PM to 11 PM. ADON WW stated she was administering medications on the ,d+[DATE] Hall in the morning and that evening returned due to the incident that occurred on the secured unit. During an interview on [DATE] at 8:39 AM, ADON E said she had 5 call-ins on the morning of [DATE] when she got to work and ADON WW was at the facility working. ADON E stated she had worked all day on [DATE] and into the early morning on [DATE] (24 hours). She stated they had 2 nurses on the floor and 2 aides (DON included). ADON E stated she had contacted the Area Director of Operations and stated to offer bonuses, but she had already called everyone, and they refused to come in. She stated she volunteered to stay over for 24 hours because it was easier than to come back in the morning. She stated she had gotten complaints about being short staffed and she had to work it. She stated she had worked night shifts and having 2 nurses was doable, but it was rough. She stated it was easier when everyone pitched in and all the CNAs that were scheduled were there because they were the backbone, and they were the first to notice any changes. She stated there should be a minimum of 3 CNAs up front and 1 in the back (secured unit). ADON E said it was important to ensure sufficient staff was in the facility for resident safety. During an interview on [DATE] at 10:59 AM, the Regional Compliance Nurse said there was no policy on sufficient staffing. The Regional Compliance Nurse stated there was not a true staffing issue. The Regional Compliance Nurses stated when a nurse was at the nursing station for over an hour then this becomes a time management problem. During an interview on [DATE] at 11:43 a.m., CNA H said she has had to work the secured unit alone. CNA H said she had voiced the inability to provide supervision to Resident #130 and prevent him from trying to ambulate on his broken leg. During an observation and interview on [DATE] at 10:55 p.m., CNA K said she had to work the secured unit many times alone. CNA K said she could remember Resident #130 had a fall and fractured his hip. CNA K said she could not remember providing care to Resident #130. CNA K said she had told the DON, and ADONs previously the secured unit was not staffed enough to provide adequate supervision to the residents. During this interview there were 5 residents of the secured unit up and ambulating about the unit in and out of rooms. CNA K said she was having a difficult time keeping the residents centrally located to ensure their safety. During an interview on [DATE] at 11:30 p.m., LVN C said she had cared for R [TRUNCATED]

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 1 of 1 facility reviewed for administration. The facility administration failed to ensure adequate staff were available and aware of job functions to provide for residents needs when the facility's Administrator position experienced 4 changes within 6 months. The facility failed to ensure the DON was aware that she was the abuse coordinator in absence of the Administrator, and she did not report, investigate or prevent further incidents of abuse per the facility's policy. The facility administration failed to ensure adequate nursing staff were available to provide for residents needs which resulted in Resident #44's physical assault by Resident #41, Resident #130's, Resident #4's, and Resident #180's unwitnessed falls. The facility administration failed to ensure pharmaceutical services were provided as needed, which resulted in Resident #45's hospitalization on [DATE], Resident #127's Vesicare not being administered, and medications being administered 1-6 hours late to Resident #71, Resident #179, Resident #44, Resident #45, and Resident #57. The facility administration failed to ensure the secured unit was not staffed with only 1 direct care staff (CNA) at night, which resulted in staff not being able to prevent accidents or request emergent assistance and having to leave the secured unit unsupervised to seek assistance. The facility administration failed to ensure ADON E did not remain on a shift for over 24 hours on 02/23/2024-02/24/2024 due to excessive call ins. An Immediate Jeopardy (IJ) situation was identified on 02/28/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 03/01/2024 at 5:10 PM, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for abuse, serious injury, serious harm, serious impairment, and death. Findings included: 1. Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and steri-strips in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain. LVN YY noted she administered a mild pain reliever to Resident #44. Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVNYY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's bruise by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. Record review of the Consolidated Physician's orders dated February 2024 indicated Resident #44 was ordered Cephalexin 500 milligrams three times daily for a urinary tract infection. Record review of a Medication Administration Record dated February 2024 indicated Resident #44's Cephalexin was ordered for administration on 2/26/2024 at 8:00 p.m., the medication administration record indicated Resident #44 received her antibiotic therapy Cephalexin at 2:51 a.m. on 2/27/2024. Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #44 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and reported the bruising. During an interview on 03/01/2024 at 8:52 AM, Administrator ZZ (previous administrator) said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. 2. Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications and monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell . LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 2/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on 12/26/2024 there was no remarks indicating anything in regarding Resident #41. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit on 2/25/2024 at 6:30 p.m. by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell . LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on 2/26/2024 at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night with Resident #'s 41 and 44. 3. Record review of a face sheet dated 2/27/2024 indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated 1/22/2024 and revised on 2/05/2024 indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't fall call sign at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an Admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had 1-2 falls in the past, required assistance with elimination, and took 3-4 medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated 2/24/2024 at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated 2/24/2023 at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated 2/26/2024 at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took 3-4 medications which could cause falls. Record review of a Fall Nurses Note dated 2/26/2024 at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated 2/26/2024 at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on 2/27/2024 at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA K was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on 2/27/2024 at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. Record review of an incident report dated 2/27/2023 at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated 2/27/2024 at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 4. Record review of a face sheet dated 2/29/2024 indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Resident #130 resided on the secured unit. Record review of the Comprehensive Care Plan dated 9/07/2023 and revised on 12/09/2023 indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on 11/26/2023 and 11/27/2023. Record review of an incident report dated 11/26/2023 at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of a fall risk assessment completed by LVN C on 11/26/2023 indicated Resident #130 was always disoriented. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated 11/01/2023 - 11/30/2023 indicated on 11/25/2023 Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on 11/26/2023 and on the morning of 11/27/2023. Record review of an Event Nurses-Note dated 11/26/2023 at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on 11/25/2024. Record review of an incident report dated 11/27/2023 at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated 11/27/2023 at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated 11/27/2023 at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on 11/27/2023 indicated Resident #130 fell and was sent to the local emergency room . The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facility. Record review from the hospital orthopedist report dated 11/27/2023 indicated Resident #130 had fallen over the last couple of weeks at least 8-9 times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated 11/27/2023 indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated 11/27/2023 indicated right femoral neck fracture. Record review of a progress note dated 11/29/2023 at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated 11/29/2023 indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated 12/01/2023 at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated 12/02/2023 at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. During an interview on 2/26/2024 at 11:51 p.m., LVN D said she worked the 6:00 p.m. - 6:00 a.m. shift as the nurse for the secured unit and Hall 400. LVN D said her job duties on this shift was to pass the assigned residents their medications, provide nursing care, and assist with nurse aide care as needed. LVN D said on this night she had Resident #44 was assaulted by Resident #41 in the room of Resident #55. LVN D said she had to stop the tasks she was completing to assess the situation, send Resident #44 to the local emergency room , place Resident #41 on 1:1 oversight, and then complete all the tasks this associated with this incident. LVN D said CNA A was alone in the unit when Resident #41 assaulted Resident #44 according to Resident #55's statement. LVN D said CNA A tried to separate Resident #41 and Resident #55 but Resident #41 was too aggressive. During an observation and interview on 2/26/2024 at 6:15 p.m., LVN D was at the nursing desk when she said she had a bit more to complete on the tasks from her shift before leaving. LVN D said she had been at the facility now 24 hours. During an interview on 2/27/2024 at 8:48 a.m., LVN C said she was not able to physically able to visualize Resident #41 but relied on the CNA to do 1:1 with Resident #41. LVN C said due to having only 2-3 CNAs on the 6:00 p.m. to 6:00 a.m. shift she was unable to complete her resident care tasks including administration of medications timely according to the orders. LVN C said she had many times informed the nursing management she would have to invoke Safe Harbor to ensure resident safety. LVN C said only when she would tell management she would invoke Safe Harbor would she get extra help to pass medications at least to the assigned Hall 400. LVN C said she had also notified the Medical Director of the nursing duties she was unable to complete timely. LVN C said in the secured unit the CNA was most often working alone and she would assist as she could. LVN C said CNA K was in a room with another resident when Resident #44 fell . During an interview on 2/27/2024 at 10:55 a.m., LVN C said she had not completed all the tasks from her shift regarding resident care but was told by nursing management she had to leave because she was scheduled for her next shift at 6:00 p.m. Record review of the Schedule Sheet dated 2/25/2024 indicated the census was 81 and the facility had scheduled: 6:00 a.m. - 6:00 p.m.: 2 student nurse aides, and 3 CNAs with one a no call no show status; 2 RNs and 1 LVN 6:00 p.m. - 6:00 a.m.: 2 CNAs and 1 student nurse aide who called off; and 1 RN and 1 LVN 6:00 a.m. - 2:00 p.m. 1 MA was scheduled 2:00 p.m. - 10:00 p.m. 1 CNA who called off. 10:00 p.m. - 6:00 a.m. 1 CNA Record review of the Employee Punch Report dated 2/25/2024 - 2/26/2024 indicated: LVN YY, RN U, LVN EEE, and LVN RRR worked 6:00 a.m. - 6:00 p.m. shift on 2/25/2024. LVN D and RN DD worked 6:00 p.m. -6:00 a.m. shift, on 2/25/2024. ADON E worked 7:47 p.m. - 11:11 p.m. on 2/25/2024. ADON WW worked 7:19 p.m. - 11:17 p.m. on 2/25/2024. CNA Y, CNA GGG, SNAs RR and PPP worked 6:00 a.m. - 6:00 p.m. shift on 2/25/2024. CNA SSS worked 6:00 p.m. - 6:00 a.m. shift on 2/25/2024. CNA H worked 5:00 a.m. - 5:00 p.m. shift on 2/25/2024. CNA K worked 10:00 p.m. - 6:00 p.m. shift on 2/25/2024. CNA A worked 6:00 p.m. - 9:00 p.m. shift on 2/25/2024. Record review of a Daily Census form dated 2/26/2024 indicated on Hall 400 resided 24 residents and on the secured unit there were 15 residents. During an interview on 02/27/2024 at 8:28 AM, ADON WW stated she was at the facility working on 02/25/2024. ADON WW said she went to work at 5:23 AM and stayed until 1 PM then returned to the facility and worked from 7 PM to 11 PM. ADON WW sta

Based on observation, interview, and record review, the facility to ensure the right of the residents to be free from abuse and neglect 7 of 11 residents reviewed for abuse and neglect. (Resident #'s 44, 55, 41, 47, 52, 179 and 36) The facility failed to ensure Resident #44 was protected from Resident #41 after an alleged resident to resident assault resulting in Resident 44 being sent to a local emergency. Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel) when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was not left alone with Resident #41 after he allegedly assaulted Resident #44. The facility failed to ensure Resident #179 was not verbally and physically abused by CNA B. The facility failed to ensure Resident #179 was not suffering on-going neglect by CNA B of not performing incontinent care and not responding to his call light. The facility failed to ensure Resident #36 was not verbally abused when cursed by CNA B. The facility failed to prevent verbal abuse when Resident #47 cursed at Resident #52 and did not allow him to enter his room. The facility failed to prevent abuse and neglect when LVN C reported abuse to the DON and the DON did not report it to HHSC. An IJ was identified on 2/27/2024. The IJ template was provided to the facility on [DATE] at 3:39 p.m. While the IJ was removed on 3/01/2024,the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1)Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #44 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note indicated interventions in place prior to this fall was none. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #41 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented after the Resident #44's incident with Resident #41 by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). During an observation and interview on 2/27/2024 at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2) Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #44 against the closet door and she fell . LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated 2/25/2023 at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell . LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #41 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 02/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on 02/26/2024 there was no remarks indicating anything in regarding Resident #41. During an observation on 2/25/2024 at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed . LVN F said the nurse was responsible for documenting all the events occurring with the incident with Resident #'s 41,44, and 55. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell . LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on 2/26/2024 at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one on the unit to get help when CNA A needed help. During an interview on 2/26/2024 at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room , and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. 3) Record review of a face sheet dated 3/02/2024 indicated Resident #55 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, high blood pressure, and dementia (memory loss). Record review of the Annual MDS dated [DATE] indicated Resident #55 was usually understood, and usually understands. The MDS indicated Resident #55 had severe cognitive impairment. The MDS indicated Resident #55 had not displayed any verbal or physical behaviors. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night. This was determined to be an Immediate Jeopardy (IJ) on 2/27/2024 at 3:39 p.m. The facility Administrator and assistant Administrator were notified. The Administrator was provided with the IJ templates on 2/27/2024 at 3:39 p.m and a Plan of Removal was requested. 4)Record review of the face sheet, dated 02/29/2024, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and altered mental status (broad term used to indicate an abnormal state of alertness or awareness). Record review of the significant change MDS assessment, dated 12/20/2023, revealed Resident #47 had clear speech and was usually understood by others. The MDS revealed Resident #47 was sometimes able to understand others. The MDS revealed Resident #47 had short-term and long-term memory problems. The MDS revealed Resident #47 was not able to recall the current season, the location of his room, staff names or faces, and that he was in a nursing facility. The MDS revealed Resident #47 had severely impaired decision-making skills. The MDS revealed Resident #47 had continuous inattention and disorganized thinking. The MDS revealed Resident #47 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 02/21/2024, revealed Resident #47 had potential to demonstrate verbally abuse behaviors. The interventions included: analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document .assess resident's coping skills and support system .evaluate for side effects of medications .notify the charge nurse of any abusive behaviors .provide positive feedback for good behavior, emphasize the positive aspects of compliance .psychiatric/psychogeriatric consult as indicated. Record review of the nursing progress note on 02/19/2024 at 12:20 AM, revealed Resident #47 was repeatedly yelling at his roommate [Resident #52] You son-of-a-bitch get out of my room! The nursing progress note further revealed the DON was notified immediately and told LVN C to notify the Medical Director because there was no abuse coordinator at the facility. The progress note revealed the Medical Director was notified and Resident #47 was placed in a different room. 5) Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. Record review of Resident #52's care plan last revised 02/02/2024 indicated Resident #52 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #52's progress notes indicated: o 02/19/2024 12:20 AM Resident #52 was very forgetful and usually confused. He was pacing, wandering, and coming in and out of his room. This resident was redirected numerous times back to his room and to bed. The last time resident was redirected back to his room, his roommate was cursing, repeatedly telling this resident, You son-of-a-bitch get out of my room! Which explained why Resident #52 would not stay in his room. CNA remained in the room with both residents until the DON and doctor were notified. DON notified immediately and stated to call the Medical Director. 12:35 AM both residents were separated with the roommate moved to another room. o Strike out note dated 2/23/2024, effective date for the note prior to strike out 02/19/2024 created by LVN C indicated, 12:20 AM the DON stated they did not have an abuse coordinator at the time, that their new administrator was supposed to start work that day (02/19/24). The DON stated to call the Medical Director and report it to him. During an observation and attempted interview on 02/23/2024 at 3:48 PM Resident #52 was observed walking down the hall with his rollator (walker with wheels). Resident #52 did not want to be interviewed at the time. During an interview on 02/26/2024 at 9:07 PM, LVN C said Resident #52 kept getting up and coming out of his room, and she kept telling him to go back to his room because it was in the middle of the night. LVN C said she finally decided to take him back to his room, and that was when she realized Resident #52's roommate, Resident #47, was yelling and cursing at Resident #52 to get out of the room and calling him a son of a bitch'. LVN C said this was really confusing Resident #52. LVN C said she called the DON, who was the abuse coordinator at the time, and she told her to keep them separated. LVN C said she called the Medical Director, and he told her to separate them and place them in 2 different rooms. Regarding the struck out note about the incident, LVN C said when she called the DON, she did not know the DON was the abuse coordinator. LVN C said the DON told her they currently did not have an abuse coordinator, but the new administrator was starting that day to notify the Medical Director. LVN C said she learned the DON was the abuse coordinator after talking to the DON on the phone. LVN C said one of her co-workers informed her if there was no administrator it automatically fell on the DON to be the abuse coordinator. LVN C said ADON E instructed her to correct her note to show that she did call the DON immediately. LVN C said after notifying the DON of the incident the night it occurred, the DON never talk to her about the incident again. LVN C said there had been a lot of changes in administrators and administration and they were not providing education on who was the abuse coordinator. LVN C said in the past she had called to report other incidents of abuse to who she thought was the abuse coordinator for them to tell her they were no longer employed at the facility. During an interview on 02/27/2024 at 8:46 AM, the DON said she was not able to recall any incident with Resident #47 and Resident #52. The DON said she did not remember an incident where Resident #47 cursed out Resident #52. The DON said the staff were supposed to report abuse to the Administrator and herself. The DON said the staff were notified when there were changes in administration one-on-one. The DON denied LVN C calling her to report when Resident #47 cursed at Resident #52. The DON said if the Administrator was not in the facility, she was the abuse coordinator. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility and that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities, she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no consistency, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said resident to resident altercations were a regular situation on the secured unit and was directly related to lack of supervision. The Medical Director said the residents should never have been left unsupervised. The Medical Director said the issue with the resident-to-resident altercations was staffing, and the facility being understaffed. The Medical Director said he had expressed his concerns regarding staffing to upper management. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. The Medical Director said one evening he had been in to assess Resident #57, and he had noticed Resident #57 had 2 spots on her skin as if somebody had grabbed her strong and a very large skin tear on her body. The Medical Director said he told the staff those were traction marks as if somebody had been holding her too tight. The Medical Director said he had told the staff they might have to use the Hoyer lift to transfer her. The Medical Director said the incident happened earlier in February 2024 . During an interview on 03/01/2024 at 1:22 PM, the Administrator said he expected bruises to be automatically reported to him, and if not to him directly to the DON or nursing supervisor and they would report it to him. The Administrator said when he was notified of an injury of unknown injury, he would investigate it and report it within the 2 hours. The Administrator said he had not had a chance to look for Resident #44's soft file in his office (the soft file was never provided exit date 03/02/2024). The Administrator said they reviewed incidents and accidents every morning in the morning meetings and care plan the issues. The Administrator said if there was an injury of unknown origin, they should look at the last skin assessment to try to piece together a timeline, staff would be interviewed, the resident would be interviewed, if able to be interviewed. The Administrator said he expected the staff to call him and report to him any abuse concerns no matter the time of day. The Administrator said in his absence the staff should report to the DON, and the DON should report it per the requirements to HHSC and to him . During an interview on 03/01/2024 at 1:50 PM, the DON said she had started at the facility on January 13, 2024. The DON said if the nurses found a new bruise, she expected them to notify the Administrator or herself, so it could be reported to HHSC within 2 hours and investigated. The DON said the staff should report abuse to the abuse coordinator, the Administrator, and in his absence to her. During an interview on 03/02/2024 at 10:04 AM, Resident #52 said he did not remember his roommate (Resident #47) yelling and cursing at him. During an interview on 03/02/2024 at 5:36 PM, ADON E said she had been employed at the facility for 3 years, but she had been out for several months for medical reasons. ADON E said she had told LVN C to edit her note regarding notifying the DON about Resident #47 cursing at Resident #52 because the DON had denied LVN C notifying her about the incident. ADON E proceeded to say they called her and told her to tell LVN C to change her documentation. ADON E said she often gets called and instructed to tell the nurses to edit their documentation. ADON E said she could not remember who called her to instruct her to tell the nurses to edit their documentation. 6) Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. Record review of the care plan last revised 02/23/2024 indicated Resident #179 had quadriplegia to assist with ADLs and locomotion as required. During an observation and interview on 02/26/2024 at 10:46 AM, Resident #179 said he did not like it at night. Resident #179 said CNA B was mean to him, and she throws me around with the sheet. He said CNA B ignored his call light and did not provide incontinent care. Resident #179 became very emotional and started crying because he said CNA B said she was not going to take care of him, and he had to wait to be changed until 6 AM the next morning. Resident #179 said he was not able to remember the exact day of the incident, but he had told the DON one night she had worked on the floor. Resident #179 said the DON told him she would handle it, but she never returned to tell him how she handled it. Resident #179 said CNA B was still supposed to provide care for him, but she refused to provide care to him. Resident #179 remained tearful throughout the rest of the interview. During an interview on 02/26/2024 at 12:22 PM, the DON said she had worked on the floor on the night shift to help the CNAs provide ADL care (the DON did not specify the date). The DON said no residents had reported to her any abuse allegations. The DON said if a resident reported an abuse allegation to her, she would start and investigation, fill out a grievance, and notify the abuse coordinator, the AIT, immediately, and call the Social Worker. The DON said she had talked to Resident #179, and he was a bit hard to understand, but he had not notified her of any abuse or neglect allegations. The DON said no residents had complained about CNA B to her. The DON said Resident #179 could have reported the abuse to another staff member. During an interview on 02/27/2024 at 10:35 AM, CNA B said she had been employed at the facility since October 2022, and she worked the night shift. CNA B said she provided care to Resident #179. CNA B said she answered Resident #179's call light and denied any abuse towards Resident #179 . CNA B said there were times when she was not able to provide the care required to the residents because the facility was shorthanded. CNA B said sometimes from 6 PM-10PM the facility only had 2 CNAs. CNA B said Resident #179 was needy. CNA B said Resident #179 was very needy, and he required 2 staff assist with his ADLs. CNA B said she could do what he asked her to do and ask him if he was satisfied, and when she walked out, he would turn his call light on. CNA B repeated that Resident #179 was very needy, and she would have to tell him that she had other people to take care of and he would say ok. During an observation and interview on 02/27/2024 at 4:40 PM, CNA EE and SNA O were in Resident #179's room. Upon entering room, surveyor noticed Resident #179 was crying uncontrollably and emotionally distraught. CNA EE and SNA O were attempting to reassure and comfort Resident #179. CNA EE said Resident #179 was crying because he did not want them to leave for the day (referring to the 6 AM- 6PM shift) because the night shift would not turn him or answer his call light. Resident #179 started crying even more and said CNA OO had called him a rat for telling on CNA B, took his call light away, and told him nobody wanted to answer his call light the previous night (02/26/24). Resident #179 had not reported the incident to any other facility staff . During an interview on 03/02/2024 at 10:43 AM, CNA OO said Resident #179 was a high-risk care because he was a 2-person total assist with mobility and his ADLs. CNA OO said she had never had any issues with him, and she had not taken his call light away. CNA OO said generally when she went into Resident #179's room there was another staff member with her. CNA OO said she had not called Resident #179 a rat . 7)Record review of Resident #36's face sheet dated 02/27/2024, indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar disorder, current episode depressed, severe, without psychotic features (depressed, as in severe depressive episode without psychotic symptoms, and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past). Record review of Resident # 36's Quarterly MDS assessment dated [DATE], indicated Resident #36 was understood and was able to understand others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 had no delusions or hallucinations. The MDS assessment indicated Resident #36 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #36's a care plan dated 02/26/2024, indicated Resident #36 has a behavior problem: will request certain services and tasks then refuse or state it was not offered. (Showers, therapy, meal preferences). Record review of Resident #36's progress notes dated 02/27/2024, revealed no documented incidents regarding Resident #36's allegations with CNA B. During an interview on 02/26/2024 at 10:23 AM, Resident # 36 stated CNA came into her room with an attitude. Resident #36 stated she asked the CNA if she was having a bad day and the CNA said do not worry about me. Resident #36 stated she said then do not worry about me either. Resident #36 stated the CNA said well fuck you

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations for 8 of 11 residents (Resident #'s 44, 55, 41, 47, 52, 179, 57 and 36) reviewed for abuse and neglect. The facility failed to report and investigate when Resident #44 was found to have a large purple bruise to her inner thigh and a fractured hip. The facility failed to ensure Resident #44 was protected from Resident #41 after a resident to resident assault allegation resulting in Resident # 44 being sent to a local emergency room . Resident #44 was assessed with a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). when she was left alone with her alleged assailant Resident #41. The facility failed to ensure Resident #55 was protected by not leaving him alone with Resident #41 after Resident #41 allegedly assaulted Resident #44. The facility failed to ensure Resident #179 was not verbally and physically abused by CNA B. The facility failed to ensure Resident #179 was not suffering on-going neglect abuse by CNA B of not performing incontinent care and not responding to his call light. The facility failed to ensure Resident #36 was not verbally abused when cursed by CNA B. The facility failed to ensure the DON reported physical and verbal abuse and neglect to the abuse coordinator after Resident #179 reported it to her in February 2024. The facility failed to ensure the DON reported abuse to HHSC, after LVN C reported abuse to her on 02/19/2024. The facility failed to ensure Resident #52 was not cursed at and not allowed in his room by Resident #47 who had a history of verbal abuse. The facility failed to report to the state agency when Resident #57 had shearing, hematoma, bruising, and a skin tear. An IJ was identified on 3/01/2024. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 3/01/2024, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's policy dated 03/29/2018, titled, Abuse/Neglect, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals . Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc . 5. Physical Abuse: Includes, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Abuse as defined in 40 TAC 19.101 (1). 6. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Abuse as defined in 40 TAC 19.101(1). 7. Neglect: is the failure of the facility. its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 12. Injury of Unknown Source any injury to a resident where: o The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and o The injury is suspicious because of the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time . The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation . Resident to Resident the above policy will apply to potential resident-to-resident abuse . 1) Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and Steri-strips (tape like strips) in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head (hip joint) was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty (joint restoration) was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain but no pain level was documented. LVN YY noted she administered a mild pain reliever to Resident #44 . Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVNYY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture (connects the hip ball to the femur bone) a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. LVN YY said reporting to the DON and Administrator was the policy of the facility. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and report the bruising. During an interview on 03/01/2024 at 8:52 AM, previous Administrator ZZ said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. During an interview on 03/01/2024 at 1:22 PM, the Administrator said he expected bruises to be automatically reported to him, and if not to him directly to the DON or nursing supervisor and they would report it to him. The Administrator said when he was notified of an injury of unknown injury, he would investigate it and report it within the 2 hours. The Administrator said he had not had a chance to look for Resident #44's soft file in his office (the soft file was never provided prior to the exit date of 03/02/2024). The Administrator said they reviewed incidents and accidents every morning in the morning meetings and care plan the issues. The Administrator said if there was an injury of unknown origin, they should look at the last skin assessment to try to piece together a timeline, staff would be interviewed, the resident would be interviewed, if able to be interviewed. The Administrator said he expected the staff to call him and report to him any abuse concerns no matter the time of day. The Administrator said in his absence the staff should report to the DON, and the DON should report it per the requirements to HHSC and to him. 2)Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 on the floor bedside the closet door on her back with Resident #41 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). Record review of the of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #41 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital Record review of a progress note dated 2/25/2024 at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination document indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated 2/25/2024 indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). 3)Record review of a face sheet dated 3/2/2024 indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated 8/08/2023 and revised on 9/08/2023 indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated 2/25/2024 at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #44 against the closet door and she fell . LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated 2/25/2023 at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell . LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #44 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated 2/25/2024 at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on 2/25/2024 at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. -5:45 a.m. on 2/26/2024 there was no remarks indicating anything in regarding Resident #44. During an interview on 2/26/2024 at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on 2/26/2024 at 11:46 a.m., the DON said on 2/25/2024 CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on 2/26/2024 at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on 2/25/2024. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell . LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an observation and interview on 2/27/2024 at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 4) Record review of a face sheet dated 3/02/2024 indicated Resident #55 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, high blood pressure, and dementia (memory loss). Record review of the Annual MDS dated [DATE] indicated Resident #55 was usually understood, and usually understands. The MDS indicated Resident #55 had severe cognitive impairment. The MDS indicated Resident #55 had not displayed any verbal or physical behaviors. During an observation on 2/25/2024 at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on 2/26/2024 at 10:54 a.m., LVN F said Resident #44 was discharged to the hospital and Resident #41 was on every 15-minute checks for aggressive behaviors. LVN F said after she reviewed Resident #44's electronic medical record and said there was not a progress note, a SBAR (situation, background, assessment, recommendation) note, a transfer note, or an incident report. LVN F said the electronic medical record should have had those assessments completed. During an observation and interview on 2/26/2024 at 12:42 p.m., Resident #55 was sitting at the dining table and was unable to recall the incident in his room last night. 5)Record review of the face sheet, dated 02/29/2024, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and altered mental status (broad term used to indicate an abnormal state of alertness or awareness). Record review of the significant change MDS assessment, dated 12/20/2023, revealed Resident #47 had clear speech and was usually understood by others. The MDS revealed Resident #47 was sometimes able to understand others. The MDS revealed Resident #47 had short-term and long-term memory problems. The MDS revealed Resident #47 was not able to recall the current season, the location of his room, staff names or faces, and that he was in a nursing facility. The MDS revealed Resident #47 had severely impaired decision-making skills. The MDS revealed Resident #47 had continuous inattention and disorganized thinking. The MDS revealed Resident #47 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 02/21/2024, revealed Resident #47 had potential to demonstrate verbally abuse behaviors. The interventions included: analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document .assess resident's coping skills and support system .evaluate for side effects of medications .notify the charge nurse of any abusive behaviors .provide positive feedback for good behavior, emphasize the positive aspects of compliance .psychiatric/psychogeriatric consult as indicated. Record review of the nursing progress note on 02/19/2024 at 12:20 AM, revealed Resident #47 was repeated yelling at his roommate [Resident #52] You son-of-a-bitch get out of my room! The nursing progress note further revealed the DON was notified immediately and told LVN C to notify the Medical Director because there was no abuse coordinator at the facility. The progress note revealed the Medical Director was notified and Resident #47 was placed in a different room. 6) Record review of a face sheet dated 03/02/2024 indicated Resident #52 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors) , anxiety disorder, and depression. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #52 was usually able to understand others and was usually understood by others. The MDS assessment indicated Resident #52 had a BIMS score of 5, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #52 had no physical, verbal, or other behaviors directed toward others. The MDS assessment indicated Resident #52 required setup or cleanup assistance with eating, supervision for oral, toileting, and personal hygiene, and partial to moderate assistance with showering and dressing. Record review of Resident #52's care plan last revised 02/02/2024 indicated Resident #52 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #52's progress notes indicated: o 02/19/2024 12:20 AM Resident #52 was very forgetful and usually confused. He was pacing, wandering, and coming in and out of his room. This resident was redirected numerous times back to his room and to bed. The last time resident was redirected back to his room, his roommate was cursing, repeatedly telling this resident, You son-of-a-bitch get out of my room! Which explained why Resident #52 would not stay in his room. CNA remained in the room with both residents until the DON and doctor were notified. DON notified immediately and stated to call the Medical Director. 12:35 AM both residents were separated with the roommate moved to another room. o Strike out note dated 2/23/2024, effective date for the note prior to strike out 02/19/2024 created by LVN C indicated, 12:20 AM the DON stated they did not have an abuse coordinator at the time, that their new administrator was supposed to start work that day (02/19/24). The DON stated to call the Medical Director and report it to him. During an observation and attempted interview on 02/23/2024 at 3:48 PM Resident #52 was observed walking down the hall with his rollator (walker with wheels). Resident #52 did not want to be interviewed at the time. During an interview on 02/26/2024 at 9:07 PM, LVN C said Resident #52 kept getting up and coming out of his room, and she kept telling him to go back to his room because it was in the middle of the night. LVN C said she finally decided to take him back to his room, and that was when she realized Resident #52's roommate, Resident #47, was yelling and cursing at Resident #52 to get out of the room and calling him a son of a bitch'. LVN C said this was really confusing Resident #52. LVN C said she called the DON, who was the abuse coordinator at the time, and she told her to keep them separated. LVN C said she called the Medical Director, and he told her to separate them and place them in 2 different rooms. Regarding the struck out note about the incident, LVN C said when she called the DON, she did not know the DON was the abuse coordinator. LVN C said the DON told her they currently did not have an abuse coordinator, but the new administrator was starting that day to notify the Medical Director. LVN C said she learned the DON was the abuse coordinator after talking to the DON on the phone. LVN C said one of her co-workers informed her if there was no administrator it automatically fell on the DON to be the abuse coordinator. LVN C said ADON E instructed her to correct her note to show that she did call the DON immediately. LVN C said after notifying the DON of the incident the night it occurred, the DON never talk to her about the incident again. LVN C said there had been a lot of changes in administrators and administration and they were not providing education on who was the abuse coordinator. LVN C said in the past she had called to report other incidents of abuse to who she thought was the abuse coordinator for them to tell her they were no longer employed at the facility. During an interview on 02/27/2024 at 8:46 AM, the DON said she was not able to recall any incident with Resident #47 and Resident #52. The DON said she did not remember an incident where Resident #47 cursed out Resident #52. The DON said the staff were supposed to report abuse to the Administrator and herself. The DON said the staff were notified when there were changes in administration one-on-one. The DON denied LVN C calling her to report when Resident #47 cursed at Resident #52. The DON said if the Administrator was not in the facility, she was the abuse coordinator. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility and that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities, she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no consistency, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said resident to resident altercations were a regular situation on the secured unit and was directly related to lack of supervision. The Medical Director said the residents should never have been left unsupervised. The Medical Director said the issue with the resident-to-resident altercations was staffing, and the facility being understaffed. The Medical Director said he had expressed his concerns regarding staffing to upper management. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 11 residents (Resident #'s 4, 44, 130, and 180) reviewed for accidents. The facility failed to ensure Resident #44 was provided with adequate supervision when she was physically assaulted by Resident #41 on [DATE]. The facility failed to ensure Resident #4 who required 1 person assistance with toileting was provided adequate supervision to prevent an unwitnessed fall on [DATE] at 10:30 p.m. The facility failed to ensure Resident #4 was not left unsupervised on the toilet on [DATE] and was able to self-transfer between the toilet and the wheelchair. The facility failed to ensure Resident #130 was not provided adequate supervision to prevent an unwitnessed fall on [DATE] and [DATE]. The facility failed to prevent incidents and accidents when Resident #180 sustained an unwitnessed fall with injury (moderate sized frontal scalp soft tissue hematoma (blood collected outside of the blood vessels due to injury or trauma to the right side of the forehead)) and expired on [DATE]. An IJ was identified on [DATE] at 3:39 PM. The IJ template was provided to the facility on [DATE] at 3:39 PM. While the IJ was removed on [DATE], the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision. The findings included: 1)Record review of a face sheet dated [DATE] indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered ,d+[DATE] days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated [DATE] and updated on [DATE] indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and as the intervention resides on the secured unit. Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #414 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #414 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in the area of space and tissue between the skull and skin). Record review of the of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented she was called to Resident #55's room. LVN D documented Resident #44 was lying on the floor beside the closet door on the floor on her back with Resident #41 standing over her. LVN D documented Resident #55 had an abrasion to her right temple area with bruising to her right inner arm. LVN D documented Resident #44 was unable to state what had happened but Resident #55 said Resident #44 pushed Resident #44 against the closet door. The event note indicated LVN D sent Resident #44 to the local hospital. The note in #17 interventions in place prior to this fall was none of the above. Record review of a progress note dated [DATE] at 7:30 p.m., LVN D wrote she was called to another resident room where she found Resident #44 was found on the floor bedside the closet door on her back with Resident #44 standing over her, and Resident #55 stated Resident #41 pushed Resident #44 against the closet door. Record review of a Fall-Risk assessment dated [DATE] documented by LVN D indicated Resident #44 had intermittent confusion, no falls in the past 3 months, was ambulatory, and was incontinent. LVN D documented Resident #44 had a balance problem while standing, balance problem while walking, decreased muscular coordination, and change in her gait pattern when walking through a doorway. Record review of a hospital Emergency Department History of Present Illness indicated Resident #44 was sent to the local emergency roiagnom on [DATE] with the chief complaint as assault. The note written by the physician indicated Resident #44 assessment revealed a head contusion (bruise) and a hematoma (a collection of blood outside of the vessel). The note indicated in the review of systems Resident #44 had a headache. The physical examination documented indicated Resident #44 was moderately distressed, had ecchymosis (bruising caused by injury), swelling, and tenderness to the right side of her head. Record review of a CT Head without Intravenous Contrast dated [DATE] indicated Resident #44's CT impression indicated she had a right parietal scalp hematoma (A scalp hematoma is a collection of blood (either flowing or clotted from ruptured blood vessels that will then collect in space and tissue between the skull and skin). During an observation and interview on [DATE] at 9:00 a.m., Resident #44 was sitting at the dining table with a large size raised area with bruising noted to her right side of her head in the temporal/parietal region. Resident #44 said she felt well but she denied having her head hurt. 2) Record review of a face sheet dated [DATE] indicated Resident #41 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, the need for continuous supervision, and high blood pressure. Record review of a Significant Change MDS dated [DATE] indicated Resident #41 was usually understood and sometimes understands. The MDS indicated Resident #41's cognition was severely impaired. The MDS indicated Resident #41 had no physical, or verbal behaviors exhibited. The MDS indicated Resident #41 wandered daily. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #41 was at risk for mood problems and received medications. The goal of the care plan indicated Resident #41 would have an improved mood state. The care plan interventions included administer medications, behavioral health consults as needed, monitor and record mood to determine if problems seem to be related to external causes. Record review of a progress note dated [DATE] at 6:00 p.m., LVN D documented she was called to a resident room by CNA A. LVN D documented Resident #41 was in Resident #55's room where she found Resident #44 on the floor beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented she asked Resident #41 and Resident #44 what had occurred, and neither could explain. LVN D documented Resident #55 said Resident #41 pushed Resident #55 against the closet door and she fell . LVN D documented Resident #41 was very uncooperative and had tried to hit CNA A and Resident #55. Record review of Behavior Nurses Note dated [DATE] at 6:30 p., LVN D documented she was called to the secured unit by the nurse aide. LVN D documented Resident #41 was in Resident #55's room. LVN D documented she found Resident #44 on the floor lying beside the closet door. LVN D documented Resident #41 was standing over Resident #44. LVN D documented Resident #55 said he pushed her up against the closet door and she fell . LVN D said Resident #41 and #44 was unable to indicate what had happened. LVN D said Resident #44 was very uncooperative and had tried to the hit the CNA on duty and Resident #55. Record review of an Event Nurses' note dated [DATE] at 6:30 p.m., indicated LVN D documented Resident #41 was found in another resident room. LVN D documented Resident #41 had displayed physical, and resident to resident behaviors with another resident injured. The Event Nurses' note indicated LVN D moved Resident #41's room and initiated every 15-minute checks. Record review of a Every 15 Minute Check sheet indicated Resident #41 was placed on every 15-minute checks starting on [DATE] at 6:30 p.m. The Every 15- minute checks at 0015 indicated LVN D documented at 12:15 a.m., Resident #44 was asleep. LVN D had only her initials beside the other every 15-minute checks starting at 12:30 a.m. - 5:45 a.m. on [DATE] there was no remarks indicating anything in regarding Resident #41. During an observation on [DATE] at 9:31 a.m., Resident #41 was lying in his bed asleep. During an interview on [DATE] at 4:17 p.m., the SW said she was notified by the DON regarding the incident with Resident #44 and Resident #41. The SW said upon her arrival Resident #44 was already at the local emergency room , and Resident #41 was wandering on the unit. The SW said Resident #41 and Resident #55 both were unable to recollect the recent incident. During an interview on [DATE] at 9:32 p.m., CNA A said she was alone on the secured unit gathering her supplies in the spa/communal shower room when she heard a loud scream. CNA A said she ran out of the spa room and ran toward the end of the hall where she believed the sound was heard from. CNA A said upon entering the room, Resident #44 was lying in the floor, Resident #55 said Resident #41 had thrown Resident #44 into the door. CNA A said Resident #41 was aggressive with her at the time and tried to swing at her. CNA A said she left Resident #55's room and ran the length of the secured unit, opened the door, and yelled for help. CNA A said she was alone on the secured unit and had no other recourse than to go for help. CNA A said LVN D was passing medications and another nurse responded to her call for help. During an interview on [DATE] at 11:46 a.m., the DON said on [DATE] CNA A heard a noise and responded to the noise. The DON said LVN D called and said Resident #41 was upset and wandering in other rooms. The DON said CNA A had said Resident #44 was on the floor. The DON said she was unsure of Resident #44 hitting her head although she had an abrasion to her head. The DON said Resident #44 was sent to the emergency room closer to midnight due to complaining her head was hurting. During an interview on [DATE] at 11:51 a.m., LVN D said she was called to the unit by CNA A. LVN D said Resident #44 was lying in the floor of Resident #55's room, with Resident #41 standing over Resident #44 around 6:30 p.m. on [DATE]. LVN D said Resident #55 said Resident #41 pushed Resident #44 against the closet and Resident #41 fell . LVN D said at the time of the incident Resident #44 had an abrasion to her right temple area and a bruise to her inner right arm. LVN D said Resident #41 was very uncooperative and attempted to hit others. LVN D said she was advised to place Resident #41 on every 15-minute checks by the DON. LVN D said although her documentation was not completed yet Resident #41 remained asleep. LVN D said CNA A had to leave Resident #44 to come for help. LVN D said she was not on the secured unit but was on hall 400 when the incident occurred. During an interview on [DATE] at 12:22 p.m., CNA H said CNA A had always worked the secured unit alone. CNA H said when CNA A was in the room with other residents who would be watching the other residents, or who would go for help. CNA H said there was no one was on the unit to get help when CNA A needed help. 3) Record review of a face sheet dated [DATE] indicated Resident #130 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia with behavioral disturbances, lack of coordination, and a need for assistance with personal care. Record review of the Comprehensive Care Plan dated [DATE] and revised on [DATE] indicated Resident #130 was a high risk for falls related to wandering. The goal of the care plan was Resident #130 would be free of falls. The care plan interventions included to anticipate and met Resident #130's needs, ensure his call light was within reach, encourage the use of the call light, and have prompt response to the request for assistance, and ensure Resident #130 wore appropriate footwear. The comprehensive care plan failed to have interventions after the falls on [DATE] and [DATE]. Record review of an incident report dated [DATE] at 10:00 p.m., LVN C indicated Resident #130 was found by the CNA on the floor, with no signs of pain. The note indicated Resident #130 was limping on the left leg and was sent to the local emergency room at 10:35 p.m. via the ambulance. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of a fall risk assessment completed by LVN C on [DATE] indicated Resident #130 was disoriented at all times to person, place, and time. The assessment indicated Resident #130 had no previous falls, was ambulatory, continent, had balance problems, decreased muscular coordination, and gait pattern changes. Record review of a Medication Administration Record dated [DATE] - [DATE] indicated on [DATE] Resident #130 was administered Ativan 0.5 milligrams for anxiety or agitation. The record also indicated Resident #130 received the Ativan 0.5 milligrams twice daily on [DATE] and on the morning of [DATE]. Record review of an Event Nurses-Note dated [DATE] at 10:00 p.m., indicated Resident #130 had an unwitnessed fall in his room. LVN C documented Resident #130 was assisted up and was noted to be limping on the left leg. LVN C documented the physician was notified and Resident #130 was sent to the local hospital. The note indicated the interventions included interval monitoring (specify below) there was no documentation below. The note indicated in additional interventions there were interventions of a low bed and interval monitoring (again not specified). The note indicated Resident #130 was independent with bed mobility, toileting, and transferring. The note indicated Resident #130 had an unsteady gait, balance problem, and lack of mobility strength. The note indicated Resident #130 was wearing shoes or anti-slip socks. The note indicated Resident #130 had Ativan 0.5 milligrams twice daily started on [DATE]. Record review of an incident report dated [DATE] at 5:30 p.m., indicated Resident #130 was found with his head lying against the closet door by LVN HHH. The note indicated Resident #130 had a bruise to his right shoulder and a skin tear to his left hand. The note indicated the conclusion was Resident #130 had an unwitnessed fall with injuries. The note indicated his bed was changed to a low bed. Record review of an Event Nurses-Note dated [DATE] at 6:39 p.m., indicated Resident #130 was found by LVN HHH when she was passing dining trays. The note indicated Resident #130 was lying with his head against the closet door. The note indicated Resident #130 had a skin tear. The note indicated Resident #130 had a purple bruise to his right shoulder. The note indicated Resident #130 was in pain noted by his occasional moans or groans, and facial grimacing. The note indicated Resident #130's physical factors included previous fall, urinary tract infection, pain, and incontinence. The note indicated Resident #130 required 1 staff with bed mobility, toileting, transferring, and walking. The note indicated Resident #130 leaned forward. Record review of an e-Transfer Form dated [DATE] at 6:00 p.m., indicated Resident #130 was transferred to the local hospital due to a fall by LVN HHH. Record review of a Fall-Risk assessment dated [DATE] at 6:47 p.m. indicated Resident #130 was disoriented, has fallen 3 or more falls in the past 3 months, ambulatory, and incontinent. The assessment indicated Resident #130 had balance problems while standing and walking. Record review of the History of Present Illness from the local hospital on [DATE] indicated Resident #130 fell and was sent to the local emergency room . The note indicated Resident #130 had a right hip fracture. The note indicated Resident #130 was seen 24 hours prior to this visit related to multiple falls at the facilitydur . Record review from the hospital orthopedist report dated [DATE] indicated Resident #130 had fallen over the last couple of weeks at least ,d+[DATE] times. The orthopedist documented Resident #130 was in the emergency room the day before post a fall with negative x-rays at the time. The note indicated the CT results indicated a minimally impacted right femoral neck fracture. The note indicated the physician spoke to the family and the family wanted a non-operative treatment and return to the facility with palliative care. Record review of hospital records dated [DATE] indicated Resident #130 was admitted at 6:59 p.m. with the diagnosis of closed fracture of the right hip. The discharge records indicated Resident #130 was returned to the facility on hospice services. Resident #130's discharge orders included bedrest, non-weight bearing to the right leg, and pain management. Record review of the cat scan of the chest, abdomen, and pelvis dated [DATE] indicated right femoral neck fracture. Record review of a progress note dated [DATE] at 4:25 p.m., indicated the social worker documented Resident #130 returned from the hospital, admitted on a hospice service, and was made a do not resuscitate status. Record review of a physician's progress note dated [DATE] indicated Resident #130 had a fall with a fracture to the right hip and he was being treated conservatively. Record review of an Incident Report dated [DATE] at 3:30 p.m., completed by LVN YY indicated Resident #130 was observed sitting on the floor beside his bed with his back leaning on the mattress. The note indicated Resident #130's bed was in low position. The note indicated the predisposing physiological factors were confusion, incontinent, recent medication changes, and impaired memory. Record review of a progress note dated [DATE] at 8:00 p.m., LVN D documented Resident #130 had a fall slipped off of the bed. LVN D documented there were no injuries. LVN D documented she administered Tramadol 50 milligrams due to Resident #130 appeared in pain, and then he was assisted up to the recliner because he refused to rest in his bed. During an interview on [DATE] at 11:43 a.m., CNA H said she has had to work the secured unit alone. CNA H said she had voiced the inability to provide supervision to Resident #130 during the time his leg was fractured and to prevent him from trying to ambulate on his broken leg. During an observation and interview on [DATE] at 10:55 p.m., CNA K said she had to work the secured unit many times alone. CNA K said she could remember Resident #130 had a fall and fractured his hip. CNA K said she could not remember providing care to Resident #130. CNA K said she had told the DON, and ADONs previously the secured unit was not staffed enough to provide adequate supervision to the residents. During this interview there were 5 residents of the secured unit up and ambulating about the unit in and out of rooms. CNA K said she was having a difficulty time keeping the residents centrally located to ensure their safety. During an interview on [DATE] at 11:30 p.m., LVN C said she had cared for Resident #130. LVN C said she had voiced concern numerous times and threatened to call safe harbor due to the inability to provide adequate supervision and care to her assigned residents. LVN C said due to the lack of staff on the secured unit she was unable to ensure the residents remained safe. LVN C said it was not unusual to have only one staff member on the secured unit from 10:00 p.m. - 6:00 p.m. LVN C said she still had medication to administer to Resident #4, therefore she was on her way to the secured unit. 4) Record review of a face sheet dated [DATE] indicated Resident #4 admitted on [DATE] and readmitted [DATE] with the diagnosis of diabetes, muscle weakness, lack of coordination, reduced mobility, repeated falls, dementia, and assistance with personal care. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #4 had an ADL self-care performance deficit. The goal of the care plan indicated Resident #4 would remain at her current level of function in transfers, and toileting. The care plan interventions included Resident #4 required one staff assistance with toileting. The comprehensive care plan indicated Resident #4 was at risk for falls related to weakness and impaired cognition. The goal of the care plan was Resident #4 would not sustain a serious injury. The care plan interventions included ensure Resident #4's call light was within reach, ensure don't call fall sign (fall prevention sign) at the foot of the bed visible by Resident #4, and frequent visual checks while in bed. Record review of an Admission MDS dated [DATE] indicated Resident #4 was usually understood and understands others. The MDS indicated Resident #4's cognition was moderately impaired. The MDS in section GG indicated Resident #4 required partial to moderate assistance with toileting, bed to chair transfers, toileting transfers and to sit and stand. Record review of a Fall-Risk assessment dated [DATE] at midnight LVN D indicated Resident #4 had ,d+[DATE] falls in the past, required assistance with elimination, and took ,d+[DATE] medications which could increase the risk of falls. The fall risk assessment indicated Resident #4 was at high risk to fall. Record review of a fall incident report dated [DATE] at midnight, LVN D indicated Resident #4 ambulated without assistance and was not wearing any shoes or socks. Record review of a progress note dated [DATE] at midnight, LVN D documented Resident #4 was sitting in the hallway on her bottom with her legs straight in front of her. LVN D said Resident #4 said she had slipped down. LVN D documented Resident #4 was not wearing shoes or socks. LVN D documented Resident #4 complained of right foot pain. Record review of a fall incident report dated [DATE] at 10:30 p.m., LVN C indicated no injuries were observed. The incident report was left blank. Record review of a Fall-Risk assessment dated [DATE] at 10:30 p.m., LVN C documented Resident #4 was at high risk to fall. LVN C documented Resident #4 was disoriented, had 3 or more falls in the past 3 months, required assistance with elimination, had problems with balance, and took ,d+[DATE] medications which could cause falls. Record review of a Fall Nurses Note dated [DATE] at 10:46 a.m., LVN F documented Resident #4 had a fall without injury. LVN F documented fall interventions were the bed low, interval monitoring, neurological checks, frequent visual checks, encourage and educate use of the call light. Record review of a progress note dated [DATE] at 11:30 p.m., LVN C indicated Resident #4 said she had fallen on the floor, and she had been pulling up her pants. During an interview on [DATE] at 8:48 a.m., LVN C said CNA K was in another resident's room providing care when she heard Resident #4 calling for help. LVN C said CNA K was alone, so she had to hurriedly finish in the room to be able to assist Resident #4. LVN C said Resident #4 was lying on the bathroom floor when CNA C was able to get to her. LVN C said the secured unit was understaffed to provide adequate supervision for Resident #4 and other residents. During an observation and interview on [DATE] at 11:48 a.m., CNA H responded to the surveyor assisting Resident #4 with activating her call light for assistance to the bathroom. CNA H responded and assisted Resident #4 from her bed to the wheelchair, then from the wheelchair to the toilet. CNA H left Resident #4 alone on the toilet and went to get Resident #4's lunch tray. Upon returning to the room, Resident #4 was exiting the bathroom already in her wheelchair. CNA H said Resident #4 had a history of falls and was a fall risk. CNA H said she should have not left Resident #4 alone because of her risk to fall. Record review of an incident report dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had a fall with no injuries noted. The incident report had no further documentation within. Record review of an Event Nurses' Note-Fall dated [DATE] at 11:45 p.m., LVN C documented Resident #4 had an unwitnessed fall. LVN C documented Resident #4 was found on the floor, indicated Resident #4 said legs gave out, and Resident #4 attempted to self-toilet. LVN C documented in the area of Nursing Description: Resident #4 indicated she got up to use the bathroom, failed to call for help, denied bumping her head, and was found sitting on the floor. 5) Record review of a face sheet dated [DATE] indicated Resident #180 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of the left lower leg, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #180 was understood and understood others. The MDS assessment indicated Resident #180 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #180 was frequently incontinent of urine and occasionally incontinent of bowel. The MDS assessment indicated Resident #180 had not had any falls since admission/entry or reentry or the prior assessment. Record review of the care plan last revised [DATE] indicated Resident #180 was at risk for falls related to weakness and confusion with a goal of Resident #180 will be free of falls through the review date. Interventions included to anticipate and meet her needs, be sure her call light was within reach and encourage the resident to use it for assistance as needed, bed in low position when care is not being provided, Resident #180 needed a safe environment, mechanical lift with 2 staff assistance with transfers, and to review information on past falls and attempt to determine the cause of the falls record possible root causes. The care plan indicated Resident #180 had bladder incontinence to provide incontinent care at least every 2 hours. The care plan indicated Resident #180 had bowl incontinence to check her every two hours and assist with toileting as needed and to provide peri care after each incontinent episode. The care plan indicated Resident #180 had an ADL self-care performance deficit and required a lift for all transfers, one staff assistance with bed mobility, dressing and two staff assistance for toileting. Record review of Resident #180's Order Summary report dated active orders as of [DATE] indicated she was admitted to hospice on [DATE] and resident was weight bearing as tolerated with walking boot on her left lower leg with a start date of [DATE]. Record review of Resident #180's progress notes indicated: [DATE] at 5:17 PM, late entry, 6:15 AM this morning RN U went down to assess patient and she had a change in her mental and respiratory status. Blood pressure was ,d+[DATE], heart rate 80, respirations 26, oxygen saturation 86% RN U immediately contacted EMS, the Medical Director, and her family member at 6:30 AM. The note indicated Resident #180 had diagnoses of congestive heart failure, cellulitis to both lower extremities and mild dementia and had oxygen ordered at 2 liters via nasal canula but apparently, she would take it off. RN U reapplied the oxygen 2 liters via nasal canula and Resident #180's oxygen saturation improved to 90%. RN U noted that fire and EMS arrived and pt started speaking more clearly and told them she was not going to the hospital. Resident #180 stated she would not die at the hospital she wanted to die at the facility. Resident #180 refused to go to the ER. RN U contacted Resident #180's family member and he stated to honor her wishes and she did not have to go to the hospital. RN U notified the doctor and noted she would monitor the patient every 15 minutes for 3 hours then every 30 minutes for 5 hours and every hour thereafter. [DATE] at 10:30 PM, late entry, LVN D documented Resident #180 returned from the ER at this time. Resident #180 was awake and appeared a little lethargic, [TRUNCATED]

Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) and 1 of 1 medication storage room reviewed for pharmacy services. 1. The facility failed to ensure Resident #45's hospital discharge orders were reconciled accurately to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) after his discharge on [DATE] which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and hyperglycemia (elevated blood sugar at 926) on [DATE]. 2. The facility failed to ensure Resident #127 received his Vesicare as ordered after being admitted on [DATE]. 3. The facility failed to ensure Resident #179 was administered his antidepressant, antianxiety and pain medications timely on [DATE] and [DATE]. 4. The facility failed to ensure Resident #36's Sertraline (anxiety), Keppra (seizures), Diltiazem (anti-hypertension), Hydralazine (anti-hypertension) were administered at the prescribed time. 5. The facility failed to ensure Resident #9's Lisinopril (ant- hypertension), Trazadone (insomnia), Atorvastatin (hyperlipidemia), Clonazepam (anxiety), and Valproate Sodium Solution (bipolar and depression) were administered at the prescribed time. 6. The facility failed to ensure Resident #57's antihypertensive, antidepressant, anticoagulant, antihyperlipidemic, diuretic, supplemental and pain medications during [DATE]-[DATE] were provided timely. 7. The facility failed to ensure Resident #71's blood pressure met the parameters for the administration of an anti-hypertensive medication. 8. The facility failed to ensure Resident #44 received the ordered Cephalexin an antibiotic medication to treat her urinary tract infection timely. 9. The facility failed to ensure Resident #41 received the ordered weight loss supplement to treat weight loss timely. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on [DATE] at 5:10 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 10. The facility failed to discard 9 bottles of We Care Enema Saline laxative expired on ,d+[DATE] in the medication storage room on [DATE]. These failures could place residents at risk of serious harm, not receiving their medications as ordered, illnesses, hospitalization s, exacerbation of their disease processes, coma, and death. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #45 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and type 2 diabetes mellitus with ketoacidosis without coma (chronic condition that affects the way the body processes blood sugar resulting in high blood sugars). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #45 was rarely/never understood and sometimes understood others. Resident #45 required supervision for eating and substantial/maximal assistance with shower/bathe self, upper body dressing, and personal hygiene. The MDS assessment did not indicate Resident #45 received insulin. Record review of the care plan last revised [DATE] indicated Resident #45 had diabetes and would refuse his blood sugars and insulin at times. The goal was for Resident #45 to have no complications related to diabetes through the review date. Interventions included Diabetes medication as ordered by doctor, blood sugar checks as ordered by doctor, if infection is present, consult doctor regarding any changes in diabetic medications. Record review of the Order Summary Report dated [DATE]-[DATE] did not indicate orders for Resident #45's Lantus (long-acting insulin used to lower blood sugars), Humalog (short acting used to lower blood sugars) Farxiga 10 mg (used to control high blood sugar) daily, or Augmentin 875 mg-125 mg (antibiotic). Record review of Resident #45's [DATE] MAR indicated: Farxiga 10 mg one tablet by mouth in the morning discontinued on [DATE]. Farxiga was administered from [DATE]-[DATE]. Check blood sugar at bedtime for hyper/hypoglycemia (high or low blood sugars) discontinued on [DATE]. [DATE] blood sugar was 239, [DATE] blood sugar was 169, [DATE] blood sugar was 210, [DATE] blood sugar was 266, [DATE] blood sugar was 209, [DATE] blood sugar was 345, [DATE] blood sugar was 434, [DATE] blood sugar was 190, [DATE] blood sugar was 134, [DATE] blood sugar was 258, [DATE] blood sugar was 324, [DATE] blood sugar was 106, [DATE] blood sugar check refused, [DATE] blood sugar was 315, [DATE] blood sugar was 120, [DATE] hospitalized . Lantus SoloStar Pen-injector 100 unit/ml inject 40 units subcutaneously (under the skin) every morning discontinued [DATE] [DATE] medication not given due to low blood sugar, [DATE] administered, [DATE] administered, [DATE] not administered due to low blood sugar, [DATE]-[DATE] administered, [DATE] not administered due to low blood sugar, [DATE]-[DATE] administered, [DATE] not administered due to low blood sugar, [DATE] administered, [DATE] medication refused. Fasting Blood Sugar twice a day discontinued [DATE]. 6:30 AM [DATE] blood sugar was 66, [DATE] blood sugar was 175, [DATE] blood sugar was 163, [DATE] blood sugar was 72, [DATE] blood sugar was 72, [DATE] blood sugar was 220, [DATE] blood sugar was 201, [DATE] blood sugar was 180, [DATE] blood sugar was 88, [DATE] blood sugar was 118, [DATE] blood sugar was 107, [DATE] blood sugar was 134, [DATE] blood sugar was 79, [DATE] blood sugar was 58, [DATE] blood sugar was 88, [DATE] refused. 4:30 PM [DATE] blood sugar was 148, [DATE] blood sugar was 367, [DATE] blood sugar was 328, [DATE] blood sugar was 293, [DATE] resident sleeping , [DATE] blood sugar was 198, [DATE] blood sugar was 148, [DATE] blood sugar was 249, [DATE] blood sugar was 242, [DATE] blood sugar was 235, [DATE] blood sugar was 102, [DATE] refused, [DATE] blood sugar was 71, [DATE] blood sugar was 268, [DATE] blood sugar was 290, [DATE] resident sleeping. Humalog Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units 450 and greater give the 12 units and call MD, subcutaneously before meals may only use 3 times a day discontinue date [DATE]. Humalog was administered per sliding scale from [DATE]-[DATE]. Record review of Resident #45's February 2024 MAR did not indicate the administration of Farxiga, Lantus or Humalog. Resident #45's February 2024 MAR did not indicate his blood sugar was checked. Record review of Resident #45's progress notes from [DATE]-[DATE] indicated: [DATE] at 11:00 AM Resident #45 was transferred to the behavioral hospital. Documented by LVN HHH. The progress notes did not include documentation of Resident #45's readmission on [DATE] or that Resident #45's orders were reconciled with the Medical Director. The progress notes did not include documentation regarding Resident #45's discontinuation of his insulins or blood sugar checks. [DATE] at 1:05 PM, CNA reported Resident #45 was not acting like his normal self. Upon entering residents room resident was found lethargic lying horizontally across the bed, eyes looked glossy, resident's speech was incoherent, he was clammy upon touch. Blood pressure was ,d+[DATE], heart rate 86, oxygen saturation 96%, respirations 18, temperature 98.7 F, fingerstick blood sugar too high to read. NP was notified and order was given to send to the ER for evaluation. 1:20 PM 911 contacted for transport 1:25 PM report given to the RN in the ER. EMS arrived on the seen fingerstick blood sugar per EMS was 568. 1:43 PM residents responsible party was notified 2:20 PM the DON and the AIT were notified. Documented by LVN RRR. Record review of the Readmission Nurses' Note effective date [DATE] completed by LVN W on [DATE] indicated Resident #45 was readmitted to the facility on [DATE] the area for blood glucose indicated if not diabetic enter N/A (not applicable), N/A was documented. There was no documentation to indicate Resident #45's orders were reconciled with the Medical Director. Record review of Resident #45's Discharge Medication Summary for Patient (in bold) dated [DATE] indicated do not continue these medications at home (noted in big letters across the page) Lantus (also known as insulin glargine) 100 units/ml 40 units under skin once daily, Namenda (also known as memantine used to treat confusion related to Alzheimer's) 10 mg twice a day, Farxiga (also known as dapagliflozin used to treat high blood glucose) 10 mg once daily. The Discharge Medication Summary for Patient continued Medications to take after discharge (in bold letters at the top of the page) buspirone (also known as buspar dividose medication for anxiety) 30 mg twice a day, Trileptal (also known as oxcarbazepine used to treat mood disorders) 150 mg twice a day, Zoloft (also known as sertraline used to treat depression) 100 mg once daily, Desyrel (also known as trazadone used to treat insomnia) 25 mg at bedtime as needed. The behavioral hospitals discharge papers for Resident #45 continued Discharge/Aftercare Instructions-Nursing (bold print at the top of the page): amoxicillin-clavulanate (antibiotic) 875 mg-125 mg 1 tablet by mouth every 12 hours buspirone (anxiety medication) 30 mg by mouth twice daily donepezil (used to treat confusion related to Alzheimer's disease) 10 mg by mouth every hour of sleep Farxiga 10 mg by mouth daily Ferrous sulfate (iron supplement) 325 mg by mouth daily Glucagon injectable (raises blood sugar when it is low) 1 mg intramuscular (in the muscle) injection every 1 hour for blood glucose less than 70 and not able to drink orange juice Humalog per sliding scale subcutaneously before meals Lantus 10 units subcutaneously every hour of sleep Namenda 10 mg by mouth daily Multivitamin 1 tablet by mouth daily Zoloft 100 mg by mouth daily Desyrel 25 mg by mouth every hour of sleep as needed Trilepta 300 mg by mouth twice daily Vitamin B-12 500 mcg by mouth daily Tylenol 650 mg by mouth every 8 hours for pain or fever Mylanta (used to treat upset stomach, heartburn and indigestion) 30 ml by mouth every 6 hours as needed. During an observation and interview on [DATE] at 8:45 PM, Resident #45 was in the hospital in the ICU resting in his hospital bed. Resident #45 was unable to answer questions appropriately. Resident #45's nurse at the hospital said he was awaiting transfer to the medical surgical floor but there were no beds available. Resident #45's nurse said when he arrived to the ER they had to obtain his blood glucose level by a blood specimen due to it not reading on the hospital glucometer. Resident #45's blood glucose level was 929. Resident #45's nurse said when he arrived at the ER he was not alert, he was lethargic and it had taken him ,d+[DATE] hours to return to his baseline (normal). Resident #45 was being administered Humalog and Lantus during his hospitalization . Record review of Resident #45's undated hospital medical records indicated he admitted on [DATE] arrived to the ER via EMS from the local nursing home due to altered mental status and elevated glucose. In the emergency room his blood glucose was in excess of 900. Resident #45 had other metabolic abnormalities and was worrisome for UTI. The nursing home staff reported that Resident #45 had been out of his insulin for 1 month because the medication was on backorder. The nursing home staff said there was no replacement for his insulin since that time. Resident #45's problem list included acute metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), hyperosmolar hyperglycemic state (life threatening complication of diabetes characterized by severe high blood glucose, extreme dehydration and altered consciousness), sepsis (condition as a result of an infection that can lead to organ failure and death if not treated quickly), urinary tract infection, volume depletion (blood plasma is too low and causes rapid heartbeat, weak pulse, confusion and loss of consciousness), lactic acidemia (too much lactic acid buildup in the body), acute kidney injury on chronic kidney disease, hypernatremia (high sodium levels), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), atrial fibrillation with rapid ventricular response (rapid, irregular heartbeat). During an interview on [DATE] at 11:14 AM, ADON S said when residents came back from a hospitalization , they were readmitted into the computer system. ADON S said the admitting nurse was responsible for reconciliating the admitting medication orders with the medical director, and the ADONS looked over them to ensure accuracy. ADON S said she was responsible for monitoring the orders for Halls 1 and 2, ADON WW was responsible for Halls 3 and 4, and the secured unit was split between the 2 of them. ADON S said it was important to accurately reconcile the admitting orders to ensure the medications were correct, allergies were discussed, and to discuss with the doctor new medication orders and dosages and ensure the administration times were appropriate. ADON S said if medications were not accurately reconciled upon admission residents could miss a scheduled medication. During an interview on [DATE] at 11:25 AM, the DON said when a resident readmitted to the facility the nurses should call the doctor to reconcile medications with him. The DON said the orders were then reviewed the next day in the morning meetings to double check the residents received the right medications. The DON said the ADONs and herself were responsible for reviewing the orders the day after a resident admitted . The DON said generally ADON S was responsible for checking the orders the day after a resident's admission. The DON said it was important for the medications to be reconciled on admission to ensure the residents received the proper medications and were getting what was necessary and to keep the residents safe. The DON said if medications were not reconciled appropriately this could lead to the residents not receiving the necessary medications. The DON said she was not familiar with Resident #45. During an interview on [DATE] at 11:42 AM, the NP said Resident #45 had been a resident at the facility for quite some time. The NP said she was aware he was diabetic, and she thought he had readmitted to the facility in [DATE], but she could not recall for sure. The NP said she had not spoken to the nurses upon his readmission to the facility. The Medical Director was the one notified of his readmission. The NP said the facility notified her of the issue with Resident #45's insulin this week. The NP said when a resident readmitted to the facility the nurses were supposed to call the Medical Director or herself with the changes and ask if they wanted to reconcile and continue previous orders and what changes should be made. The NP said a lot of times the hospital or the behavioral health units will stop residents' insulin because they do not want to take the risk of hypoglycemia (low blood sugars). The NP said if medications were not reconciled appropriately on admission residents could not get medications that they would need, and this could lead to hyperglycemia (high blood sugars), hypertension (high blood pressure) depending on the disease process. The NP said not receiving necessary medications could lead to exacerbation of the residents' disease processes. During an attempted interview on [DATE] at 11:49 AM, ADON WW did not answer the phone. During an interview on [DATE] at 12:21 PM, the Administrator said he expected for the nurses to follow the discharge orders. The Administrator said he had only been at the facility for about a week, and typically the IDT in the morning meetings reviewed the admissions orders together the day after a resident admitted to ensure the orders were correct and so multiple eyes could verify the orders were correct. The Administrator said in other places the DON and ADON were responsible for reviewing orders after a resident's admission, but he was not sure at the facility what the process was. The Administrator said it was important for the medication orders to be reconciled upon a resident's admission to ensure they were getting the correct medications to treat the diagnoses that the residents had. During an interview on [DATE] at 12:26 PM, Pharmacist XX said when a resident was out of the facility past midnight, the residents' medication orders were discontinued. Pharmacist XX said when the resident returned to the facility there was a renew button in the computer system that the nurses clicked and then they could reconciliate the residents' previous orders with the new orders. Pharmacist XX said once the orders were reconciliated they were transmitted, and medications sent out to the facility. During an interview on [DATE] at 12:33 PM, LVN W said she was aware Resident #45 was diabetic. LVN W said she had done part of the readmission orders for Resident #45. LVN W said there were no orders for Resident #45's insulin, and she had questioned the orders and notified the Medical Director, but he provided instructions to not restart Resident #45's insulin at that time because his blood sugars were running low, and he was not eating much. LVN W said the Medical Director had not given orders to monitor blood sugars, and she had asked him, but he said no. LVN W said to be honest Resident #45 was not acting like he was having problems with his blood sugars. LVN W said he was active and did not think he required blood sugar checks. LVN W said she had called the behavioral unit to ask them about the insulin orders and the nurse that had given her report said they had been holding Resident #45's insulin because he was not eating. LVN W said she had not seen Resident #45's insulin orders on his discharge paperwork. LVN W said it was important for medications to be reviewed and reconciled upon a resident's admission because if a mistake was made the residents would not get medications they required. LVN W said more than one person should have reviewed Resident #45's orders upon his admission because she was human and could miss things. LVN W said Resident #45 not receiving his insulin could hurt his kidneys and liver. LVN W said she had placed Resident #45's orders in the file box for the ADON to review the orders and to audit them. LVN W said she assumed the ADON was the one responsible for reviewing the medications orders, but there had been a lot of changes and there were other people also reviewing the orders. During an interview on [DATE] at 3:33 PM, the Area Director of Operations said her expectations when a resident admitted to the facility were for the nurses to follow the physician orders, review the hospital records and put in the medications order and review the medication orders with the physician. The Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on [DATE] at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no constancy, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said then there was the human factor, and if they had ,d+[DATE] loose links it destroyed everything. The Medical Director said he was at the facility almost every night spending hours trying to figure out mistakes with medication management issues. The Medical Director said staffing had become a big challenge for the facility that they had major staffing issues. The Medical Director said the staffing shortage was contributing to the falls, worsening wounds, nutrition issues, medication administration issues. The Medical Director said he reconciled the orders with the nurses on admission by phone call because he was not always in the facility when a resident admitted . The Medical Director said with Resident #45 nursing had miscommunicated the information regarding his insulin orders to him. The Medical Director said he was not aware that both of Resident #45's insulins (the short acting and long acting) had been stopped. The Medical Director said stopping both insulins resulted in Resident #45 having high blood sugars, which could lead to severe dehydration and a coma. The Medical Director said he was not able to physically look at the discharge orders from the behavioral health unit. The Medical Director said Resident #45's blood sugars should have been checked three times a day because he was diabetic. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. During an interview on [DATE] at 3:26 PM, the Pharmacy Consultant said she preferred not to answer general questions regarding the risks of administering medications late or the effects of not administering insulin, and she was not currently in her office, so she had no access to resident information. During an attempted interview on [DATE] at 5:02 PM, LVN RRR did not answer the phone. During an interview on [DATE] at 5:32 PM, the DON said the reconciliation for Resident #45 was not done properly. The DON said there was confusion with the discharge orders, and the nurse should have made sure the reconciliation of meds was done properly when Resident #45 readmitted . The DON said she was not employed at the facility when Resident #45 readmitted . The DON said when residents were readmitted /admitted the nurse reconciled the orders with the physician and then the orders would be reviewed in the morning meeting by nurse management. The DON said medications not being reconciled properly could lead to exacerbation of conditions and injury to the residents. Record review of the EvenCare G2 blood glucose monitoring system's user guide indicated on page 50 a HI(high) reading on the glucometer was seen it means your blood glucose if above 600. 2. Record review of a face sheet dated [DATE] indicated Resident #127 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of dementia, and overactive bladder. Record review of the admission papers dated [DATE] provided by the Resident #127's primary physician indicated Resident #127 had an overactive bladder requiring medication management. Resident #127's active medication regimen provided included Vesicare (Solifenacin) 5 milligrams daily with a start date of [DATE] (active medication). Record review of the February 2024 Medication Administration Record indicated Solifenacin Succinate (Vesicare) oral tablet 5 milligrams daily was ordered on [DATE] and discontinued on [DATE] with no administrations provided to Resident #127. Record review of the Admission MDS dated [DATE] indicated Resident #127 was understood and understands others. The Admission MDS indicated Resident #127 had moderate cognitive impairment. The MDS indicated Resident #127 was occasionally incontinent of urine. Record review of the Order Summary Report dated [DATE] failed to include the medication Vesicare on the facility orders. Record review of the Comprehensive Care Plan dated [DATE] failed to indicate Resident #127 had an overactive bladder requiring medication management or his occasional incontinence. During an observation and interview on [DATE] at 3:56 p.m., Resident #127 was sitting in the dining room/ day room with his peers. Resident #127 was unsure if he was taking any medications for his overactive bladder. 3. Record review of a face sheet dated [DATE] indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 had pain almost constantly and it frequently interfered with his ability to sleep. The MDS assessment indicated Resident #179 received antianxiety, antidepressant, and opioids in the last 7 days. Record review of the care plan last revised on [DATE] indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 had a potential for uncontrolled pain to evaluate pain interventions. The care plan indicated Resident #179 was on pain medication therapy to administer medications as ordered. Record review of the Order Summary Report dated [DATE] indicated Resident #179 had the following medication orders: Buspirone (medication for anxiety) 15 mg give 1 tablet via g-tube two times a day with a start date of [DATE]. Trazodone 50 mg (medication for depression) give 1 tablet via g-tube two times a day with a start date of [DATE]. Pregabalin (medication for nerve pain) 75 mg give 1 capsule via g-tube three times a day with a start date of [DATE]. Hydrocodone (pain medication) ,d+[DATE] mg give 1 tablet via g-tube four times a day with a start date of [DATE]. Gabapentin (medication for nerve pain) 100 mg give 1 capsule via g-tube three times a day with a start date of [DATE]. Record review of Resident #179's medication administration audit report dated [DATE]-[DATE] indicated the following: On [DATE] the following medications were scheduled to be received at 8:00 PM were administered over 6 hours late, after the 1-hour grace period: Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 3:58 AM Gabapentin 100 mg give 1 capsule via g-tube three times a day administered at 5:33 AM Trazodone 50 mg give 1 tablet via g-tube two times a day administered at 5:33 AM Hydrocodone ,d+[DATE] mg give 1 tablet via g-tube four times a day for pain administered at 5:33 AM On [DATE] the following medications were scheduled to be received at 8:00 PM were administered over 1 hour late, after the 1-hour grace period: Hydrocodone ,d+[DATE] mg give 1 tablet via g-tube four times a day for pain administered at 10:28 PM Buspirone 15 mg give 1 tablet via g-tube two times a day administered at 10:28 PM Trazadone 50 mg give 1 tablet via g-tube two times a day administered at 10:29 PM Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 1:26 AM During an interview on [DATE] at 10:46 AM, Resident #179 said his night medications were due at 8 PM and sometimes he was not receiving them until midnight. Resident #179 said he had asked the nurses about his medications being administered late, and they had said it was because they were short staffed on the night shift. 4. Record review of Resident #36's face sheet dated [DATE], indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar disorder, current episode depressed, severe, without psychotic features (depressed, as in severe depressive episode without psychotic symptoms, and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past) hypertension (when the pressure in your blood vessels is to high (,d+[DATE]mmhg or higher), heart failure (progressive disease that affects pumping action of the heart muscle), type 2 Diabetes Mellitus (a disease of inadequate control of blood levels of glucose) other seizures (convulsion, sensory disturbance, or loss of consciousness). Record review of Resident #36's a care plan with dated [DATE], indicated Resident #36 had the following problems: *Resident #36 had hypertension (high blood pressure) with interventions to give antihypertensive medications as ordered and to monitor for side effects such as orthostatic hypotension (blood pressure drops after sitting or lying down) and increased heart rate. *Resident #36 had diabetes mellitus (high blood sugar) with interventions to give medications as ordered and to monitor for side effects. *Resident #36 required antidepressant medications (Doxepin and Zoloft) with interventions to administer medications as ordered by the physician. Resident #36 had a potential for pain and took routine pain medications (Tylenol with Codeine) with interventions to administer medications as per orders. Record review of Resident # 36's Quarterly MDS assessment dated [DATE], indicated Resident #36 was understood and was able to understand others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 had received antidepressant, and insulin dur [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 9 of 24 residents (Resident #9, Resident #36, Resident #41, Resident #44, Resident #45, Resident #57, Resident #71, Resident #127 and Resident #179) residents reviewed for medication errors. 1. The facility failed to ensure Resident #45's hospital discharge orders were implemented to include his Lantus (long-acting insulin used to lower blood sugar) 10 units every hour of sleep, Humalog (short acting insulin used to lower blood sugar) per sliding scale before meals, Farxiga 10 mg (used to control high blood sugar) daily, and Augmentin 875 mg-125 mg (antibiotic) every 12 hours after his discharge on 01/29/2024 which resulted in his hospitalization for metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and hyperglycemia (elevated blood sugar at 926) on 02/25/2024. 2. The facility failed to ensure Resident #127 received his Vesicare as ordered after being admitted on [DATE]. 3. The facility failed to ensure Resident #179 was administered his antidepressant, antianxiety and pain medications timely. 4. The facility failed to ensure Resident #36's Sertraline (anxiety), Keppra (seizures), Diltiazem (anti-hypertension), Hydralazine (anti-hypertension) were administered at the prescribed time. 5. The facility failed to ensure Resident #9's Lisinopril (ant- hypertension), Trazadone (insomnia), Atorvastatin (hyperlipidemia), Clonazepam (anxiety), and Valproate Sodium Solution (bipolar and depression) were administered at the prescribed time. 6. The facility failed to ensure Resident #57's antihypertensive, antidepressant, anticoagulant, antihyperlipidemic, diuretic, supplemental and pain medications during 02/01/2024-02/27/2024 were provided timely. 7. The facility failed to ensure Resident #71's blood pressure met the parameters for the administration of an anti-hypertensive medication. 8. The facility failed to ensure Resident #44 received the ordered Cephalexin an antibiotic medication to treat her urinary tract infection timely. 9. The facility failed to ensure Resident #41 received the ordered weight loss supplement to treat weight loss timely. An Immediate Jeopardy (IJ) situation was identified on 02/28/2024 at 3:50 PM. The IJ template was provided to the facility on [DATE] at 4:19 PM. While the IJ was removed on 03/01/2024 at 5:10 PM, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents who require medications administered by the facility at risk of not receiving their medications as ordered, illness, hospitalization s, exacerbation of their disease processes, and death. Findings included: 1. Record review of a face sheet dated 02/28/2024 indicated Resident #45 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and type 2 diabetes mellitus with ketoacidosis without coma (chronic condition that affects the way the body processes blood sugar resulting in high blood sugars). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #45 was rarely/never understood and sometimes understood others. Resident #45 required supervision for eating and substantial/maximal assistance with shower/bathe self, upper body dressing, and personal hygiene. The MDS assessment did not indicate Resident #45 received insulin. Record review of the care plan last revised 10/20/2023 indicated Resident #45 had diabetes and would refuse his blood sugars and insulin at times. The goal was for Resident #45 to have no complications related to diabetes through the review date. Interventions included Diabetes medication as ordered by doctor, blood sugar checks as ordered by doctor, if infection is present, consult doctor regarding any changes in diabetic medications. Record review of the Order Summary Report dated 01/01/2024-02/29/2024 did not indicate orders for Resident #45's Lantus (long-acting insulin used to lower blood sugars), Humalog (short acting used to lower blood sugars) Farxiga 10 mg (used to control high blood sugar) daily, or Augmentin 875 mg-125 mg (antibiotic). Record review of Resident #45's January 2024 MAR indicated: o Farxiga 10 mg one tablet by mouth in the morning discontinued on 01/27/2024. Farxiga was administered from 01/01/2024-01/16/2024. o Check blood sugar at bedtime for hyper/hypoglycemia (high or low blood sugars) discontinued on 01/27/2024. 01/1/2024 blood sugar was 239, 01/02/2024 blood sugar was 169, 01/03/2024 blood sugar was 210, 01/04/2024 blood sugar was 266, 01/05/2024 blood sugar was 209, 01/06/2024 blood sugar was 345, 01/07/2024 blood sugar was 434, 01/08/2024 blood sugar was 190, 01/09/2024 blood sugar was 134, 01/10/2024 blood sugar was 258, 01/11/2024 blood sugar was 324, 01/12/2024 blood sugar was 106, 01/13/2024 blood sugar check refused, 01/14/2024 blood sugar was 315, 01/15/2024 blood sugar was 120, 01/16/2024 hospitalized . o Lantus SoloStar Pen-injector 100 unit/ml inject 40 units subcutaneously (under the skin) every morning discontinued 01/27/2024 01/01/2024 medication not given due to low blood sugar, 01/02/2024 administered, 01/03/2024 administered, 01/04/2024 not administered due to low blood sugar, 01/05/2024-01/08/2024 administered, 01/09/2024 not administered due to low blood sugar, 01/10/2024-01/13/2024 administered, 01/14/2024 not administered due to low blood sugar, 01/15/2024 administered, 01/16/2024 medication refused. o Fasting Blood Sugar twice a day discontinued 01/27/2024. 6:30 AM 01/1/2024 blood sugar was 66, 01/02/2024 blood sugar was 175, 01/03/2024 blood sugar was 163, 01/04/2024 blood sugar was 72, 01/05/2024 blood sugar was 72, 01/06/2024 blood sugar was 220, 01/07/2024 blood sugar was 201, 01/08/2024 blood sugar was 180, 01/09/2024 blood sugar was 88, 01/10/2024 blood sugar was 118, 01/11/2024 blood sugar was 107, 01/12/2024 blood sugar was 134, 01/13/2024 blood sugar was 79, 01/14/2024 blood sugar was 58, 01/15/2024 blood sugar was 88, 01/16/2024 refused. 4:30 PM 01/1/2024 blood sugar was 148, 01/02/2024 blood sugar was 367, 01/03/2024 blood sugar was 328, 01/04/2024 blood sugar was 293, 01/05/2024 resident sleeping , 01/06/2024 blood sugar was 198, 01/07/2024 blood sugar was 148, 01/08/2024 blood sugar was 249, 01/09/2024 blood sugar was 242, 01/10/2024 blood sugar was 235, 01/11/2024 blood sugar was 102, 01/12/2024 refused, 01/13/2024 blood sugar was 71, 01/14/2024 blood sugar was 268, 01/15/2024 blood sugar was 290, 01/16/2024 resident sleeping. o Humalog Injection Solution 100 unit/ml Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units 450 and greater give the 12 units and call MD, subcutaneously before meals may only use 3 times a day discontinue date 01/27/2024. Humalog was administered per sliding scale from 01/01/2024-01/16/2024. Record review of Resident #45's February 2024 MAR did not indicate the administration of Farxiga, Lantus or Humalog. Resident #45's February 2024 MAR did not indicate his blood sugar was checked. Record review of Resident #45's progress notes from 12/29/2023-02/29/2024 indicated: o 01/16/2024 at 11:00 AM Resident #45 was transferred to the behavioral hospital. Documented by LVN HHH. o The progress notes did not include documentation of Resident #45's readmission on 01/29/2024 or that Resident #45's orders were reconciled with the Medical Director. The progress notes did not include documentation regarding Resident #45's discontinuation of his insulins or blood sugar checks. o 02/25/2024 at 1:05 PM, CNA reported Resident #45 was not acting like his normal self. Upon entering residents room resident was found lethargic lying horizontally across the bed, eyes looked glossy, resident's speech was incoherent, he was clammy upon touch. Blood pressure was 128/76, heart rate 86, oxygen saturation 96%, respirations 18, temperature 98.7 F, fingerstick blood sugar too high to read. NP was notified and order was given to send to the ER for evaluation. 1:20 PM 911 contacted for transport 1:25 PM report given to the RN in the ER. EMS arrived on the seen fingerstick blood sugar per EMS was 568. 1:43 PM residents responsible party was notified 2:20 PM the DON and the AIT were notified. Documented by LVN RRR. Record review of the Readmission Nurses' Note effective date 01/29/2024 completed by LVN W on 01/30/2024 indicated Resident #45 was readmitted to the facility on [DATE] the area for blood glucose indicated if not diabetic enter N/A (not applicable), N/A was documented. There was no documentation to indicate Resident #45's orders were reconciled with the Medical Director. Record review of Resident #45's Discharge Medication Summary for Patient (in bold) dated 01/29/2024 indicated do not continue these medications at home (noted in big letters across the page) o Lantus (also known as insulin glargine) 100 units/ml 40 units under skin once daily, o Namenda (also known as memantine used to treat confusion related to Alzheimer's) 10 mg twice a day, o Farxiga (also known as dapagliflozin used to treat high blood glucose) 10 mg once daily. The Discharge Medication Summary for Patient continued Medications to take after discharge (in bold letters at the top of the page) o buspirone (also known as buspar dividose medication for anxiety) 30 mg twice a day, o Trileptal (also known as oxcarbazepine used to treat mood disorders) 150 mg twice a day, o Zoloft (also known as sertraline used to treat depression) 100 mg once daily, o Desyrel (also known as trazadone used to treat insomnia) 25 mg at bedtime as needed. The behavioral hospitals discharge papers for Resident #45 continued Discharge/Aftercare Instructions-Nursing (bold print at the top of the page): o amoxicillin-clavulanate (antibiotic) 875 mg-125 mg 1 tablet by mouth every 12 hours o buspirone (anxiety medication) 30 mg by mouth twice daily o donepezil (used to treat confusion related to Alzheimer's disease) 10 mg by mouth every hour of sleep o Farxiga 10 mg by mouth daily o Ferrous sulfate (iron supplement) 325 mg by mouth daily o Glucagon injectable (raises blood sugar when it is low) 1 mg intramuscular (in the muscle) injection every 1 hour for blood glucose less than 70 and not able to drink orange juice o Humalog per sliding scale subcutaneously before meals o Lantus 10 units subcutaneously every hour of sleep o Namenda 10 mg by mouth daily o Multivitamin 1 tablet by mouth daily o Zoloft 100 mg by mouth daily o Desyrel 25 mg by mouth every hour of sleep as needed o Trilepta 300 mg by mouth twice daily o Vitamin B-12 500 mcg by mouth daily o Tylenol 650 mg by mouth every 8 hours for pain or fever o Mylanta (used to treat upset stomach, heartburn and indigestion) 30 ml by mouth every 6 hours as needed. During an observation and interview on 02/28/2024 at 8:45 PM, Resident #45 was in the hospital in the ICU resting in his hospital bed. Resident #45 was unable to answer questions appropriately. Resident #45's nurse at the hospital said he was awaiting transfer to the medical surgical floor but there were no beds available. Resident #45's nurse said when he arrived to the ER they had to obtain his blood glucose level by a blood specimen due to it not reading on the hospital glucometer. Resident #45's blood glucose level was 929. Resident #45's nurse said when he arrived at the ER he was not alert, he was lethargic and it had taken him 24-48 hours to return to his baseline (normal). Resident #45 was being administered Humalog and Lantus during his hospitalization . Record review of Resident #45's undated hospital medical records indicated he admitted on [DATE] arrived to the ER via EMS from the local nursing home due to altered mental status and elevated glucose. In the emergency room his blood glucose was in excess of 900. Resident #45 had other metabolic abnormalities and was worrisome for UTI. The nursing home staff reported that Resident #45 had been out of his insulin for 1 month because the medication was on backorder. The nursing home staff said there was no replacement for his insulin since that time. Resident #45's problem list included acute metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), hyperosmolar hyperglycemic state (life threatening complication of diabetes characterized by severe high blood glucose, extreme dehydration and altered consciousness), sepsis (condition as a result of an infection that can lead to organ failure and death if not treated quickly), urinary tract infection, volume depletion (blood plasma is too low and causes rapid heartbeat, weak pulse, confusion and loss of consciousness), lactic acidemia (too much lactic acid buildup in the body), acute kidney injury on chronic kidney disease, hypernatremia (high sodium levels), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), atrial fibrillation with rapid ventricular response (rapid, irregular heartbeat). During an interview on 02/28/2024 at 11:14 AM, ADON S said when residents came back from a hospitalization , they were readmitted into the computer system. ADON S said the admitting nurse was responsible for reconciliating the admitting medication orders with the medical director, and the ADONS looked over them to ensure accuracy. ADON S said she was responsible for monitoring the orders for Halls 1 and 2, ADON WW was responsible for Halls 3 and 4, and the secured unit was split between the 2 of them. ADON S said it was important to accurately reconcile the admitting orders to ensure the medications were correct, allergies were discussed, and to discuss with the doctor new medication orders and dosages and ensure the administration times were appropriate. ADON S said if medications were not accurately reconciled upon admission residents could miss a scheduled medication. During an interview on 02/28/2024 at 11:25 AM, the DON said when a resident readmitted to the facility the nurses should call the doctor to reconcile medications with him. The DON said the orders were then reviewed the next day in the morning meetings to double check the residents received the right medications. The DON said the ADONs and herself were responsible for reviewing the orders the day after a resident admitted . The DON said generally ADON S was responsible for checking the orders the day after a resident's admission. The DON said it was important for the medications to be reconciled on admission to ensure the residents received the proper medications and were getting what was necessary and to keep the residents safe. The DON said if medications were not reconciled appropriately this could lead to the residents not receiving the necessary medications. The DON said she was not familiar with Resident #45. During an interview on 02/28/2024 at 11:42 AM, the NP said Resident #45 had been a resident at the facility for quite some time. The NP said she was aware he was diabetic, and she thought he had readmitted to the facility in October 2023, but she could not recall for sure. The NP said she had not spoken to the nurses upon his readmission to the facility. The Medical Director was the one notified of his readmission. The NP said the facility notified her of the issue with Resident #45's insulin this week. The NP said when a resident readmitted to the facility the nurses were supposed to call the Medical Director or herself with the changes and ask if they wanted to reconcile and continue previous orders and what changes should be made. The NP said a lot of times the hospital or the behavioral health units will stop residents' insulin because they do not want to take the risk of hypoglycemia (low blood sugars). The NP said if medications were not reconciled appropriately on admission residents could not get medications that they would need, and this could lead to hyperglycemia (high blood sugars), hypertension (high blood pressure) depending on the disease process. The NP said not receiving necessary medications could lead to exacerbation of the residents' disease processes. During an attempted interview on 02/28/2024 at 11:49 AM, ADON WW did not answer the phone. During an interview on 02/28/2024 at 12:21 PM, the Administrator said he expected for the nurses to follow the discharge orders. The Administrator said he had only been at the facility for about a week, and typically the IDT in the morning meetings reviewed the admissions orders together the day after a resident admitted to ensure the orders were correct and so multiple eyes could verify the orders were correct. The Administrator said in other places the DON and ADON were responsible for reviewing orders after a resident's admission, but he was not sure at the facility what the process was. The Administrator said it was important for the medication orders to be reconciled upon a resident's admission to ensure they were getting the correct medications to treat the diagnoses that the residents had. During an interview on 02/28/2024 at 12:26 PM, Pharmacist XX said when a resident was out of the facility past midnight, the residents' medication orders were discontinued. Pharmacist XX said when the resident returned to the facility there was a renew button in the computer system that the nurses clicked and then they could reconciliate the residents' previous orders with the new orders. Pharmacist XX said once the orders were reconciliated they were transmitted, and medications sent out to the facility. During an interview on 02/28/2024 at 12:33 PM, LVN W said she was aware Resident #45 was diabetic. LVN W said she had done part of the readmission orders for Resident #45. LVN W said there were no orders for Resident #45's insulin, and she had questioned the orders and notified the Medical Director, but he provided instructions to not restart Resident #45's insulin at that time because his blood sugars were running low, and he was not eating much. LVN W said the Medical Director had not given orders to monitor blood sugars, and she had asked him, but he said no. LVN W said to be honest Resident #45 was not acting like he was having problems with his blood sugars. LVN W said he was active and did not think he required blood sugar checks. LVN W said she had called the behavioral unit to ask them about the insulin orders and the nurse that had given her report said they had been holding Resident #45's insulin because he was not eating. LVN W said she had not seen Resident #45's insulin orders on his discharge paperwork. LVN W said it was important for medications to be reviewed and reconciled upon a resident's admission because if a mistake was made the residents would not get medications they required. LVN W said more than one person should have reviewed Resident #45's orders upon his admission because she was human and could miss things. LVN W said Resident #45 not receiving his insulin could hurt his kidneys and liver. LVN W said she had placed Resident #45's orders in the file box for the ADON to review the orders and to audit them. LVN W said she assumed the ADON was the one responsible for reviewing the medications orders, but there had been a lot of changes and there were other people also reviewing the orders. During an interview on 02/28/2024 at 3:33 PM, the Area Director of Operations said her expectations when a resident admitted to the facility were for the nurses to follow the physician orders, review the hospital records and put in the medications order and review the medication orders with the physician. The Area Director of Operations said she was a consultant for the facility. The Area Director of Operations said she was there as a resource for the facility administration to reach out to her with assistance regarding the policies and procedures. The Area Director of Operations said the administrators were responsible for the facility that is why when one administrator left an interim was put in place. The Area Director of Operations said she did not provide oversight for the facility that was the administrators responsibility because she had 10 other facilities she was over. The Area Director of Operations said she made sure the facilities were in the green and monitored their spending to help them reach their financial goals. During an interview on 02/28/2024 at 9:24 PM, the Medical Director said there had been at least 5 administrators and half a dozen DONs and several ADONs in the past year. The Medical Director said there was no constancy, and the staff were unfamiliar with the residents and left often, which resulted in difficulty maintaining staff stability. The Medical Director said then there was the human factor, and if they had 1-2 loose links it destroyed everything. The Medical Director said he was at the facility almost every night spending hours trying to figure out mistakes with medication management issues. The Medical Director said staffing had become a big challenge for the facility that they had major staffing issues. The Medical Director said the staffing shortage was contributing to the falls, worsening wounds, nutrition issues, medication administration issues. The Medical Director said he reconciled the orders with the nurses on admission by phone call because he was not always in the facility when a resident admitted . The Medical Director said with Resident #45 nursing had miscommunicated the information regarding his insulin orders to him. The Medical Director said he was not aware that both of Resident #45's insulins (the short acting and long acting) had been stopped. The Medical Director said stopping both insulins resulted in Resident #45 having high blood sugars, which could lead to severe dehydration and a coma. The Medical Director said he was not able to physically look at the discharge orders from the behavioral health unit. The Medical Director said Resident #45's blood sugars should have been checked three times a day because he was diabetic. The Medical Director said amongst all the changes in administrators and DONs he did not know who was supposed to be keeping the facility together to prevent system failures, but he knew the Area Director of Operations was one of the major decision makers. During an interview on 03/02/2024 at 3:26 PM, the Pharmacy Consultant said she preferred not to answer general questions regarding the risks of administering medications late or the effects of not administering insulin, and she was not currently in her office, so she had no access to resident information. During an attempted interview on 03/02/2024 at 5:02 PM, LVN RRR did not answer the phone. During an interview on 03/02/2024 at 5:32 PM, the DON said the reconciliation for Resident #45 was not done properly. The DON said there was confusion with the discharge orders, and the nurse should have made sure the reconciliation of meds was done properly when Resident #45 readmitted . The DON said she was not employed at the facility when Resident #45 readmitted . The DON said when residents were readmitted /admitted the nurse reconciled the orders with the physician and then the orders would be reviewed in the morning meeting by nurse management. The DON said medications not being reconciled properly could lead to exacerbation of conditions and injury to the residents. Record review of the EvenCare G2 blood glucose monitoring system's user guide indicated on page 50 a HI(high) reading on the glucometer was seen it means your blood glucose if above 600. 2. Record review of a face sheet dated 3/02/2024 indicated Resident #127 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of dementia, and overactive bladder. Record review of the admission papers dated 2/09/2024 provided by the Resident #127's primary physician indicated Resident #127 had an overactive bladder requiring medication management. Resident #127's active medication regimen provided included Vesicare (Solifenacin) 5 milligrams daily with a start date of 1/05/2024 (active medication). Record review of the February 2024 Medication Administration Record indicated Solifenacin Succinate (Vesicare) oral tablet 5 milligrams daily was ordered on 2/12/2024 and discontinued on 2/27/2024 with no administrations provided to Resident #127. Record review of the Admission MDS dated [DATE] indicated Resident #127 was understood and understands others. The Admission MDS indicated Resident #127 had moderate cognitive impairment. The MDS indicated Resident #127 was occasionally incontinent of urine. Record review of the Order Summary Report dated 3/02/2024 failed to include the medication Vesicare on the facility orders. Record review of the Comprehensive Care Plan dated 2/13/2024 failed to indicate Resident #127 had an overactive bladder requiring medication management or his occasional incontinence. During an observation and interview on 2/26/2024 at 3:56 p.m., Resident #127 was sitting in the dining room/ day room with his peers. Resident #127 was unsure if he was taking any medications for his overactive bladder. 3. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), congenital insufficiency of aortic valve (heart defect that prevents blood from flowing backward through the heart), neuromuscular dysfunction of the bladder (condition where a person lacks bladder control due to brain, spinal cord, or nerve problems), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #179's speech was unclear, was sometimes able to make himself understood, and understood others. The MDS assessment indicated Resident #179 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #179 was dependent on staff for all ADLs. The MDS assessment indicated Resident #179 had pain almost constantly and it frequently interfered with his ability to sleep. The MDS assessment indicated Resident #179 received antianxiety, antidepressant, and opioids in the last 7 days. Record review of the care plan last revised on 02/23/2024 indicated Resident #179 required antidepressant medication to give medications as ordered. The care plan indicated Resident #179 had a potential for uncontrolled pain to evaluate pain interventions. The care plan indicated Resident #179 was on pain medication therapy to administer medications as ordered. Record review of the Order Summary Report dated 02/26/2024 indicated Resident #179 had the following medication orders: Buspirone (medication for anxiety) 15 mg give 1 tablet via g-tube two times a day with a start date of 02/23/2024. Trazodone 50 mg (medication for depression) give 1 tablet via g-tube two times a day with a start date of 02/14/2024. Pregabalin (medication for nerve pain) 75 mg give 1 capsule via g-tube three times a day with a start date of 02/25/2024. Hydrocodone (pain medication) 10-325 mg give 1 tablet via g-tube four times a day with a start date of 02/13/2024. Gabapentin (medication for nerve pain) 100 mg give 1 capsule via g-tube three times a day with a start date of 02/13/2024. Record review of Resident #179's medication administration audit report dated 02/01/2024-02/27/2024 indicated the following: On 02/25/2024 the following medications were scheduled to be received at 8:00 PM were administered over 6 hours late, after the 1-hour grace period: Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 3:58 AM Gabapentin 100 mg give 1 capsule via g-tube three times a day administered at 5:33 AM Trazodone 50 mg give 1 tablet via g-tube two times a day administered at 5:33 AM Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 5:33 AM On 02/26/2024 the following medications were scheduled to be received at 8:00 PM were administered over 1 hour late, after the 1-hour grace period: Hydrocodone 10-325 mg give 1 tablet via g-tube four times a day for pain administered at 10:28 PM Buspirone 15 mg give 1 tablet via g-tube two times a day administered at 10:28 PM Trazadone 50 mg give 1 tablet via g-tube two times a day administered at 10:29 PM Pregabalin 75 mg give 1 capsule via g-tube three times a day administered at 1:26 AM During an interview on 02/26/2024 at 10:46 AM, Resident #179 said his night medications were due at 8 PM and sometimes he was not receiving them until midnight. Resident #179 said he had asked the nurses about his medications being administered late, and they had said it was because they were short staffed on the night shift. 4. Record review of Resident #36's face sheet dated 02/27/2024, indicate Resident # 36 was a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis which include Metabolic Encephalopathy (a problem in the brain), morbid severe obesity due to excess calories (BMI greater than 40, a BMI of greater than 35 with at least one serious obesity-related condition, or being more than 100 pounds over your recommended weight), abnormal posture (rigid body movements and chronic abnormal positions of the body), muscle weakness (commonly due to lack of exercise, aging, muscle injury) chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing-related problems). Bipolar disorder, current episode depressed, severe, without psychotic features (depressed, as in severe depressive episode without psychotic symptoms, and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past) hypertension (when the pressure in your blood vessels is to high (140/90mmhg or higher), heart failure (progressive disease that affects pumping action of the heart muscle), type 2 Diabetes Mellitus (a disease of inadequate control of blood levels of glucose) other seizures (convulsion, sensory disturbance, or loss of consciousness). Record review of Resident #36's a care plan with dated 02/26/2024, indicated Resident #36 had the following problems: *Resident #36 had hypertension (high blood pressure) with interventions to give antihypertensive medications as ordered and to monitor for side effects such as orthostatic hypotension (blood pressure drops after sitting or lying down) and increased heart rate. *Resident #36 had diabetes mellitus (high blood sugar) with interventions to give medications as ordered and to monitor for side effects. *Resident #36 required antidepressant medications (Doxepin and Zoloft) with interventions to administer medications as ordered by the physician. Resident #36 had a potential for pain and took routine pain medications (Tylenol with Codeine) with interventions to administer medications as per orders. Record review of Resident # 36's Quarterly MDS assessment dated [DATE], indicated Resident #36 was understood and was able to understand others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 had received antidepressant, and insulin during the 7-day look back period. Record review of Resident #36's order summary dated 02/27/2024, indicated Resident #36 should have received: *Aspirin 8

Based interview, and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 11 residents (Resident #44) reviewed for abuse. The facility failed to thoroughly investigate when Resident #44 was found to have a large bruise to her right inner thigh measuring 17 centimeters x approximately 11 centimeters that was painful on 6/21/2023. The facility failed to thoroughly investigate when Resident #44 was transferred to the local emergency room and found to have a new fracture and dislocation of the right trochanter (hip joint) on 6/21/2023. An IJ was identified on 3/01/2024. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 3/01/2024, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having allegations of abuse, neglect or exploitation investigated properly to prevent re-occurrence. Findings Included: Record review of a face sheet dated 2/27/2024 indicated Resident #44 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness, reduced mobility, anxiety disorder. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was sometimes understood and usually understands others. The MDS indicated Resident #44 was unable to complete her BIMS exam due to her cognition. The MDS indicated Resident #44 had inattention and disorganized thinking being continuously present. The MDS indicated Resident #44 had no behavioral symptoms but wandered 1-3 days during the assessment period. The MDS indicated Resident #44 required extensive assistance of two staff for transfers, and extensive assistance of one staff member for bed mobility, and locomotion on and off the unit. The MDS indicated Resident #44 had a history of falls with fractures within the last 6 months. Record review of the comprehensive care plan dated 12/13/2023 and updated on 1/07/2024 indicated Resident #44 was at risk to fall related to unsteady gait/balance, generalized weakness, and poor safety awareness. The care plan indicated Resident #44 was at risk to wander related to a history of attempts to leave the facility related to poor safety awareness and resides on the secured unit. Record review of a Weekly Skin assessment dated [DATE] and documented by LVN CCC, indicated Resident #44's skin was normal with no bruising. The note indicated Resident #44's had a surgical incision to the right hip with staples and steri-strips in place with no drainage and no signs of infection. Record review of a Fall Nurses Note dated 6/12/2023 and documented by LVN YY indicated Resident #44 had a fall with a bump on the right side of her head. Record review of a Weekly Skin assessment dated [DATE] documented by LVN DDD, indicated Resident #44's skin was normal with no bruising. Record review of a SBAR note dated 6/18/2024 documented by LVN YY indicated Resident #44 had swelling and pain to the right hip replacement. The note indicated Resident #44 was ordered a mild pain reliever and an x-ray to the right hip. Record review of a right hip x-ray dated 6/19/2023 indicated Resident #44's prosthetic right femoral head (hip joint) was in proper alignment. Resident #44's x-ray revealed there were no fractures or acute dislocation. The x-ray indicated Resident #44's prothesis was properly situated without any loosing. The x-ray conclusion indicated the right hip arthroplasty (hip restoration) was intact. Record review of a progress note dated 6/21/2023 at 6:15 a.m., LVN YY documented Resident #44 had a bruise to the inner thigh on the right leg measuring 17 centimeters x approximately 11 centimeters with pain. LVN YY noted she administered a mild pain reliever to Resident #44. Record review of an Event Nurses' note dated 6/21/2023 at 6:15 a.m., LVN YY documented a bruise was found to Resident #44's right inner thigh measuring 17 centimeters x approximately 11 centimeters. The note indicated Resident #44's bruise was blue/purple and painful. LVN YY documented Resident #44 could not provide a statement related to her cognitive impairment. LVN YY said previous factors included previous falls. Record review of an incident note dated 6/21/2023 documented by LVN YY indicated Resident #44 had a large purple bruise on her inner right thigh (front) measuring 17 centimeters x approximately 11 centimeters. LVN YY said Resident #44 was unable to state what had happened. LVN YY documented there were no predisposing environmental factors, and the predisposing physiological factor was Resident #44 had memory impairment. Record review of a Weekly Skin assessment dated [DATE] indicated Resident #44 skin color was normal, temperature was normal, with a large purple bruise to the right inner thigh with a firm center with bruising to her knee. Record review of a Consultation note dated 6/21/2023 indicated the orthopedic physician documented he knew Resident #44. The physician said he had treated her femoral neck fracture(connection between the ball of the hip and the femur bone) a month previous. The physician wrote he had seen Resident #44 a week ago and the x-rays showed a well-fitted well-fixed bipolar hip. The physician wrote he had plans to surgically repair Resident #44's right hip by removing the prothesis, wire her with cables then reimplant the prothesis and then put a plate and screws with wires and screws around the periprosthetic fracture. During an interview on 2/29/2024 at 11:42 a.m., LVN YY said she was notified of Resident #44's by CNA K. LVN YY said she assessed and measured the bruising and notified the physician, family, DON, and Administrator (previous). LVN YY said she was unsure how Resident #44 sustained the bruise and unsure why no one else had seen the bruise. During an interview on 2/29/2024 at 3:22 p.m., CNA K said she had found the bruising to Resident #44's right leg and reported to LVN YY. CNA K said while she was providing incontinent care for Resident #44, she moved the pillow between Resident #44's legs when she found a large purple bruise. During an interview on 2/29/2023 at 3:40 p.m., the DON said she was not the DON during the incident on 6/21/2023 with Resident #44 but she indicated she would have investigated and report the bruising. During an interview on 03/01/2024 at 8:52 AM, previous Administrator ZZ said she always did an investigation when something was reported to her but depending on her investigation if she reported. Administrator ZZ said if she had not reported the incident with Resident #44's bruising/hip fracture it had to be for a reason. Administrator ZZ said she did not remember the specifics off the top of her head, and she kept a soft file in the administrator's office with her investigations . The soft file was not could not be located. Administrator ZZ said a bruise that was not correlated with an incident was considered an injury of unknown injury and should be reported within 2 hours of finding it or being notified. Record review of an Abuse/Neglect policy dated 3/29/2018 indicated the resident had a right to be free from abuse, neglect, misappropriation of property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and /or Abuse Preventionist within 24 hours of complaint. Appropriate notification to the state and home office will be the responsibility of the administrator and per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect, the facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. This was determined to be an Immediate Jeopardy (IJ) on 3/01/2024 at 11:05 a.m. The facility Administrator and assistant Administrator were notified. The Administrator was provided with the IJ templates on 3/01/2024 at 11:05 a.m. The facility's plan of removal was accepted on 03/01/2024 at 11:01 AM and included the following: Facility: Date: 3/1/24 Problem: Failure to thoroughly Investigate Abuse Interventions: 1. A head-to-toe skin assessment was completed on resident #44 on 3/1/24 by the Charge Nurse. No additional issues were noted. 2. A pain assessment was completed on resident #44 on 3/1/24 by the Charge Nurse. No pain was voiced. 3. All residents in the facility have had a head-to-toe assessment completed as of 3/1/24 by the DON, ADON, and Charge Nurses. No signs or symptoms of injuries of unknow origin noted. 4. The Administrator and DON were in-serviced 1:1 on the Provider Letter and the Abuse/Neglect Policy by the Area Director of Operation on 3/1/24. The in-service included reporting injuries of unknown origin and conducting a thorough investigation. 5. A review of the Abuse and Neglect policy was reviewed by Corporate Management on 3/1/24. The policy included reporting and investigating events of abuse and neglect. No changes have been made to the policy. 6. The Medical Director was notified of the immediate jeopardy situation on 3/1/24 by the Administrator. 7. An ADHOC QAPI meeting was completed with QA committee to include the Medical Director on 3/1/24. 8. The following in-services were initiated by the Administrator, DON, and Regional Compliance Nurse as of 3/1/24 for all staff. All staff not present on 3/1/24 will be in-serviced prior to the start of next shift. All new hires will be in-serviced during orientation. All agency staff will be in-serviced prior to the start of their shift. Abuse and Neglect Policy to include reporting any signs of injury such as bruising, redness, swelling and pain. All allegations of abuse must be reported to the Administrator who is the abuse coordinator. In the absence of the administrator, allegations of abuse must be reported to the DON. On 03/01/2024 the surveyor conformed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Weekly Skin Assessment, dated 02/27/2024, revealed Resident #44 had a bruise to the right side of her forehead, which measured 2 cm x 3.3 cm. The assessment further revealed a bruise to her right forearm, which measured 3.5 cm x 2.1 cm. Record review of the pain assessment was completed for Resident #44, and she received a mild pain reliever acetaminophen 325 milligrams give two tablets every 4 hours as needed for pain. Record review of the skin assessments, completed on 02/27/2024, revealed no injuries of unknown origin. Record review of the In Service Training Attendance Roster, dated 03/01/2024 , revealed the Administrator and DON were provided education on the abuse and neglect policy, procedure, and the long-term care regulatory provider letter on abuse, neglect, exploitation, misappropriation of resident property, and other incidents that a nursing facility must report to the Health and Human Services Commission. During an interview on 3/01/2024 at 1:23 p.m., the Administrator said he expected all allegations of abuse, neglect to be reported to him promptly to ensure he had enough time to initiate an investigation to include when he called the allegation to the state agency. The Administrator said the alleged perpetrator would be suspended during the investigation. The Administrator said he in the past had used reviewing bath sheets, incident and accidents as a way to evaluate areas concerning abuse and neglect. During an interview on 3/01/2024 at 2:00 p.m., the DON said she expected the nurses to notify her and the Administrator with any injuries including bruises and fractures immediately. The DON said reporting immediately allows for a starting of an investigation to include when reporting to the state agency in the required time frame. Record review of the Off Cycle (ad hoc) QA Meeting Document, dated 02/01/2024, revealed an action plan was initiated and discussed. Record review of the In Service Training Attendance Roster, dated 03/01/2024, revealed LVN L, Cook M, the Administrator, MDS Coordinator N, SNA O, SNA P, DA UU, LVN Q, MDS Coordinator R, ADON S, the Marketing Coordinator, the Maintenance Supervisor, Housekeeper T, DA W, RN U, CNA V, the Medical Records, LVN W, the HR Coordinator, CNA K, CNA X, CNA Y, CNA Z, the BOM, CNA BB, CNA CC, the DON, LVN F, the DOR, LVN AA, RN DD, CNA EE, the Social Worker, CNA H, LVN C, LVN FF, COTA GG, the DM, LA HH, Housekeeper KK, and MA LL had been in-serviced on the abuse and neglect policy, to include reporting resident injuries immediately. The in-service further revealed education was provided on reporting allegations of abuse immediately to the Administrator, who was the abuse coordinator. The in-service stated, In the absence of the administrator, allegations of abuse must be reported to the DON. During interviews on 03/01/2024 between 12:33 PM and 4:38 PM, LVN L, Cook M, the Administrator, MDS Coordinator N, SNA O, SNA P, DA UU, LVN Q, MDS Coordinator R, ADON S, the Marketing Coordinator, the Maintenance Supervisor, Housekeeper T, DA W, RN U, CNA V, the Medical Records, LVN W, the HR Coordinator, CNA K, CNA X, CNA Y, CNA Z, the BOM, CNA BB, CNA CC, the DON, LVN F, the DOR, LVN AA, RN DD, CNA EE, the Social Worker, CNA H, LVN C, LVN FF, COTA GG, the DM, LA HH, Housekeeper KK, and MA LL had been provided education on abuse and neglect policy, to include reporting injuries immediately. The staff further indicated allegations of abuse must be reported immediately to the Administrator, who was the abuse coordinator. The staff indicated in the absence of an administrator the DON was the abuse coordinator. On 03/01/2024 at 5:10 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 5 of 18 residents (Resident #30, Resident #1, Resident #2, Resident #12, and Resident #37) in the sample. The facility failed to ensure Resident #30 had replacement [CONDITION(S)] supplies (inner cannulas or [CONDITION(S)] tubes) in the facility or at the bedside and a bag valve mask (handheld device used to provide rescue breaths during cardiac pulmonary resuscitation) at the bedside. The facility failed to ensure Resident #2, Resident #12, Resident #1, and Resident #37's oxygen concentrator filters were cleaned for 4 days. The facility did not ensure Resident #37's oxygen tubing was change weekly. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 5:19 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as patterned due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The failure could place residents at risk of respiratory infection, respiratory distress, and death. Findings included: 1. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #30 was [AGE] years old, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #30 sometimes understood others and sometimes made herself understood. The MDS indicated Resident #30 had moderate cognitive impairment with a BIMS score of 08. the MDS indicated Resident #30 was independent with bed mobility, locomotion on and off the unit, walking in room and in the corridor, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #30 required special treatments of oxygen therapy, suctioning, and [CONDITION(S)] care. Record review of the care plan revised on [DATE] indicated Resident #30 had a [CONDITION(S)]. The care plan indicated interventions included keep an extra [CONDITION(S)] tube and obturator (is used to insert a [CONDITION(S)] tube. It fits inside the tube to provide a smooth surface that guides the [CONDITION(S)] tube when it is being inserted.) at bedside; if the tube is coughed out, open stoma with hemostat; if tube cannot be reinserted, monitor/document signs of respiratory distress; obtain medical help immediately. Record review of the nursing progress note dated [DATE] stated Resident returned from procedure (Flex [MEDICATION(S)], tracheal dilation) with no new orders and no documentation. Per family the physician reported she will need a [CONDITION(S)] the remaining of her life due to the stenosis (narrowing) descends further down the airway than anticipated. Record review of the nursing note date [DATE] stated, removed one side of strap on [CONDITION(S)], pt. did deep cough and [CONDITION(S)] came all the way out, cleaned with NS and gently applied lubricant and quickly got [CONDITION(S)] back in to prevent closure, [CONDITION(S)] site did have a little bleeding, ADON came to assist cleaning inner nasal cannula and was notified of situation. During an interview and observation on [DATE] at 11:36 a.m. LVN A was performing [CONDITION(S)] care on Resident #30. During [CONDITION(S)] care LVN A dropped inner cannula on the floor, picked it up, got a new [CONDITION(S)] kit, cleaned inner cannula that had been on the floor, and inserted into [CONDITION(S)]. LVN A said the facility did not have any [CONDITION(S)] replacement supplies for resident #30. LVN A said the inner cannulas and [CONDITION(S)] tubes in the facility were not compatible with Resident #30's [CONDITION(S)]. During an interview on [DATE] at 02:00 p.m. LVN A said Resident #30 would require rescue breathing via a bag valve mask through her [CONDITION(S)] in the event she needed cardiac pulmonary resuscitation. During an interview on [DATE] at 02:01 p.m. the DON said Resident #30 would require rescue breathing via a bag valve mask through her [CONDITION(S)] in the event she needed cardiac pulmonary resuscitation. During an interview and observation on [DATE] at 02:09 p.m. LVN A took the surveyor to the oxygen supply room to show there were no replacement supplies for Resident #30. LVN A verified after looking in oxygen supply room there were no [CONDITION(S)] replacement supplies in the facility for Resident #30. During an interview and observation on [DATE] at 02:19 p.m. LVN B took the surveyor to the oxygen supply room to show there were no replacement supplies for Resident #30. LVN B took the survey to Resident #30's room and verified there were no replacement supplies or bag valve mask at the bedside. During an interview on [DATE] at 03:02 p.m. LVN B said when she looked for replacement inner cannula there was not a replacement [CONDITION(S)] tube in the facility for Resident #30. LVN B said the only [CONDITION(S)] tube in the facility was a size 8 and resident's [CONDITION(S)] size was 6. LVN B said that a size 8 was not compatible with Resident #30 size 6 [CONDITION(S)] tube. During an interview on [DATE] at 03:15 p.m. RN C, Regional Director of Clinical Operations said she expected the facility to have emergency [CONDITION(S)] equipment at the Resident #30's bedside including a [CONDITION(S)] tube one size smaller than in the resident and a bag valve mask. During an interview on [DATE] at 3:26 p.m. LVN D said Resident #30's [CONDITION(S)] tube size was a 6. LVN D said there was not a replacement [CONDITION(S)] tube or inner cannula in the facility compatible with Resident #30's [CONDITION(S)] site. LVN D said she had received [CONDITION(S)] training at the facility. LVN D said the [CONDITION(S)] training included what emergency equipment should be at the bedside. LVN D said emergency [CONDITION(S)] equipment that should be at the bedside was an inner cannula, a [CONDITION(S)] tube the same size as in the resident, and bag valve mask, and oxygen. During an interview on [DATE] at 3:23 p.m., the DON said in the event of an emergency with Resident #30 that staff would immediately begin CPR via bag valve mask to her [CONDITION(S)]. The DON said she was under the impression that the facility had the correct size [CONDITION(S)] tubes and inner cannulas for Resident #30 in the facility. The DON said she was informed today they did not have the correct size [CONDITION(S)] tubes and inner cannulas in the facility for Resident #30. The DON said that the facility was finding emergency replacement equipment compatible with Resident #30's [CONDITION(S)] at this very moment. The DON said she expected an emergency replacement equipment including an inner cannula, [CONDITION(S)] tube, and bag valve mask to be at Resident #30's bedside. During an interview on [DATE] at 04:45 p.m. RT E said she had performed [CONDITION(S)] care training at the facility in [DATE]. RT E said she was not aware if the facility had a [CONDITION(S)] resident or not during when she gave the training. RT E said she informed the facility during training to keep at bedside at all times an inner cannula and replacement [CONDITION(S)] tube compatible with the resident's [CONDITION(S)] site for emergency circumstances. RT E said she recommended a bag valve mask being at bedside at all times. RT E said the replacement inner cannula and [CONDITION(S)] tube needs to be at bedside at all times because if the [CONDITION(S)] became occlude or came out the resident could die. 2. Record review of the consolidated physicians orders dated [DATE], indicated Resident #2 was [AGE] years old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not address cleaning the oxygen concentrator filters. Record review of the MDS dated [DATE], indicated Resident #2 made himself understood and understood others. The MDS indicated Resident #2 required extensive assistance with bed mobility, dressing, toileting and personal hygiene. The MDS indicated Resident #2 required extensive assistance with bed mobility, dressing, toileting and personal hygiene. The MDS indicated Resident #2 required oxygen. The MDS did not address cleaning oxygen concentrator filters. The MDS indicated Resident #2 had a BIMS (brief interview for mental status) score of 13 (Cognitively intact). The care plan dated [DATE] indicated Resident #2 had an ADL self-care performance deficit related to poor endurance, and weakness. The care plan indicated resident #2 required extensive assistance with transfers, toileting, personal hygiene, bathing, dressing and bed mobility. The care plan did not address Resident #2's oxygen. During an observation on [DATE] at 11:26 a.m., Resident #2's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:50 a.m., Resident #2's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:53 a.m., Resident #2's oxygen concentrator filter had a thin layer of dust. During an observation and interview on [DATE] at 9:30 a.m., Resident #2's oxygen concentrator filter had a thin layer of dust. Resident #2 was wearing his oxygen and said he was unaware if the staff changed or cleaned the filter on the concentrator or not. 3. Record review of the consolidated physicians' orders dated [DATE] indicated Resident #12 was [AGE] years old, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #12 required oxygen at 2 liters per nasal canula as needed for shortness of breath. Record review of the most recent MDS dated [DATE] indicated, Resident #12 made herself understood and understood others. The MDS indicated Resident #12 required supervision for transfers, dressing, eating, toileting and personal hygiene. The MDS did not address Resident #12's oxygen. The MDS indicated Resident #12 had a BIMS score of 8 (moderate cognitive impairment). Record review of the most recent care plan dated [DATE] indicated, Resident #12 had asthma and required oxygen as needed. The care plan did not address cleaning Resident #12's oxygen concentrator filters. During an observation on [DATE] at 11:28 a.m., Resident #12 was wearing her oxygen. Resident #12 said the staff changed the tubing to her oxygen weekly but she was unsure if they did anything with the filter. The oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 10:00 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:50 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:35 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. 4. During record review of the consolidated physicians' orders dated [DATE], indicated Resident #1 was [AGE] years old, admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During record review of the MDS dated [DATE] indicated Resident #1 made herself understood and understood others. The MDS indicated Resident #1 did not reject care. The MDS indicated Resident #1 required extensive assistance for bed mobility, transfers and eating. The MDS indicated Resident #1 required total dependence for dressing, toileting and personal hygiene. The MDS indicated Resident #1 required oxygen therapy. The MDS indicated Resident #1 required oxygen therapy. The care plan did not address cleaning the oxygen concentrator filter. The MDS indicated Resident #1 had a BIMS (brief interview for mental status) score of 9 (severe cognitive impairment). During record review of the care plan dated [DATE], indicated Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease process and physical limitations. The care plan indicated Resident #1 had a self-care performance deficit related to impaired cognition, and late effects of [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. The care plan indicated Resident #1 required extensive assistance of 1 to 2 staff members for bathing/showering, transfers and bed mobility. The care plan indicated Resident #1 required the extensive assistance of one staff member for personal hygiene. During an observation and interview on [DATE] at 11:23 a.m., Resident #1 was lying in bed with wearing her oxygen. Resident #1 said she did not know about the oxygen concentrator filters. Resident #1's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 11:00 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:55 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:55 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an observation on [DATE] at 9:25 a.m., Resident #12's oxygen concentrator filter had a thin layer of dust. During an interview on [DATE] at 9:45 a.m., RN G said oxygen concentrators were to be cleaned on the 10 p.m.- 6 a.m. shift by the charge nurses. RN said dirty oxygen concentrator filters could cause bacteria to buildup in the machine. During an interview on [DATE] at 9:55 a.m., LVN H said oxygen concentrator filters should be cleaned at least weekly and as needed. LVN H said she was an agency nurse and was unsure what the facilities exact policy was on cleaning the oxygen filters. She said dirty oxygen filters could cause a buildup that could break the oxygen concentrator or maybe even be a fire hazard. During an interview on [DATE] at 10:00 a.m., RN Q said charge nurses were responsible for ensuring the oxygen concentrator filters were clean. RN Q said dirty oxygen concentrator filters could cause the resident not to get adequate airflow. RN Q said the filters should be cleaned weekly. During an interview on [DATE] at 1:30 p.m., the DON said oxygen concentrator filters should be cleaned every Sunday. She said she and the assistant director of nurses were responsible for ensuring the filters were cleaned appropriately. The DON said she was not aware of any issues arising from the oxygen concentrator filters being dirty. During an interview on [DATE] at 2:45 p.m., the executive vice president of operations said he would divert questions regarding oxygen concentrators filters to the DON but said it would vary depending on how much the concentrator were being used. 5. Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #37 was [AGE] years old, readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated o2 (oxygen) at 2 liters via nasal cannula continuously (start date [DATE]). The orders indicated to change o2 tubing and H20 (water) on Sunday evening. (start date [DATE]). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #37 made herself understood and understood others. Resident #37 had a BIMS (brief interview for mental status) score of 13 which indicated Resident #37 was cognitively intact. The MDS indicated Resident #37 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #37 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing; supervision with eating. The MDS indicated Resident #37 had an impairment on one side of her upper extremity. The MDS indicated Resident #19 received oxygen therapy. Record review of the care plan revised on [DATE] indicated Resident #37 received oxygen therapy. Interventions: oxygen stings: 02 via nasal prongs at 2 liters per order. The care plan did not address the oxygen concentrator filter or the oxygen tubing. Record review of the licensed Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #37 oxygen tubing was changed, and initialed by the nurse on [DATE], [DATE] and [DATE]. During an observation and interview on [DATE] at 10:58 a.m., Resident #37 was lying in bed completing a word puzzle and oxygen was being used by the resident via nasal cannula. The oxygen concentrator filter was covered in a thick layer of dust. The oxygen concentrator tubing was dated [DATE] and the portable oxygen tubing was dated [DATE]. During the observation Resident #37 was using the oxygen concentrator nasal tubing. Resident #37 said she used her oxygen all the time due to shortness of breath. During an observation on [DATE] at 3:10 p.m., Resident #37 was sitting in her wheelchair watching t.v. and oxygen was being used by the resident via nasal cannula. The oxygen concentrator filter was covered in a thick layer of dust. The oxygen concentrator tubing was dated [DATE] and the portable oxygen tubing was dated [DATE]. During the observation Resident #37 was using the oxygen concentrator nasal tubing. During an observation on [DATE] at 9:50 a.m., Resident #37 was lying in bed completing a word puzzle and oxygen was being used by the resident via nasal cannula. The oxygen concentrator filter was covered in a thick layer of dust. The oxygen concentrator tubing was dated [DATE] and the portable oxygen tubing was dated [DATE]. During the observation Resident #37 was using the oxygen concentrator nasal tubing. Resident #37 said she used her oxygen all the time due to shortness of breath. During an observation on [DATE] at 2:30 p.m., Resident #37 was sitting in her wheelchair completing a word puzzle and oxygen was being used by the resident via nasal cannula. The oxygen concentrator filter was covered in a thick layer of dust. The oxygen concentrator tubing was dated [DATE] and the portable oxygen tubing was dated [DATE]. During the observation Resident #37 was using the portable oxygen concentrator nasal tubing. During an observation and interview on [DATE] at 2:45 p.m., LVN P said the night nurse on Sunday nights were responsible for ensuring that filters were clean, and the nasal cannula tubing was changed and dated. LVN P observed Resident #37 oxygen concentrator tubing dated [DATE] and the portable oxygen tubing dated [DATE]. LVN P said it was important for the nasal cannula tubing to be changed weekly to prevent bacteria from entering the resident. During an interview on [DATE] at 10:52 a.m., Agency LVN H said the night nurse on Sunday nights were responsible for ensuring that filters were clean, and the nasal cannula tubing was changed and dated. Agency LVN H said it was important for oxygen concentrator filters to be clean to prevent dirt and bacteria from entering the nasal cannula and it keep the concentrator functioning. Agency LVN H said it was important for nasal cannula tubing to be changed weekly and dated to prevent a respiratory infection. During an interview on [DATE] at 1:07 p.m., RN G said the night nurse on Sunday nights were responsible for ensuring that filters were clean, and the nasal cannula tubing was changed and dated. RN G said it was important for oxygen concentrator filters to be clean and nasal cannula tubing to be changed weekly to prevent bacteria from entering the lungs and put Resident #37 at risk for a respiratory infection. During an interview on [DATE] at 1:36 p.m., the DON would not give the surveyor an exact day or shift that the filter should be cleaned, or nasal cannula tubing changed and dated. The DON said the charge nurse is responsible for ensuring that filters were clean, and the nasal cannula tubing was changed and dated. The DON said she was not aware of any issues arising from the oxygen concentrator filters being dirty. During an interview on [DATE] at 1:52 p.m. the Regional Vice President said the night nurse on Sunday nights were responsible for ensuring that filters were clean, and the nasal cannula tubing was changed and dated. The regional vice president said it was important for oxygen concentrator filters to be clean and nasal cannula tubing to be changed weekly to prevent bacteria from entering the lungs and put Resident #37 potentially at risk for a respiratory infection. During an interview on [DATE] at 3:31 p.m., the DON said there was no policy and procedure regarding oxygen concentrator filter or oxygen nasal tubing. Record review of [CONDITION(S)] Care Instructions dated [DATE] provided by the facility stated, .For safety, you should always have a spare [CONDITION(S)] tube that is the same size and type as the one currently in the neck available . Record review of https://opentextbc.ca/clinicalskills/chapter/,d+[DATE]-tracheostomies/ accessed on [DATE] indicated, .Emergency supplies at the bedside must include the following: 1. Suction equipment 2. Oxygen equipment with humidification 3. An emergency bag containing (see Figure 10.3): · Two replacement [CONDITION(S)] tubes (one of the same size, and one a smaller size than the current tube) · Obturator and spare inner cannula · 10 ml syringe · Tracheal tube exchanger · Tracheal dilators · Sterile gloves · Water-soluble lubricant · If the open stoma is below the sternal notch, an endotracheal tube as per the ENT physician . The administrator was notified on [DATE] at 05:19 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on [DATE] at 05:25 p.m. The facility's Plan of Removal was accepted on [DATE] at 02:19 p.m. and included: Resident #30 was assessed on [DATE] @ 7:00pm by a License nurse and found to be stable with vitals of T-97.8 P 76- R 16- BP ,d+[DATE]-, [CONDITION(S)] Shiley 6mm permanent non-disposable inner locking cannula in place and stable with O2 saturation of 100% on room air. No distress noted. Bag valve mask bag place / stored at bedside on [DATE] @ 19:00pm by the license nurse. Replacement [CONDITION(S)] kits of Shiley 4mm and Shiley 6mm permanent non-disposable inner locking cannula obtained and placed at bedside on [DATE] at 19:45 by the Interim Director of Nursing Services. Director of Clinical Education provided education to license nurses currently working at 19:45 regarding the expectations to ensure and maintain replacement [CONDITION(S)] kits and bag valve mask at bedside that are compatible with current inner cannula. License nurses to receive education prior to beginning shift any license nurse who has not received education will not be allowed to start work without completion of education prior to clocking in. 67% of the nurses have been educated regarding having the correct equipment at bedside for the resident. A focused QAPI meeting addressing the finding was initiated and completed on [DATE] with the attendance of the Administrator, Interim DNS, Director of Clinical Operations and Medical Director. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews of nursing staff (3-nurses on the 06:00 a.m.-02:00 p.m. shift; 3-nurses on the 08:00 a.m.-05:00 p.m. shift; 3-nurses on the 02:00 p.m.-10:00 p.m. shift; 2-nurses on the 10:00 p.m.-06:00 a.m.) were performed. During these interviews' nurses stated correctly what the correct replacement [CONDITION(S)] equipment was, where it was placed, and that it should not be removed from the bedside or Resident #30's room. During an observation [DATE] at 02:49 p.m. the appropriate emergency [CONDITION(S)] equipment was at Resident #30's bedside. On [DATE] at 03:52 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance no at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 3 of 7 residents reviewed for pressure injuries. (Resident #s 1, 2, and 3) 1.The facility did not assess Resident #1's skin weekly and did not complete thorough wound assessments of Resident #1's wounds to her coccyx, left heel, medial left foot and right heel. 2.The facility did not complete thorough wound assessments of Resident #2's stage 2 pressure injury to her right buttock and a DTI to her right heel. The facility did not update Resident #2's treatment orders to her right buttock pressure injury. 3.The facility did not assess Resident #3's skin weekly and did not complete wound assessments of Resident #3's stage 2 pressure injury to his right buttock. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1.A face sheet dated 07/21/21 for Resident #1 indicated she was [AGE] years old, admitted on [DATE], and discharged to a local hospital on 07/18/21. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set, dated dated dated [DATE] for Resident #1 indicated she had severe cognitive impairment, usually understood others, and usually made her needs known. She required extensive assistance of 1 to 2 staff with ADLs. Resident #1 was incontinent of bowel and bladder. Resident #1 was at risk for developing pressure injuries and had no unhealed pressure injuries. A Braden scale for predicting pressure sore risk dated 06/01/21 for Resident #1 indicated she was at moderate risk for developing pressure injuries. A care plan last revised on 06/04/21 for Resident #1 indicated she was at risk for impairment to her skin integrity due to decreased mobility and incontinence. Care plan interventions included to keep the resident's skin clean and dry, encourage good nutrition and hydration, and reposition frequently. Resident #1's care plan indicated she required extensive assistance of 1 to 2 staff with ADLs. The care plan did not address Resident #1's wounds. A weekly skin assessment dated [DATE], completed by RN A, for Resident #1 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A nursing note dated 06/29/21 at 6:29 a.m., written by LVN J, for Resident #1 indicated the nurse noted an open area to the resident's left gluteal cleft (area at the bottom of the spine where the buttocks split) that measured 3.0x1.3x0.2 cm with smooth wound edges. The surrounding skin of the wound was red, thickened, and blanchable and a dry dressing was placed over the area. The oncoming nurse and treatment nurse were notified. A nursing note dated 06/29/21 at 2:35 p.m., written by RN A, for Resident #1 indicated an assessment was completed to her coccyx and buttocks. A stage 2 wound was noted to the resident's coccyx and a shear was noted to the resident's right buttock. The area was cleaned with normal saline and [MEDICATION(S)] and anti-fungal ointment was applied. An order was received for daily treatment. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly skin assessment dated [DATE] for Resident #1 was blank. During an interview on 07/21/21 at 2:15 p.m., LVN B said Resident #1 had a wound to her coccyx and left buttock, not her right buttock. Dietary recommendations dated 07/06/21 for Resident #1 included to add a multivitamin and liquid protein. Review of clinical records for Resident #1 from 06/29/21 to 07/07/21 indicated there was no wound assessment. A nursing note dated 07/08/21 at 7:42 p.m., written by LVN K, for Resident #1 indicated the resident had an open area to her left buttock and sacrum. The area was cleaned and covered with a dry dressing. The oncoming nurse would be notified to notify the treatment nurse. A wound assessment dated [DATE], completed by RN A, for Resident #1 indicated she had a stage 2 pressure injury to her coccyx. The evaluation did not include measurements, description, presence of drainage, presence of odor, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #1 included a picture dated 07/08/21 of the resident's stage 2 coccyx pressure injury. The picture indicated Resident #1's coccyx wound had slough (yellow dead tissue) in the wound bed and the wound extended to the left buttock. A shower sheet dated 07/10/21 for Resident #1 indicated CNA C drew a circle and an arrow pointing at the circle on the coccyx area of the body figure and documented .it has gotten worse reported to [LVN B]. During an interview on 07/21/21 at 12:59 p.m., CNA C said she did not remember the date, but she reported Resident #1's coccyx wound to LVN B when it was really red and started to turn brown. She said she had to spread the resident's buttocks apart to see the wound. She said the wound started off as a tiny black dot and they were applying barrier cream. CNA C said she was off for several days and when she came back Resident #1's coccyx wound had worsened. She said Resident #1 was repositioned with pillows and was checked for incontinence every 2 hours. She said Resident #1 ate well and liked to drink milk. A nursing note dated 07/10/21 at 1:20 p.m., written by LVN B, for Resident #1 indicated the resident was noted with a deep wound to her coccyx that measured 5.0x4.0x1.0 cm and the treatment nurse was aware. During an interview on 07/21/21 at 2:15 p.m., LVN B said CNA F notified her of Resident #1's worsening coccyx wound on 07/10/21. She said the treatment nurse was aware of the wound. LVN B said she documented the measurements in a nursing note. She said Resident #1's wound had slough and eschar in the wound bed and the treatment was a barrier cream with no dressing. She said there was redness to Resident #1's left buttock. LVN B said she did not remember if the wound had odor or drainage. LVN B said RN A was the treatment nurse and completed skin and wound assessments. During an interview on 07/21/21 at 4:17 p.m., CNA F said Resident #1's coccyx wound was seen only when her buttocks were spread. She said when she first saw Resident #1's wound, it looked like a spider bite and she reported it to RN A. She said about 2 days later the wound opened up and she reported the wound to LVN B. CNA F said the nurses were applying cream to the wound and the wound had an odor and drainage. She said Resident #1 ate well and drank milk. A nursing note dated 07/10/21 at 4:17 p.m., LVN L, for Resident #1 indicated the resident was lethargic with labored breathing. Resident #1's oxygen saturation was 94% on 2 liters of oxygen, respirations were 22 breaths a minute, blood pressure was 126/72, and pulse was 78 beats a minute. Resident #1's physician and son were notified of the change of condition and the resident was sent to the hospital for evaluation. Hospital discharge orders dated 07/11/21 for Resident #1 indicated she was diagnosed with pneumonia and ordered an antibiotic. The discharge orders did not address Resident #1's wounds. A nursing note dated 07/11/21 at 2:55 p.m., written by LVN E, for Resident #1 indicated the resident returned to the facility from the hospital. A head to toe assessment was completed with no abnormalities noted. During an interview on 07/21/21 at 4:03 p.m., LVN E said she was working when Resident #1 returned from the hospital on 07/11/21. She said she completed a head to toe skin assessment on Resident #1 and did not observe any wounds. She said she may not have spread the resident's buttocks apart when she was performing the assessment. Review of clinical records for Resident #1 dated 07/11/21 indicated there was no skin assessment. A wound assessment dated [DATE], completed by RN A, for Resident #1 indicated she had an open lesion to her right buttock (left) that measured 4.4x2.5x0.8 cm. The evaluation did not include a description, presence of drainage, presence of odor, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The evaluation included a note indicating Resident #1's right buttock (left) wound increased in depth and area and progressed to a stage 3 wound. Review of clinical records for Resident #1 included a picture dated 07/12/21 of the resident's stage 2 coccyx pressure injury. The picture indicated Resident #1's coccyx wound had slough covering the wound bed and the wound extended to the left buttock. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound evaluation dated 07/13/21 by the wound physician for Resident #1 indicated Resident #1 had a stage 4 pressure injury to her sacrum for at least 5 days that measured 5.0x3.0 cm and the depth was not measurable. Resident #1's pressure injury had moderate serous drainage and the wound was surgically debrided (removal of necrotic tissue). Treatment orders indicated to apply collagen power and [MEDICATION(S)] gel daily and cover with a border dressing for 30 days. Resident #1 had a shear to her left buttock for at least 5 days that measured 6.0x5.5x0.1 cm with moderate serous drainage. Treatment orders for Resident #1's left buttock shear included collagen power and [MEDICATION(S)] gel daily and cover with a border dressing for 30 days. During an interview on 07/27/21 at 4:38 p.m., Resident #1's wound physician said he saw Resident #1 on 07/13/21 for the first time for her wounds on her coccyx and buttock. He said he went to the facility every Tuesday and the treatment nurse or another nurse made rounds with him. He said the facility normally made a referral to him when a wound was worsening or not healing. He said he assessed and measured wounds and made changes to the current treatment. He said he documented Resident #1's coccyx and left buttock wounds as 2 separate wounds. He said he may have had a hard time seeing the wound bed of the coccyx wound but classified it as a stage 4. He said the facility could do better with their referrals instead of waiting until the wounds have deteriorated so much. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound assessment dated [DATE], completed by RN A, for Resident #1 indicated she had an unstageable pressure injury to her left heel with an unknown date of development. Resident #1's left heel pressure injury measured 3.7x3.9 cm with 100% eschar (dead tissue that is dark in color). The evaluation did not include the presence of drainage, presence of odor, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #1 included a picture dated 07/16/21 of the resident's unstageable left heel wound. The picture indicated Resident #1's left heel pressure injury had necrotic tissue covering the wound bed. A wound assessment dated [DATE], completed by RN A, for Resident #1 indicated she had an unstageable pressure injury to her medial left foot with an unknown date of development. Resident #1's medial left foot pressure injury measured 2.9x2.9 cm with 100% eschar, light bloody drainage, and no odor. The evaluation did not include the presence of drainage, presence of odor, or treatment orders for Resident #1's medial left foot pressure injury. Review of clinical records for Resident #1 included a picture dated 07/16/21 of the resident's unstageable medial left foot wound. The picture indicated Resident #1's medial left foot pressure injury had necrotic tissue covering the wound bed. During an interview on 07/21/21 at 4:17 p.m., CNA F said on 07/16/21 Resident #1 had a wound to her left heel and left inner foot. She said she had not seen the wounds before but there was a dressing covering the wound on her left inner foot. She said RN A also saw both wounds to Resident #1's left foot and the dressing covering the left inner foot wound. CNA F said RN A told her that she (RN A) did not apply the dressing and nobody reported the wound to her (RN A). During an interview on 07/21/21 at 3:16 p.m., CNA M said she did not know Resident #1 had wounds on her feet because she wore socks. She said she saw Resident #1's wound to her coccyx and left buttock after she returned from the hospital on 07/11/21. She said the wound looked worse than it did a few weeks ago. She said Resident #1's wound had drainage and she notified an agency nurse and was told to apply barrier cream to the wound. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 07/18/21 at 1:26 p.m. for Resident #1 indicated the resident was sent to the hospital per family request due to a possible stroke. Review of clinical records for Resident #1 from 06/29/21 to 07/18/21 (date of discharge to the hospital) indicated there were no weekly skin assessments completed. Hospital emergency room records dated 07/18/21 indicated Resident #1 arrived at the emergency room at 1:32 p.m. with altered mental status and increased weakness. A hospital history and physical dated 07/18/21 indicated Resident #1 had a sacral decubitus ulcer stage 3 or 4, left heel necrotic ulcer, and left toe medial necrotic ulcer present on admission. Hospital wound records dated 07/18/21 indicated Resident #1 had a DTI to her left heel with a necrotic wound bed, DTI to her left medial foot with a necrotic wound bed, DTI to her right heel, and unstageable coccyx/sacrum wound with yellow slough and black eschar in the wound bed. Resident #1's coccyx/sacrum wound had a foul odor and a small amount of sanguineous drainage. The wound record did not include documentation of wound measurements. Pictures of Resident #1's wounds dated 07/18/21 at 4:20 p.m. were included in the wound records indicated Resident #1's coccyx/sacrum wound measured 6.0x7.0 cm, left heel wound measured 3.5x3.0 cm, left medial foot measured 2.5x2.5 cm. There was no picture or measurements of Resident #1's right heel wound. During an interview on 07/20/21 at 12:00 p.m., the DON said Resident #1 went to the hospital on 07/10/21 and returned on 07/11/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #1 had pressure injuries, but she did not know when she developed the pressure injuries. She said RN A was responsible for completing all wound care, weekly wound assessments, and weekly skin assessments. She said she was not aware that assessments were not completed as scheduled. During an observation on 07/21/21 at 9:55 a.m., Resident #1 was lying in a hospital bed. She had a DTI to her right inner heel that was approximately the size of a quarter with no drainage or odor. The DTI was dark purple in color and the skin was intact. Resident #1 had an open area to her medial left foot that was approximately the size of a quarter with no drainage or odor. The wound bed of Resident #1's medial left foot wound was covered with necrotic tissue and was not visible. Resident #1 had an open area to her left inner heel that was approximately the size of a half dollar coin with no drainage or odor. The wound bed of Resident #1's left inner heel wound was covered with necrotic tissue and was not visible. Resident #1 had an open area to her sacrum and left buttock that was approximately the diameter of a tennis ball with no drainage or odor. The wound bed of Resident #1's sacrum and left buttock wound was covered with necrotic tissues and was not visible. Resident #1's skin to her right buttock was intact. During an interview on 07/21/21 at 4:30 p.m., RN A said she was the treatment nurse and was responsible for all weekly skin assessments and wound assessments but there was no way she could complete all weekly assessments for 80-90 residents. She said she relied on CNAs to notify her of any new skin concerns and reviewed shower sheets for documentation of new skin concerns. She said the facility used agency staff and she was not always notified of new skin concerns. She said wound treatments were missed on the weekends. She said she used her tablet to take pictures of wounds and it would automatically create a new skin and wound evaluation. She said tablet measured the wounds when she placed a sticker on the resident's skin near the wound. She said the wound measurements uploaded to the skin and wound evaluation. She said Resident #1 first developed a wound to her coccyx and a new wound developed to her buttocks. She said she notified the physician and received treatment orders. She said the wound was initially a stage 2 but worsened quickly to a stage 3. She said the wound physician was notified of Resident #1's wound when it worsened, and he assessed it as a stage 4 and changed the wound treatment. RN A said Resident #1's coccyx wound had no odor and minimal drainage when she last saw the wound on 07/16/21. She said she discovered Resident #1's left heel wound and medial left foot wound on 07/16/21. She said one of the wounds on the resident's left foot had a dressing on it. She said nobody notified her of the wounds, but someone discovered the wounds to Resident #1's left foot before she saw them on 07/16/21. She said there was no wound on the resident's right heel on 07/16/21. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.A face sheet dated 07/21/21 for Resident #2 indicated she was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set, dated dated dated [DATE] for Resident #2 indicated she had severely impaired cognition, usually understood others, and usually made her needs known. She required extensive assistance of 1 to 2 staff with ADLs. She was incontinent of bowel and bladder. Resident #2 was at risk of developing pressure injuries and had no unhealed pressure injuries. A care plan last revised on 05/20/21 for Resident #2 indicated she was at risk to develop pressure injuries due to decreased mobility and incontinence. Care plan interventions included to keep the resident's bed as flat as possible to reduce shearing, monitor/document/report any changes in skin status and assist with repositioning. Resident #2's care plan indicated she required extensive assistance of 1 to 2 staff with ADLs. The care plan did not address Resident #2's wounds. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had one new wound. A nursing note dated 05/21/21 at 7:10 a.m., written by RN A, for Resident #2 indicated a skin assessment was completed and a DTI was noted to the resident's right heel. Review of clinical records for Resident #2 indicated there was no wound assessment completed on 05/21/21. Review of clinical records for Resident #2 included a picture dated 05/21/21 of the resident's right heel DTI. The DTI was intact, brown in color, and approximately the size of a quarter. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal. The skin assessment did not indicate if Resident #2 had new wounds. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A Braden scale for predicting pressure sore risk dated 06/01/21 for Resident #2 indicated she was at moderate risk for developing pressure injuries. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A shower sheet dated 07/05/21 for Resident #2 indicated CNA C drew a circle on the buttocks area of the body figure and documented red with a line drawn to the circle. A weekly skin assessment dated [DATE], completed by RN A, for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had one new wound. A nursing note dated 07/06/21 at 3:10 p.m. for Resident #2 indicated she had a stage 2 pressure injury to her right buttock. Review of clinical record for Resident #2 indicated there was no wound assessment completed on 07/06/21. Review of clinical records for Resident #2 included a picture dated 07/06/21 of the resident's right buttock wound. Resident #2's right buttock wound was approximately the size of a pencil eraser and the wound bed was pink in color. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #'2 stage 2 right buttock wound every day. Dietary recommendations dated 07/06/21 for Resident #2 included a house supplement, vitamin C, liquid protein, and [MEDICATION(S)]. A weekly skin assessment dated [DATE] for Resident #2 indicated her skin color, skin moisture, and skin condition were normal and she had no new wounds. A nursing note dated 07/15/21 at 4:36 a.m. for Resident #3 indicated she was placed on hospice services for senile degeneration and severe malnutrition. Review of clinical records from 07/06/21 to 07/15/21 for Resident #2 indicated there was no wound assessment for the resident's right buttock wound. A wound assessment dated [DATE] for Resident #2 indicated she had a stage 2 pressure injury to her right buttock with an unknown date of development that had resolved. Review of clinical records for Resident #2 included a picture dated 07/16/21 of the resident's right buttock wound. Resident #2's right buttock wound was approximately the size of a pencil eraser and the wound bed was light pink in color. During an interview on 07/20/21 at 10:53 am., RN A said was responsible for all weekly skin assessments and wound assessments but there was no way she could complete all weekly assessments for 80-90 residents. She said she relied on CNAs to notify her of any new skin concerns and reviewed shower sheets for documentation of new skin concerns. She said she was not aware of Resident #2's wound to her right buttock until it was a stage 2 on 07/06/21. She said Resident #2's wound to her right buttock resolved on 07/16/21. She said Resident #2's right buttock wound opened up again during the week she was off. RN A said Resident #2 had a DTI to her right heel for a few months that was stable. She said the CNAs did not report any skin changes to her. During an interview on 07/20/21 at 10:59 a.m., RN N said the CNAs reported skin changes to the treatment nurse or floor nurse. She said she was not aware that Resident #2 had a pressure injury to her right buttock and no staff reported the pressure injury to her. She said Resident #2 had a DTI to her right heel. RN N said they had a lot of agency staff working on Resident #2's hall. She said she would have the wound physician assess Resident #2's right buttock wound. An initial wound evaluation by the wound physician dated 07/20/21 for Resident #2 indicated she had an unstageable DTI to her right buttock for more than 14 days. The wound measured 2x2.2 cm with moderate serous drainage with 100% viable dermis, subcutaneous, and muscle tissue. Resident #2's right buttock DTI was surgically debrided. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/20/21 at 11:16 a.m., CNA C said about a week ago was the last time she saw Resident #2's wound on her bottom it was red. She said she had been off for the last 5 days. She said the resident was repositioned, provided incontinent care every 2 hours, and applied barrier cream to her bottom. She said the resident was placed on hospice services recently and hospice aides gave the resident showers/baths. She said Resident #1 did not have a good appetite. During an interview on 07/27/21 at 4:38 p.m., Resident #2's wound physician said he saw Resident #2 on 07/20/21 for an initial evaluation for her right buttock wound. He said he assessed and measured the wound and updated the wound treatment. He said he documented Resident #2's right buttock wound as a DTI. He said he did not evaluate Resident #2's right heel DTI. He said the facility could do better with their referrals instead of waiting until the wounds have deteriorated so much. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #'2 stage 2 right buttock wound every day were discontinued on 07/21/21. A nursing note dated 07/21/21 at 4:33 p.m. for Resident #2 indicated the resident's right buttock wound deteriorated to an unstageable wound. Resident #2's wound measured 1.7x1.8 cm. Resident #2's right buttock wound was cleaned with normal saline and barrier film was applied. The treatment nurse would follow up in the morning. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 07/22/21 at 4:15 p.m., Resident #2 was lying on a low air loss mattress with her heels floated. Resident #2 had a quarter size dark pink area to the right heel. There was no open area to Resident #2's right heel. Resident #2 had an open area to her right upper buttock with slough in the wound bed. There was no dressing covering the wound. The right buttock wound was approximately the size of a half dollar coin. There was no drainage or odor. Review of clinical records from 05/21/21 to 07/21/22 for Resident #2 indicated there was no wound assessment for the resident's right heel DTI. A wound assessment dated [DATE] for Resident #2 indicated she had a DTI to her right heel with an unknown date of development. The evaluation did not include measurements, description, presence of drainage, presence of odor, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #2 included a picture dated 07/22/21 of the resident's right heel DTI. The DTI was intact, brownish red in color, and approximately the size of a quarter. A wound assessment dated [DATE] for Resident #2 indicated she had a stage 2 pressure injury to her right buttock. The evaluation did not include measurements, description, presence of drainage, presence of odor, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #2 included a picture dated 07/22/21 of the resident's right buttock wound. Resident #2's right buttock wound was approximately the size of a half dollar coin. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment administration record (TAR) dated July 2021 for Resident #2 indicated [MEDICATION(S)] and anti-fungal ointment were applied to her right buttock wound on 07/21/21. The TAR indicated barrier film was applied to Resident #2's right buttock wound on 07/22/21. The TAR did not include Resident #2's new treatment orders dated 07/20/21 to apply a collagen sheet and [MEDICATION(S)] sheet to the right buttock wound 3 times a week for 30 days. During an interview on 07/22/21 at 10:10 a.m., the DON said she expected a wound assessment to be completed with any new wound. She said RN A was the treatment nurse and was responsible for all weekly skin assessments, wound assessments, and completing all wound care. She said skin assessments and wound assessments were expected to be completed weekly. She said all skin and wound assessments were documented in the electronic record. She said she was not aware that assessments were not completed as scheduled. During an interview on 07/28/21 at 3:26 p.m., the DON said there were no wound assessments completed for Resident #2's right buttock wound and right heel DTI until 07/22/21. 3.A face sheet dated 07/22/21 for Resident #3 indicated he was [AGE] years old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moisture, and skin condition were normal. The skin assessment did not indicate if Resident #3 had new wounds. A wound assessment dated [DATE] for Resident #3 indicated he had a stage 2 coccyx pressure injury. The evaluation did not include wound measurements, presence of drainage, presence of odor, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #3 included a picture dated 04/27/21 of the resident's stage 2 coccyx wound. Resident #3's coccyx wound was approximately the size of a nickel. The wound be was pink in color. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records for Resident #3 from 04/16/21 to 05/09/21 indicated no weekly skin assessment was completed. A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moisture, and skin condition were normal. The skin assessment did not indicate if Resident #3 had new wounds. A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moister, skin condition were normal and he had no new wounds. A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moister, skin condition were normal and he had no new wounds. A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moister, skin condition were normal and he had no new wounds. A weekly skin assessment dated [DATE] for Resident #3 indicated his skin color, skin moister, skin condition were normal

Based on observation, interview, and record review, facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 22 residents reviewed for quality of life (Resident #64). The facility did not ensure Resident #64 was transferred according to her care plan, resulting in a spiral fracture to her right lower leg. The facility failed to properly assess and investigate Resident #64's injury after an improper transfer, an x-ray 3 days later determined she had a spiral fracture to her lower right leg. LVN L did not address or report Resident #64's complaint regarding a CNA who tried to remove her call light as the resident requested. Findings included: Physician orders [REDACTED].#64 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #64 had clear comprehension, and understood others, required extensive to total dependence with all ADLs, except eating, she required set up help only. The MDS indicated Resident #64 required extensive assistance of one person for bed mobility and required the assistance of two persons for transfers. A care plan updated 9/6/18 indicated Resident #64 was unable to transfer and required a mechanical lift for all transfers. The care plan indicated she required assist with all ADLs and was hard of hearing with poor vision. During an observation and interview on 10/1/18 at 10:26 a.m., Resident #64 was lying in bed, she was alert and oriented to person and place. She said she broke her right leg a couple of months ago when CNA O transferred her to the bed. Resident #64 said she was in her wheelchair on the left side of her bed, CNA O told her to wrap her arms around her neck and CNA O put her arms around Resident #64's waist, picked her up, then turned to place her on the bed. Resident #64 said during the transfer, she and CNA O heard pop sound. She said CNA O said she was worried and feared she would lose her job. Resident #64 said her lower right leg hurt but the next day the pain increased. Resident #64 said she was unable to stand on her own. She said her feet dangled when she was transferred. She said since her injury she could not lay in one position for longer than an hour and required assistance with re-positioning. Resident #64 was tearful and anxious and said CNA N was angry with her this morning for using her call light. Resident #64 said she was upset because CNA N attempted to pull her call light from her hand. She said she held on to it and would not let CNA N take it from her. She said CNA N told her to stay off her call light and only call when she needed help. Resident #64 said when she used her call light it was important to her even if CNA N did not think it was necessary. Resident #64 said she told LVN L what happened and asked him to report CNA N and he promised he would report to administration. A nursing note dated 8/3/18 at 1:38 p.m. indicated Resident #64 bumped her left (sic) ankle on the lift foot rest during transfer. The note indicated Resident #64 complained of pain when her left (sic) ankle was moved, there was no swelling or discoloration and an order was received for an x-ray to the resident's ankle. An undated incident report signed by the DON, indicated on 8/3/18 at 1:38 p.m., Resident #64 bumped her left (sic) ankle on the foot rest of the lift during transfer. The incident report indicated there were no witness statements, resident statement or investigation of the incident. A radiology report dated 8/7/18 at 8:07 a.m., indicated Resident #64 had a spiral [MEDICAL CONDITION] tibia (lower leg). A nursing note dated 8/7/18 at 11:29 a.m., indicated Resident #64 requested to stay in bed due to pain in her right leg, her right lower leg had swelling and a purplish bruise to the area below the knee. A psychiatric evaluation dated 8/21/18 indicated Resident #64 had increased anxiety and depression. The examination report indicated she was alert and oriented to person, place and partially to time. The report also indicated her thought processes were logical, her insight and judgement were normal, and her immediate recall was intact. Resident #64 was placed on an anti-depressant due to her increased depression. A psychiatric progress note dated 9/4/18 indicated Resident #64 continued to have feelings of hopelessness and depression. The medication for depression was increased. During an observation and interview on 10/1/18 at 2:22 p.m., Resident #64 said she was still upset about the incident with CNA N. She said she used her call light this morning because she wanted to be turned. Resident #64 said no one talked with her about what happened with CNA N, and LVN L promised he would report it. She said she was not afraid of CNA N and that she could hold her own. During an interview on 10/2/18 at 9:18 a.m., CNA M said Resident #64 used her call light more often since her leg was injured. She said when she called for assistance she asked for help to reposition, refill her ice and water, or she requested pain medication. She said Resident #64 complained about staff who provided care but would not call staff by name. CNA M said the resident would become agitated about the amount of time she had to wait for help when she pushed her call light. CNA M said when Resident #64 became agitated, she would stay on her call light. During an interview on 10/2/18 at 9:26 a.m., CNA S said Resident #64 used her call light when she needed more water, needed to be turned, or if she needed the nurse to give her something for pain. CNA S said Resident #64 complained about staff and became tearful but would not name the staff or say what happened. She said the resident would complain that staff did not care about what she needed, and they would get an attitude with her. CNA S said she reported Resident #64's complaints to the charge nurse but did not report the resident's complaints to the abuse coordinator (administrator). During an interview on 10/2/18 at 2:22 p.m., LVN L said before breakfast on 10/1/18, Resident #64 complained about the amount of time she had to wait for CNA N to answer her call light. LVN L said Resident #64 did not tell him CNA N attempted to take her call light away, he said that conversation never happened. LVN L said he explained to Resident #64 that he and the CNAs answer her call light as quickly as possible. LVN L said the resident was not anxious or upset when he was in her room. During an interview on 10/2/18 at 3:02 p.m., the DON said if an investigation was conducted, it would be attached to the incident report along with the witness statement and resident statement. During an interview on 10/2/18 at 3:48 p.m., Resident #64 said she did not remember if she bumped her ankle when she was transferred on 8/3/18. She said she remembered CNA O lifted her out of her chair, twisted her leg, and they both heard it break. Resident #64 said she told a nurse what happened, but she could not remember the name of the nurse. She said CNA O was afraid she would lose her job. Resident #64 said the staff did not always use the mechanical lift to transfer her because it took longer. Resident #64 said it took less than 5 minutes to transfer her without the mechanical lift. A nursing note dated 10/2/18 at 5:19 p.m., indicated Resident #64 turned on her call light and requested to speak with LVN L, she was told he worked on a different hall and staff offered to assist her. Resident #64 continued to insist to speak with LVN L. A nursing note dated 10/2/18 at 5:50 p.m., indicated Resident #64 turned on her call light and insisted to speak with LVN L, staff explained he was not her nurse and offered to assist. Staff documented in the nursing note that Resident #64 continued to turn on her call light and requested to speak with LVN L. During an interview on 10/3/18 at 8:43 a.m., Resident #64 said she spoke with LVN L on 10/2/18 and he said he did not report her complaint, because he did not believe CNA N attempted to take away her call light. She said LVN L said it was her opinion it happened and his opinion it did not happen. She said LVN L said he did not say it did not happen, he just did not think it happened the way she said it happened. Resident #64 was upset and tearful, because he promised he would report it. She said he was not in her room when CNA N attempted to pull her call light from her hand, and he did not witness the incident. During an interview on 10/3/18 at 8:52 a.m., CNA O said on 8/3/18 she transferred Resident #64 to the bed and bumped her ankle on the lift. She said she heard a pop noise and it scared her but Resident #64 told her it did not hurt. CNA O said the resident's ankle hit the bar on the lift and she reported the incident to LVN L immediately. CNA O said she also reported the pop sound she heard during transfer to LVN R. She said Resident #64 was unable to stand and she always used the mechanical lift for transfer. She said she was alone when she transferred Resident #64 and said the resident required assistance of 1 person for transfers. CNA O said when she reported to work on 8/4/18 she checked on Resident #64 because she was worried about the pop sound she heard and was afraid something was broken. She said the resident did not complain of pain until the day after the incident. CNA O said she saw CNA N transfer Resident #64 multiple times without using the mechanical lift. CNA O said she had not did not reported CNA N to the nurse and she believed the fracture happened after the incident on 8/3/18. During an interview on 10/3/18 at 9:50 a.m., LVN R said on 8/3/18 CNA O reported that Resident #64 bumped her ankle on the lift during transfer. She said the resident complained of pain, and an x-ray was ordered. She said CNA O did not tell her about a pop sound during the transfer. She said Resident #64 said she bumped her foot on the lift. LVN R said the resident complained of her leg hurting 3 or 4 days later and it was x-rayed. She said she did not know how the fracture happened. LVN R said Resident #64 required assistance of 2-persons for transfers with the mechanical lift when she admitted to the facility in (MONTH) (YEAR) because she was not able to stand. She said she had not seen the resident transferred by staff without the use of the mechanical lift. During an interview on 10/3/18 at 10:46 a.m., the DON said on 8/3/18 Resident #64 was transferred with the mechanical lift and bumped her ankle. She said CNA O and Resident #64 told her the same thing and it is was documented on the incident report. The DON said she did not document her interview with the resident or staff regarding the transfer incident. She said the incident did not need to be investigated because the spiral fracture to Resident #64's right lower leg was due to the incident on 8/3/18. The DON said she did not know CNA O transferred the resident without assistance. During an interview on 10/3/18 at 12:01 p.m., the administrator said she just spoke with Resident #64 about the incident on 8/3/18. The administrator said the resident told her CNA O transferred her with the lift and she (the resident) twisted her leg. The administrator said the resident told her CNA O did not hurt her. The DON said CNA O did not report a pop noise when she transferred the resident. The administrator said the resident said she heard a pop when she twisted her leg. During an interview on 10/3/18 at 2:09 p.m., the administrator said Resident #64 confirmed that CNA O did not use a mechanical lift while transferred on 8/3/18. A social service note dated 10/3/18 at 12:09 p.m., indicated the social worker met with Resident #64 and she denied any issues or concerns. During an interview on 10/3/18 at 2:21 p.m., Resident #64 said she experienced a lot of grief today because staff asked her questions and twisted her words. She said the social worker spoke with her and did not believe her when she said CNA N tried to pull the call light out of her hand. Resident #64 said she felt like the staff thought she was crazy. During an interview on 10/3/18 at 3:34 p.m., LVN L said he did not speak to Resident #64 on 10/2/18, he said he worked on Hall 400 and he was not her nurse. He said he was not aware she requested to speak to him. During an interview on 10/3/18 at 4:02 p.m., the administrator said a therapist reported Resident #64's complaint about CNA N to the social worker on 10/1/18 and the social worker visited with the resident. The administrator said she began the investigation today. She said LVN L's statement dated 10/3/18, said Resident #64 complained about the amount of time it took CNA N to answer the call light. The administrator said Resident #64 was confused and depressed. She said CNA N attempted to move her call light and the resident interpreted it wrong. The administrator said she had not spoken with CNA N, she said she assumed she was only attempting to move the call light for the resident. During an interview on 10/3/18 at 4:52 p.m., the DON said she was aware of Resident #64's complaint and the administrator had an open investigation. The DON said she had not spoken with CNA N. During a phone interview on 10/3/18 at 4:56 p.m., CNA N said on 10/1/18 just after breakfast Resident #64 had her call light in her hand and it was wrapped around the bed control cord. CNA N said she tried to untangle it and Resident #64 thought she tried to pull it out of her hand and became angry. CNA N said she was not sure if she asked the resident for permission prior to her attempt to remove the call light from her hand. CNA N said LVN L came in the room and she heard Resident #64 asked LVN L to report her for attempting to pull her call light out of her hand. CNA N said she and LVN L explained to Resident #64 that she should only use her call light when she needed something. CNA N said the resident stayed on her call light 24/7 and LVN L told her they had other residents to take care of. CNA N said Resident #64 would push her call light when she needed to turn because her bottom hurt, when she needed more water or when she needed her bed raised or lowered. CNA N said Resident #64 complained of pain and would request to be repositioned every hour. During an interview on 10/3/18 at 5:06 p.m., the administrator said she expected residents to be treated with respect and dignity. She said if a resident reported a complaint to staff she expected it to be reported to her. The administrator said she and the social worker would continue to speak with Resident #64 and the investigation remained opened.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 22 residents reviewed for accidents. (Resident #64) The facility did not ensure Resident #64 was transferred properly resulting in Resident #64 obtaining a spiral fracture to her right lower leg. Findings included: Physician orders [REDACTED].#64 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #64 had clear comprehension, and understood others, required extensive to total dependence with all ADLs, except eating, she required set up help only. The MDS indicated Resident #64 required assist of two persons for transfers. A care plan updated 9/6/18 indicated Resident #64 was unable to transfer and required a mechanical lift for all transfers. During an observation and interview on 10/1/18 at 10:26 a.m., Resident #64 said she broke her right leg a couple of months ago when CNA O transferred her to the bed. Resident #64 said she was in her wheelchair on the left side of her bed, CNA O told her to wrap her arms around her neck and CNA O put her arms around Resident #64's waist, picked her up, then turned to place her on the bed. Resident #64 said during the transfer, she and CNA O heard a pop sound. She said CNA O said she was worried and feared she would lose her job. Resident #64 said her lower right leg hurt but the next day, the pain increased. Resident #64 said she was unable to stand on her own, she said her feet dangled when she was transferred. A nursing note dated 8/3/18 at 1:38 p.m. indicated Resident #64 bumped her left (sic) ankle on the lift foot rest during transfer. The note indicated Resident #64 complained of pain when her left (sic) ankle was moved, there was no swelling or discoloration and an order was received for an x-ray to the resident's ankle. A nursing note dated 8/3/18 at 7:39 p.m., indicated Resident #64 was lying in bed and complained of pain to her right ankle. Nursing notes on the following dates and time for Resident #64 indicated: *8/4/18 at 7:13 a.m., Resident #64 complained of pain to her left (sic) ankle, Tylenol was administered for pain and the resident was repositioned in bed; *8/4/18 at 11:01 a.m., the x-ray report was negative for fracture to Resident #64's right ankle; *8/4/18 at 6:30 p.m., Resident #64 was up in her electric chair and complained of soreness to her right leg; *8/6/18 at 9:49 a.m., Resident #64 complained of pain to her right knee and the area below her knee had a dark bruise, warmth, redness and swelling. An order was received to obtain an x-ray; *8/6/18 at 10:04 a.m., post incident on 8/3/18 with no injuries, resident now complained of pain to right knee area, Tylenol ES (extra strength) given; *8/7/18 at 1:48 a.m., Resident #64 complained of pain to right lower leg, Tylenol ES given, and right leg repositioned. Dark purple bruising and small amount of swelling under right knee; *8/7/18 at 11:29 a.m., Resident #64 requested to stay in bed due to pain in her right leg. Right lower leg had 3+ [MEDICAL CONDITION] (swelling) and purplish bruise to area below knee, awaiting x-ray results; *8/7/18 at 11:35 a.m., the x-ray results indicated a non-displaced spiral fracture to right lower leg. An orthopedic appointment was made for 8/9/18; *8/7/18 at 6:09 p.m., Resident #64 complained of chest pain, unrelieved with [MEDICATION NAME] tablets x2 (medication for chest pain). Her temperature was 99.1, blood pressure 136/105 and pulse 110. Resident #64 was sent to the emergency room ; and *8/10/18 at 2:10 p.m., Resident #64 returned to facility with [DIAGNOSES REDACTED]. An undated incident report with the DON's signature, indicated on 8/3/18 at 1:38 p.m., Resident #64 bumped her left (sic) ankle on the foot rest of the lift during a transfer. The incident report indicated there were no witness statements, resident statement or investigation of the incident. During an interview on 10/2/18 at 3:02 p.m., the DON said if an investigation was completed, the witness statements and resident statements would be included with the incident report. During an interview on 10/2/18 at 3:48 p.m., Resident #64 said she did not remember if she bumped her ankle when she was transferred on 8/3/18. She said she remembered CNA O lifted her out of her chair, twisted her leg, and they heard it break. Resident #64 said she told the nurse what happened, but she could not remember the name of the nurse. She said CNA O was afraid she would lose her job. Resident #64 said the staff did not always use the mechanical lift to transfer her because it took longer. Resident #64 said it took less than 5 minutes to transfer her without the mechanical lift. During an interview on 10/3/18 at 8:52 a.m., CNA O said on 8/3/18 she transferred Resident #64 to the bed and bumped her ankle on the lift. She said she heard a pop noise and it scared her but Resident #64 told her it did not hurt. CNA O said the resident's ankle hit the bar on the lift and she reported the incident to LVN R immediately. CNA O said she also reported the pop sound she heard during transfer to LVN R. She said Resident #64 was unable to stand and she always used the mechanical lift for transfer. She said she was alone when she transferred Resident #64 and she was a 1-person transfer. CNA O said when she reported to work on 8/4/18 she checked on Resident #64 because she was worried about the pop sound she heard and was afraid something was broken. She said the resident did not complain of pain until the day after the incident. CNA O said she saw CNA N transfer Resident #64 multiple times without using the mechanical lift. CNA O said she had not reported CNA N to the nurse and she believed the fracture happened after the incident on 8/3/18. During an interview on 10/3/18 at 9:50 a.m., LVN R said on 8/3/18 CNA O reported that Resident #64 bumped her ankle on the lift during transfer. She said the resident complained of pain, and an x-ray was ordered. She said CNA O did not tell her about a pop sound during the transfer. She said Resident #64 said she bumped her foot on the lift. LVN R said the resident complained of her leg hurting 3 or 4 days later and an x-ray was ordered on the resident's leg. She said she did not know how the fracture happened. LVN R said Resident #64 was a 2-person transfer with the mechanical lift when she admitted to the facility in (MONTH) because she was not able to stand. She said she had not seen the resident transferred by staff without the use of the mechanical lift. During an interview on 10/3/18 at 10:46 a.m., the DON said on 8/3/18 Resident #64 was transferred with the mechanical lift and bumped her ankle. She said CNA O and Resident #64 told her the same thing and it is documented on the incident report. The DON said she did not document her interview with the resident or staff. She said the incident did not need to be investigated because the spiral fracture to Resident #64's right tibia was due to the incident on 8/3/18. The DON said she did not know CNA O transferred the resident without assistance. During an interview on 10/3/18 at 12:01 p.m., the administrator said she just talked with Resident #64 about the incident on 8/3/18. The administrator said the resident told her CNA O transferred her with the lift and she (the resident) twisted her leg. The administrator said the resident said CNA O did not hurt her. The DON said CNA O did not report a pop noise when she transferred the resident. The administrator said the resident said she heard a pop when she twisted her leg. The DON said when staff used the mechanical lift they should have two staff present. During an interview on 10/3/18 at 2:09 p.m., the administrator said Resident #64 confirmed that CNA O did not use a mechanical lift while transferred on 8/3/18.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and care based on the comprehensive assessment of an indwelling urinary catheter for 1 of 23 residents reviewed for quality of care. (Resident #95) The facility did not assess or adequately secure Resident #95's indwelling urinary catheter to prevent penile erosion. This failure could place 3 residents with indwelling urinary catheters at risk of severe pain or damage to surrounding tissue. Findings included: The most recent physician orders [REDACTED].#95 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident # 95 was to have indwelling urinary catheter care every shift and as needed, with soap and water. The most recent MDS dated [DATE] indicated Resident #95 usually made his needs known and understood others. The MDS indicated Resident #95 required limited one person assistance with bathing and he had an indwelling urinary catheter. The most recent care plan dated 11/7/17 indicated Resident #95 had an indwelling urinary catheter. The care plan indicated for staff to have an ongoing evaluation of Resident #95's indwelling urinary catheter for symptoms of urinary tract infections. During an observation and interview on 12/12/17 at 11:12 a.m., Resident #95's indwelling urinary catheter had eroded a small portion of his meatus (approximately 0.5 cm) with a yellow, odorous drainage. The shaft of his penis where it met his glans penis had a white cheesy substance with a pungent odor. Resident #95 complained of pain to his peri area. Resident #95 said his penis hurt when the indwelling urinary catheter pulled. The treatment nurse said the indwelling urinary catheter appeared to have eroded the bottom of the resident's penis where the indwelling urinary catheter was inserted. She said there was also a foul odor and Resident #95's penis needed to be cleaned. During an interview on 12/14/17 at 08:47 a.m., CNA T said Resident #95's indwelling urinary catheter on Friday was not as bad as it was now. CNA T said it looked more open now than on Friday. CNA T said she provided catheter care at least 3 times a day. CNA T said she first noticed Resident #95's meatus looked eroded on 12/13/17. CNA T said she reported what she saw to LVN P who told her to just watch and make sure there was no bleeding. During an interview on 12/14/17 at 9:03 a.m., LVN P said she looked at Resident #95's penis on 12/13/17 and did not notice any erosion or anything abnormal, and no one had told her about the erosion. During an interview on 12/14/17 at 08:48 a.m., LVN E said Resident #95's indwelling urinary catheter had eroded to approximately the width of the catheter tubing and verified there was a catheter secure in place, but the tape had come loose, allowing the indwelling urinary catheter to pull on the resident's penis. LVN E said she looked at Resident #95's penis a couple of weeks ago and did not notice any erosion. LVN E said she had not had any CNAs report to her anything about Resident #95's penis being eroded. During an interview on 12/14/17 at 8:55 a.m., CNA N said she provided catheter care to Resident #95 weekly, and said she had not noticed any erosion. During an interview on 12/14/17 at 09:31 a.m., ADON O said no one had informed her that Resident #95 had an erosion to his penis. During an interview on 12/14/17 at 10:09 a.m., the DON said she was not aware of any erosion to Resident #95's penis. The DON said staff should assess residents and document the findings in nursing notes. During an interview on 12/14/17 at 1:46 p.m., the administrator said she was unaware that Resident #95 had penile erosion, the administrator said she expected the treatment nurse to report the findings of penile erosion to the charge nurse or notify Resident #95's physician. During an interview on 12/14/17 at 1:51 p.m., the treatment nurse said he did not notify Resident #95's physician or tell the charge nurse about his penile erosion. He said he just forgot. During an interview on 12/14/17 at 2:18 p.m., LVN E said when she notified Resident #95's physician he was unaware that Resident #95 had penile erosion. The clinical admission policy dated April 2017 indicated the following: Purpose To provide a comprehensive baseline physical evaluation, identify risks and establish individualized interventions for residents upon admission. Process The admission nurse is responsible for initiating the Clinical Health Status and establishing interim care plan interventions determined by individual risk indicators. * The Admission Clinical Health Status is completed within 24 hours * The Admission Clinical Health Status may direct completion of additional evaluations based upon risk identified. * A comprehensive baseline skin evaluation will be completed and documented in the EMR * A summary narrative note is completed in the EMR including information regarding general condition upon arrival. * As risk is identified, by areas such as falls, pain, smoking etc. an individualized intervention is implemented on both the interim care plan and the Care Giver Guide. The CMS 672 dated 12/11/17 indicated there were 3 residents with indwelling urinary catheters.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice, based on the resident assessment and physician orders, to prevent development and worsening of pressure injuries for 1 of 4 residents reviewed for pressure injuries. (Resident # 54) Resident #54 was admitted with contractures and was at high risk for development of pressure injuries, and was placed on a low air loss mattress. The facility removed the low air loss mattress during a bed change, and did not replace it after a physician's orders [REDACTED]. Resident #54 developed a Stage 4 pressure injury during the time the low air loss mattress was not in use. The low air loss mattress was replaced in Resident #54's bed after surveyor intervention. This failure could place 26 residents who were at a high risk for the development of new pressure injuries and place 6 residents with pressure injuries at risk for developing new pressure injuries or a decline in existing pressure injuries. Findings included: Consolidated physician orders [REDACTED].#54 was [AGE] years old, re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #54's wound was to be cleansed with normal saline, packed with algidex, foam dressing applied, and connected to a wound vac. The order indicated the resident was to have a low air loss mattress. The order was signed and dated (12/1/17) by LVN K. During an interview on 12/12/17 at 9:32 a.m., the DON said on 6/5/17, Resident #54 was placed in a bariatric bed with a standard pressure relieving mattress. The DON said Resident #54 would fling herself out of the standard bed onto the floor. During an observation and interview on 12/11/17 at 2:33 p.m., Resident #54 was lying in a bariatric bed on a regular mattress. The treatment nurse said Resident #54 was previously on a low air loss air mattress prior to being placed in a bariatric bed with a regular mattress in June 2017. He said Resident #54 had frequent falls out of bed prior to being placed in a bariatric bed. The treatment nurse said he did not know why Resident #54 was not on a low air loss mattress. A Braden risk scale assessment (for predicting pressure injury) dated 7/7/17 indicated Resident #54 was at a very high risk for developing pressure injuries. A skin assessment dated [DATE] indicated a shear wound was identified on Resident #54's right buttock with a large amount of serosanguineous drainage and measurements of 3.20 cm x 4.50 cm x 0.20 cm. A skin assessment dated [DATE] indicated the shear wound on Resident #54's right buttock was diagnosed as a Stage 4 pressure injury following debridement, and measured 2.5 cm x 2.5 cm x 1.5 cm. The most recent MDS dated [DATE] indicated Resident #54 rarely/never made her needs known. The MDS indicated Resident #54 required extensive assistance of 2 staff with all ADLs. The MDS indicated Resident #54 was at risk of developing pressure injuries and currently had one facility acquired Stage 4 pressure injury that had worsened since her prior assessment. A physician order [REDACTED].#54 was to have a low loss air mattress with alternating air. During an interview on 12/13/17 at 3:13 p.m., the DON said that she expected the LVN charge nurse on duty to review all orders from the physician once a resident returned from a physician appointment and make the changes as needed. She said that she was not aware of the order (originally dated 11/3/17) for Resident #54 to have a low air loss mattress. During an interview on 12/13/17 at 2:41 p.m., LVN K said that when Resident #54 returned from the wound care center on 12/1/17 he looked over the physician orders [REDACTED]. He said he signed and dated the order on 12/01/17, but did not see the order for a low air loss mattress. During an interview on 12/12/17 at 9:32 a.m., the DON said Resident #54's wound began on 8/20/17 as a shear. She said it developed eschar on 9/28/17, and the physician debrided the wound and diagnosed it as a Stage 4 pressure injury following debridement. The DON said that a low air loss mattress was usually placed on a resident's bed when there was a Stage 4 pressure injury. The DON said she would get Resident #54 a low air loss mattress even though it would not do any good. During an observation and interview on 12/13/17 at 8:23 a.m., the treatment nurse performed wound care for Resident #54's Stage 4 pressure injury on her right hip. The wound measured 1.1 cm x 0.9 cm x 2.3 cm. The wound bed was red and surrounding tissue was blanchable and dark pink. The treatment nurse said that he had been in the position as treatment nurse for one year. He said that he had no formal training and that he was trained by a treatment nurse in another facility for three days when placed in his current position, but had no formal wound care training. During an interview on 12/13/17 at 2:43 p.m., the treatment nurse said that Resident #54 usually returned from the wound care center after his shift. He said he was not aware of an order for [REDACTED].>During an observation on 12/14/17 at 8:07 a.m., after surveyor intervention, Resident #54 had a low air loss mattress on her bed. The skin care guideline policy received from the DON dated June 2017 said the purpose was to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. The process indicated that when an open area is identified interventions would be implemented immediately, including a specialty mattress . On 12/14/17 at 3:03 p.m., web page: http://www.npuap.org/ was accessed and said; Stage 4 pressure injury: full thickness skin and tissue loss- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. The CMS 672 dated 12/11/17 indicated 6 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for code status. (Resident #1) Resident #1 was admitted to the facility on [DATE] at 5:26 p.m. An admission assessment was done at that time and no other staff assessed or provided medication or care for Resident #1 until 12:50 a.m. at which time he was unresponsive (approximately 7.5 hours later). Resident #1 was a full code and cardiopulmonary resuscitation (CPR) was not immediately initiated. When CPR was initiated, resuscitative measures were unsuccessful and Resident # 1 expired in the facility. The facility did not have a system in place to immediately determine residents' code status or to ensure temporary care plans were developed to ensure necessary care for new admissions. Resident #1 was not checked every 2 hours per protocol. Resident #1 did not receive medications as ordered. The CNAs were not made aware of necessary care to provide for new residents. This failure created an Immediate Jeopardy situation identified on [DATE] at 11:20 a.m. The Immediate Jeopardy was removed on [DATE] at 4:40 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 8 new residents who required timely and ongoing assessments as well as staff knowledge of code status at risk for not receiving necessary care or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for hospice services. An initial admission assessment completed by RN B dated [DATE] at 5:26 p.m. noted Resident #1 was a total care resident. He had a [MEDICAL CONDITION] and was incontinent of urine. The assessment included he had no family; he was alert but not oriented and was thin and frail. Resident #1's vital signs were: blood pressure ,[DATE], pulse 86, respirations 22, and oxygen saturation was at 91 percent. The assessment did not indicate his code status. Nursing notes for Resident #1 included the following documentation: *[DATE] at 5:28 p.m., the resident was admitted with skin issues, he had three pressure areas to his back that were Stage 1, they were covered. He also had a Stage II pressure ulcer to his coccyx and a crusty skin tear that was healing on his left elbow. There was no other documentation in the nursing notes until 12:50 a.m. *[DATE] at 12:50 a.m., LVN A entered Resident #1's room to obtain his vital signs. The resident was found to be not breathing, no respirations, and no pulse. The hospice RN was notified and informed LVN A Resident #1 was a full code. CPR was then initiated and emergency medical services EMS was notified, CPR was continued until EMS arrived and took over. CPR was continued by EMS until orders were obtained from the medical director to stop CPR, Resident # 1 was pronounced dead at 1:25 a.m. The [DATE] MAR indicated [REDACTED] 8:00 p.m. - [MEDICATION NAME] 10 milligram (mg) 8:00 p.m. - [MEDICATION NAME] 20 mg 8:00 p.m. - [MEDICATION NAME] 0.25 mg 8:00 p.m. - [MEDICATION NAME] 5 mg There was no documentation Resident #1 received any of these medications. During an interview on [DATE] at 11:25 a.m. the hospice nurse said Resident #1 was admitted on [DATE] at approximately 5:30 p.m. She said she wrote physician orders [REDACTED]. She said the do not resuscitate (DNR) would be faxed the next morning to his responsible party. The hospice nurse said she got a call around 12:50 a.m. from LVN A that the resident was not breathing. The hospice nurse said she informed LVN A Resident #1 was still a full code and she responded, "are you kidding me?" During an interview on [DATE] at 2:00 p.m., RN B said she assessed Resident #1 on admission at 5:26 p.m. and looked in on him at 9:00 p.m., but did not document anything more at that time. She said it was understood that you check on residents every two hours. RN B said she forgot to give Resident #1's medications. She said, "I was wrong." RN B said she told the oncoming shift nurse, LVN A that Resident #1 was on hospice, but was a full code. She said she did not write the information on the 24 hour report. RN B said the social worker was responsible for putting the code status information in the charts. During an interview on [DATE] at 2:05 p.m., NA D said she was assigned to Resident #1 and she worked a double shift, but did not "lay eyes" on Resident #1 during the 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shifts on [DATE] or [DATE]. During an interview on [DATE] at 4:10 p.m., EMS E said they received a call from the facility, and upon arrival at 1:00 a.m. they found LVN A doing chest compressions. He said he and another paramedic took over the code and pronounced Resident #1 dead at 1:25 a.m. EMS E said he estimated the resident had been dead from one to three hours because he had some lividity (gravitational pooling of blood that occurs within 30 minutes of the heart stopping) and was a little stiff. During an interview on [DATE] at 5:20 p.m., LVN A said she reported to work on [DATE] at around 9:45 p.m. and was told about a new admission. She said the evening shift nurse RN B told her Resident #1 was a hospice resident, but not that he was a full code. LVN A said it was understood residents should be checked on every two hours but she did not "lay eyes" on Resident #1 until 12:50 a.m. on [DATE] and he was not breathing. She said she ran down the hall and called the hospice nurse who informed her he was a full code. She said she had another staff call 911 while she started CPR on the resident. LVN A said EMS arrived and took over CPR without success and Resident #1 was pronounced dead on [DATE] at 1:25 a.m. During an interview on [DATE] at 9:15 a.m., the DON said Resident #1 was admitted on [DATE] on the evening shift. The DON said he was found unresponsive and LVN A did not know he was a full code. The DON said the charge nurses were responsible for placing a red or green sheet on the front of a new resident's record when the social worker was not available. She also said the charge nurses were responsible for the initial care plan and administering ordered medications. The DON said NA D failed to provide care for Resident #1 on the night shift on [DATE]. The DON said the nurse had not checked on the new resident even though he should have been checked every two hours. The DON said CNAs checked on Resident #1; however, there was no documentation that any staff checked Resident #1 after his initial assessment at 5:26 p.m. During an interview on [DATE] at 10:30 a.m., CNA C said he passed ice around 10:45 p.m. and Resident #1 was in his room in bed. He said the resident appeared asleep, was breathing slowing, and his eyes were twitching. CNA C said he did not know Resident #1's code status. He said there was no communication between nurses and CNAs regarding assistance with ADLS, code status, or anything pertaining to the resident care issues. He said he did not provide any care for Resident #1. An ADL assistance record dated [DATE] had no documentation regarding care provided for Resident #1. An undated care plan was found in Resident #1's record; however, the care plan was blank. During an interview on [DATE] at 9:12 a.m., the administrator she said she was unaware of a resident expiring in the facility on [DATE]. The administrator and DON were notified on [DATE] at 11:20 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on [DATE] at 3:07 p.m. and included: The POR included: "1). Role of the charge nurse on new admits regarding verifying code status and communicating to the next shift. Placing the new admit code status on the 24 hour report. Flagging the chart, shift to shift communication regarding plan of care. 2). The charge nurse each shift will be responsible for conducting a shift huddle to inform staff of after-hours admit and their current code status. 3). During regular working hours the social services director will be responsible for communication of code status of new admissions. 4). Assessing, monitoring and documenting clinical condition and status: 1. During their shift and communicating the changes to oncoming nurse. 2. Nurses will make rounds on new admits every 2 hours and/or as based on current clinical condition. 3. Clinical documentation based on resident clinical status. 4. Role of nurse during emergency and implementing immediate interventions as indicated based on resident clinical status. 5. Center conducted 100 % audit of current advance directives. All staff will be educated on code status identifier based on name color code on the door of their rooms. " On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: 8 CNAs were interviewed and said the resident's code status was going to be placed on the resident's doors using a green or red sticker. The CNAs said red means DNR and green means full code. The CNAs also said they were to check new admissions as well as other residents every two hours and more often depending on the resident's condition. They said they would report any changes to the charge nurses immediately. 8 nurses were interviewed and said they would verify code status of new residents and communicate to the next shift by using the 24 hour report. They also said they would make rounds every two hours and/or more often as based on current clinical condition. All licensed nursing personnel were in-serviced by 3:00 p.m. on [DATE]. On [DATE] at 4:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list dated [DATE] provided by the administrator on [DATE] noted eight residents were admitted during [DATE].

Based on interview and record review the administrator and director of nurses (DON) failed to ensure the facility's resources were managed effectively and efficiently to attain or maintain the highest practicable physical, mental and psycho-social well-being for 1 of 6 residents reviewed for advance directives (Resident #1) The administrator and DON did not monitor and supervise care and services to ensure the following for Resident #1: *obtain and verify code status for new admissions after business hours, and communicate to staff, and *charge nurse to assess and monitor new admissions every 2 hours and document in resident's clinical record as needed. Resident #1 was admitted to the facility on [DATE] at 5:26 p.m., an admission assessment was done at that time and no other staff saw Resident # 1 until 12:50 a.m. at which time he was unresponsive (approximately 7.5 hours later). Resident #1 was a full code and cardio [MEDICAL CONDITION] resuscitation (CPR) was not immediately initiated. The facility did not have a system in place to determine residents' code status or to ensure temporary care plans were developed to ensure necessary care for new admissions. Resuscitative measures were unsuccessful and Resident #1 expired in the facility. This failure created an Immediate Jeopardy situation was identified on [DATE] at 11:20 a.m. The Immediate Jeopardy was removed on [DATE] at 4:40 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the census of 8 newly admitted residents at risk of not receiving necessary care or death. Findings included: During an interview on [DATE] at 12:43 p.m. the administrator said staff should use best nursing practice to ensure residents' needs were met. The administrator said she had a system for monitoring staff to ensure competency and she monitored the DON by attending morning meetings and talking with residents. The administrator said the Immediate Jeopardy occurred because the staff failed to do their job. She said she was not aware of the situation until the following day. The administrator said she investigated and corrective measures were completed. During an interview on [DATE] at the DON said there had not been an in-service for do not resuscitate (DNR) status and when and where to post. She said she ensured nurses were competent by watching skills and performing check offs annually. The DON said the IJ occurred because LVN A did not assess Resident #1 and RN B did an admission assessment but did not communicate the resident's code status in writing. Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for hospice services. An initial admission assessment completed by RN B dated [DATE] at 5:26 p.m. noted Resident #1 was a total care resident. He had a [MEDICAL CONDITION] and was incontinent of urine. The assessment included he had no family; he was alert but not oriented and was thin and frail. Resident #1's vital signs were: blood pressure ,[DATE], pulse 86, respirations 22, and oxygen saturation was at 91 percent. The assessment did not indicate his code status. Nursing notes for Resident #1 included the following documentation: *[DATE] at 5:28 p.m., the resident was admitted with skin issues, he had three pressure areas to his back that were Stage 1, they were covered. He also had a Stage II pressure ulcer to his coccyx and a crusty skin tear that was healing on his left elbow. There was no other documentation in the nursing notes until 12:50 a.m. *[DATE] at 12:50 a.m., LVN A entered Resident #1's room to obtain his vital signs. The resident was found to be not breathing, no respirations, and no pulse. The hospice RN was notified and informed LVN A Resident #1 was a full code. CPR was then initiated and emergency medical services EMS was notified, CPR was continued until EMS arrived and took over. CPR was continued by EMS until orders were obtained from the medical director to stop CPR, Resident # 1 was pronounced dead at 1:25 a.m. The [DATE] MAR indicated [REDACTED] 8:00 p.m. - [MEDICATION NAME] 10 milligram (mg) 8:00 p.m. - [MEDICATION NAME] 20 mg 8:00 p.m. - [MEDICATION NAME] 0.25 mg 8:00 p.m. - [MEDICATION NAME] 5 mg There was no documentation Resident #1 received any of these medications. During an interview on [DATE] at 11:25 a.m. the hospice nurse said Resident #1 was admitted on [DATE] at approximately 5:30 p.m. She said she wrote physician orders [REDACTED]. She said the do not resuscitate (DNR) would be faxed the next morning to his responsible party. The hospice nurse said she got a call around 12:50 a.m. from LVN A that the resident was not breathing. The hospice nurse said she informed LVN A Resident #1 was still a full code and she responded, "are you kidding me?" During an interview on [DATE] at 2:00 p.m., RN B said she assessed Resident #1 on admission at 5:26 p.m. and looked in on him at 9:00 p.m., but did not document anything more at that time. She said it was understood that you check on residents every two hours. RN B said she forgot to give Resident #1's medications. She said, "I was wrong." RN B said she told the oncoming shift nurse, LVN A that Resident #1 was on hospice, but was a full code. She said she did not write the information on the 24 hour report. RN B said the social worker was responsible for putting the code status information in the charts. During an interview on [DATE] at 2:05 p.m., NA D said she was assigned to Resident #1 and she worked a double shift, but did not "lay eyes" on Resident #1 during the 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shifts on [DATE] or [DATE]. During an interview on [DATE] at 4:10 p.m., EMS E said they received a call from the facility, and upon arrival at 1:00 a.m. they found LVN A doing chest compressions. He said he and another paramedic took over the code and pronounced Resident #1 dead at 1:25 a.m. EMS E said he estimated the resident had been dead from one to three hours because he had some lividity (gravitational pooling of blood that occurs within 30 minutes of the heart stopping) and was a little stiff. During an interview on [DATE] at 5:20 p.m., LVN A said she reported to work on [DATE] at around 9:45 p.m. and was told about a new admission. She said the evening shift nurse RN B told her Resident #1 was a hospice resident, but not that he was a full code. LVN A said it was understood residents should be checked on every two hours but she did not "lay eyes" on Resident #1 until 12:50 a.m. on [DATE] and he was not breathing. She said she ran down the hall and called the hospice nurse who informed her he was a full code. She said she had another staff call 911 while she started CPR on the resident. LVN A said EMS arrived and took over CPR without success and Resident #1 was pronounced dead on [DATE] at 1:25 a.m. During an interview on [DATE] at 9:15 a.m., the DON said Resident #1 was admitted on [DATE] on the evening shift. The DON said he was found unresponsive and LVN A did not know he was a full code. The DON said the charge nurses were responsible for placing a red or green sheet on the front of a new resident's record when the social worker was not available. She also said the charge nurses were responsible for the initial care plan and administering ordered medications. The DON said NA D failed to provide care for Resident #1 on the night shift on [DATE]. The DON said the nurse had not checked on the new resident even though he should have been checked every two hours. The DON said CNAs checked on Resident #1; however, there was no documentation that any staff checked Resident #1 after his initial assessment at 5:26 p.m. During an interview on [DATE] at 10:30 a.m., CNA C said he passed ice around 10:45 p.m. and Resident #1 was in his room in bed. He said the resident appeared asleep, was breathing slowing, and his eyes were twitching. CNA C said he did not know Resident #1's code status. He said there was no communication between nurses and CNAs regarding assistance with ADLS, code status, or anything pertaining to the resident care issues. He said he did not provide any care for Resident #1. An ADL assistance record dated [DATE] had no documentation regarding care provided for Resident #1. An undated care plan was found in Resident #1's record; however, the care plan was blank. During an interview on [DATE] at 9:12 a.m., the administrator she said she was unaware of a resident expiring in the facility on [DATE]. The administrator and DON were notified on [DATE] at 11:20 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on [DATE] at 3:07 p.m. and included: The POR included: "1). Role of the charge nurse on new admits regarding verifying code status and communicating to the next shift. Placing the new admit code status on the 24 hour report. Flagging the chart, shift to shift communication regarding plan of care. 2). The charge nurse each shift will be responsible for conducting a shift huddle to inform staff of after-hours admit and their current code status. 3). During regular working hours the social services director will be responsible for communication of code status of new admissions. 4). Assessing, monitoring and documenting clinical condition and status: 1. During their shift and communicating the changes to oncoming nurse. 2. Nurses will make rounds on new admits every 2 hours and/or as based on current clinical condition. 3. Clinical documentation based on resident clinical status. 4. Role of nurse during emergency and implementing immediate interventions as indicated based on resident clinical status. 5. Center conducted 100 % audit of current advance directives. All staff will be educated on code status identifier based on name color code on the door of their rooms. " On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: 8 CNAs were interviewed and said the resident's code status was going to be placed on the resident's doors using a green or red sticker. The CNAs said red means DNR and green means full code. The CNAs also said they were to check new admissions as well as other residents every two hours and more often depending on the resident's condition. They said they would report any changes to the charge nurses immediately. 8 nurses were interviewed and said they would verify code status of new residents and communicate to the next shift by using the 24 hour report. They also said they would make rounds every two hours and/or more often as based on current clinical condition. All licensed nursing personnel were in-serviced by 3:00 p.m. on [DATE]. On [DATE] at 4:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list dated [DATE] provided by the administrator on [DATE] noted eight residents were admitted during [DATE].

Based on observation, interview, and record review, the facility failed to ensure the physician was immediately consulted for a significant change in condition for 2 of 5 residents reviewed for changes of conditions. (Resident #s 14 and 3) Immediate Jeopardy 1. The facility failed to notify and consult with the physician when Resident #14, who had a recent hospitalization for gastrointenstinal bleeding, had a blood pressure drop and increased heart rate (symptoms of [MEDICAL CONDITION]). One hour and twenty minutes later, she was found unresponsive with no pulse and no respirations. CPR was initiated and she was transferred to hospital where she died 2 days later. This failure contributed to the death of Resident #14. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Resident #3's oxygen saturation dropped to 88% (reference range ,[DATE]%). Staff administered oxygen from [DATE] to [DATE] without consulting the physician regarding Resident #3's drop in oxygen saturation. This failure could place 36 residents experiencing changes in condition at risk for unmet medical needs or death. Findings included: 1. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #14 was dependent on staff for ADLs, transfers, and personal hygiene. The clinical record for Resident #14 contained no care plans for [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th edition, page 605 indicated a rapid heart rate and drop in blood pressure were signs and symptoms of [MEDICAL CONDITION]. A nursing note dated [DATE] at 6:01 p.m. indicated Resident #14 was complaining of fullness in her upper abdomen and nausea. The resident's primary physician was notified and new orders were received to check her vital signs every four hours for twelve hours and report any "abnormal vital signs". The nursing note indicated Resident #14's blood pressure at 5:40 p.m. was ,[DATE] and her heart rate was 74. A nursing note dated [DATE] at 3:10 a.m., indicated Resident #14's blood pressure was ,[DATE] at 1:15 a.m. and her heart rate was 89. The note indicated she continued to complain of abdominal pain, distention, and diarrhea. The note indicated she had decreased bowel sounds. The note did not indicate the physician was consulted regarding Resident #14's drop in blood pressure, increased heart rate, abdominal pain, distention, or diarrhea. Nursing notes dated [DATE] at 3:26 a.m. indicated the following: *2:35 a.m., nurse called to Resident #14's room by CNA, resident was unresponsive without a heart rate and breath sounds. CPR was started; *2:36 a.m., staff arrived in resident room with the crash cart as CPR continued. Oxygen was applied at 15 liters per minute, resident was suctioned; *2:38 a.m., no heart rate felt, CPR continued; *2:45 a.m., EMS arrived to relieve nurse of CPR; *3:00 a.m., EMS reported resident had a heart rate and was transported to the hospital and physician notified. A hospital patient summary report dated [DATE] indicated Resident #14 was received at the emergency room unconscious following a [MEDICAL CONDITION]. The report indicated Resident #14 had a heart rate on arrival to the emergency room , but no spontaneous respirations. According to the report, Resident #14 was admitted to the intensive care unit in critical condition on a ventilator. Resident #14's hospital physician progress notes [REDACTED]. "9:50 a.m. overall prognosis poor; and 6:15 p.m. absent of respiration and heart rate, pupils dilated and nonreactive, time of death 6:12 p.m." During an interview on [DATE] at 11:35, Resident #14's primary care physician said considering the resident's recent hospital admission for a [MEDICAL CONDITION], he would have expected to be notified when Resident #14's blood pressure dropped from ,[DATE] to ,[DATE]. He said he would have given orders to have the resident transferred to the hospital at the time the blood pressure of ,[DATE] was obtained. During an interview on [DATE] at 6:20 p.m., LVN I said Resident #14 complained of "feeling full", nausea, and like she needed to belch on [DATE]. She said she gave Resident #14 a dose of [MEDICATION NAME]. She said she called the physician and received orders to take Resident #14's blood pressure and heart rate every 4 hours for 12 hours and notify him of abnormal findings. She said she was aware Resident #14 had a history of [REDACTED]. During an interview on [DATE] at 6:30 p.m., CNA D said Resident #14 complained of having diarrhea at 10:00 p.m. on [DATE]. She said she gave Resident #14 orange juice at 1:15 a.m. She checked on the resident again at 1:30 a.m. and Resident #14 was sitting in bed drinking her juice. When she made rounds at 2:30 a.m., she found Resident #14 unresponsive without a heart rate or respirations. She said Resident #14 had a white foamy substance coming out of her mouth. During an interview on [DATE] at 3:30 a.m., RN P said Resident #14 was alert when she assessed her at 1:15 a.m. on [DATE]. She said she checked Resident #14's blood pressure at that time and it was ,[DATE]. She said she did not consult the physician because she did not think the resident's blood pressure was low enough to call him. She said given the resident's history of a [MEDICAL CONDITION], she should have consulted the physician with the drop in blood pressure. The policy and procedure for Documentation Guidelines dated [DATE] indicated the staff were to accurately communicate information to physicians and other health care practitioners. The administrator was notified on [DATE] at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:20 p.m. and included: *all licensed nurses would be educated about consulting physician of changes in condition such as physical, mental, psychosocial such as deterioration in health, life threatening condition, clinical complications; A need to alter treatment significantly; and need to transfer or discharge a resident to the hospital; *all nurses would be educated on head to toe assessments; *CNAs would be in-serviced regarding identifying early risk of significant changes and the "stop and watch tool"; and *all current residents would be assessed. The physician would be consulted on any out of parameters change of condition. The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Fourteen CNAs were interviewed and said they had recently been in-serviced regarding changes in resident condition and used the "stop and watch" tool. Five nurses were interviewed and said they had recently been in-serviced regarding physician consultation with significant change of condition and assessment and documentation. The new undated policy for notification of changes in condition with residents with a history or [DIAGNOSES REDACTED]. The new physician notification log was reviewed and the following parameters were included: "If the systolic blood pressure drops 30 points EXP: ,[DATE] then drops to ,[DATE]; If the diastolic blood pressure drops 15 points EXP: ,[DATE] then drops to ,[DATE]; and If heart rate increases by 20 beats per minute EXP: 80 bpm to 100 bpm the MD needs to be notified of change of condition for medical intervention". On [DATE] at 9:20 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Physician orders [REDACTED]. The orders did not include an order for [REDACTED]. The MDS dated [DATE] indicated Resident #3 was moderately hard of hearing, was sometimes able to make herself understood and sometimes understood others. The MDS did not indicate she received oxygen. The care plan dated [DATE] indicated Resident #3 had difficulty making decisions and communicating. The care plan did not address breathing difficulties or oxygen use. During observations on [DATE], Resident #3 was wearing oxygen at 3 liters per nasal cannula at the following times: *11:38 a.m., *2:10 p.m., and *4:12 p.m. During observations on [DATE], Resident #3 was wearing oxygen at 3 liters per nasal cannula (oxygen tubing carrying oxygen to the nose) at the following times: *8:20 a.m., *9:02 a.m., *9:40 a.m., *1:02 p.m., *5:15 p.m., and *5:47 p.m. A nursing note dated [DATE] at 5:55 p.m., indicated Resident #3 was in bed lethargic. She was unresponsive and her eye lids were halfway closed. Her pupils were fixed and she had labored respirations. The note indicated oxygen at 2 liters via nasal cannula was placed at that time. During an interview on [DATE] at 5:20 p.m., LVN J said on [DATE], Resident #3's oxygen saturation (amount of oxygen in the blood stream) dropped to 88%. She said she put oxygen on Resident #3 at 2 liters per nasal cannula at that time. She said she forgot to consult the physician about Resident #3's oxygen saturation dropping to 88% and obtain an order for [REDACTED]. The website http://www.mayoclinic.com/health/hypoxemia/MY accessed [DATE] indicated, "Normal oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low". During an interview on [DATE] at 5:50 p.m., after surveyor intervention, LVN K said she received an order from Resident #3's physician for oxygen at 2 liters per nasal cannula. A physician's orders [REDACTED]. During an interview on [DATE] at 11:30 a.m., the DON said the physician should be consulted concerning an oxygen saturation of 88%. During an interview on [DATE] at 9:30 a.m., the administrator provided an undated list of 36 residents currently experiencing a change of condition. A physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for changes in condition. (Resident #14) The facility also failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 3 of 9 residents reviewed for pain. (Resident #s 14, 11, and 13) Immediate Jeopardy 1. The facility failed to consult with the physician when Resident #14, who had a recent hospitalization for gastrointenstinal bleeding, had a blood pressure drop and increased heart rate (symptoms of [MEDICAL CONDITION]). One hour and twenty minutes later, she was found unresponsive with no pulse and no respirations. CPR was initiated and she was transferred to hospital where she died 2 days later. This failure contributed to the death of Resident #14. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non Immediate Jeopardy 2. Resident #11 complained of pain during incontinent care and CNAs B and C did not acknowledge or report Resident #11's complaints of pain to the charge nurse. Her scheduled pain medication was not given. Staff were not aware of pain management interventions for Resident #11. 3. CNAs T and U continued to transfer Resident #13 using a mechanical lift, although the resident complained of pain during the transfers. These failures could place 36 residents experiencing changes in condition at risk for unmet medical needs or death and could also place 51 residents receiving pain management at risk for unrelieved pain. Findings included: 1. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #14 was dependent on staff for ADLs, transfers, and personal hygiene. The clinical record for Resident #14 contained no care plans for [MEDICAL CONDITION]. The Lippincott Manual of Nursing Practice, 7th edition, page 605 indicated a rapid heart rate and drop in blood pressure were signs and symptoms of [MEDICAL CONDITION]. A nursing note dated [DATE] at 6:01 p.m. indicated Resident #14 was complaining of fullness in her upper abdomen and nausea. The resident's primary physician was notified and new orders were received to check her vital signs every four hours for twelve hours and report any "abnormal vital signs". The nursing note indicated Resident #14's blood pressure at 5:40 p.m. was ,[DATE] and her heart rate was 74. A nursing note dated [DATE] at 3:10 a.m., indicated Resident #14's blood pressure was ,[DATE] at 1:15 a.m. and her heart rate was 89. The note indicated she continued to complain of abdominal pain, distention, and diarrhea. The note indicated she had decreased bowel sounds. The note did not indicate the physician was consulted regarding Resident #14's drop in blood pressure, increased heart rate, abdominal pain, distention, or diarrhea. Nursing notes dated [DATE] at 3:26 a.m. indicated the following: *2:35 a.m., nurse called to Resident #14's room by CNA, resident was unresponsive without a heart rate and breath sounds. CPR was started; *2:36 a.m., staff arrived in resident room with the crash cart as CPR continued. Oxygen was applied at 15 liters per minute, resident was suctioned; *2:38 a.m., no heart rate felt, CPR continued; *2:45 a.m., EMS arrived to relieve nurse of CPR; *3:00 a.m., EMS reported resident had a heart rate and was transported to the hospital and physician notified. A hospital patient summary report dated [DATE] indicated Resident #14 was received at the emergency room unconscious following a [MEDICAL CONDITION]. The report indicated Resident #14 had a heart rate on arrival to the emergency room , but no spontaneous respirations. According to the report, Resident #14 was admitted to the intensive care unit in critical condition on a ventilator. Resident #14's hospital physician progress notes [REDACTED]. "9:50 a.m. overall prognosis poor; and 6:15 p.m. absent of respiration and heart rate, pupils dilated and nonreactive, time of death 6:12 p.m." During an interview on [DATE] at 11:35, Resident #14's primary care physician said considering the resident's recent hospital admission for a [MEDICAL CONDITION], he would have expected to be notified when Resident #14's blood pressure dropped from ,[DATE] to ,[DATE]. He said he would have given orders to have the resident transferred to the hospital at the time the blood pressure of ,[DATE] was obtained. During an interview on [DATE] at 6:20 p.m., LVN I said Resident #14 complained of "feeling full", nausea, and like she needed to belch on [DATE]. She said she gave Resident #14 a dose of [MEDICATION NAME]. She said she called the physician and received orders to take Resident #14's blood pressure and heart rate every 4 hours for 12 hours and notify him of abnormal findings. She said she was aware Resident #14 had a history of [REDACTED]. During an interview on [DATE] at 6:30 p.m., CNA D said Resident #14 complained of having diarrhea at 10:00 p.m. on [DATE]. She said she gave Resident #14 orange juice at 1:15 a.m. She checked on the resident again at 1:30 a.m. and Resident #14 was sitting in bed drinking her juice. When she made rounds at 2:30 a.m., she found Resident #14 unresponsive without a heart rate or respirations. She said Resident #14 had a white foamy substance coming out of her mouth. During an interview on [DATE] at 3:30 a.m., RN P said Resident #14 was alert when she assessed her at 1:15 a.m. on [DATE]. She said she checked Resident #14's blood pressure at that time and it was ,[DATE]. She said she did not consult the physician because she did not think the resident's blood pressure was low enough to call him. She said given the resident's history of a [MEDICAL CONDITION], she should have consulted the physician with the drop in blood pressure. The policy and procedure for Documentation Guidelines dated [DATE] indicated the staff were to accurately communicate information to physicians and other health care practitioners. The administrator was notified on [DATE] at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:20 p.m. and included: *all licensed nurses would be educated about consulting physician of changes in condition such as physical, mental, psychosocial such as deterioration in health, life threatening condition, clinical complications; A need to alter treatment significantly; and need to transfer or discharge a resident to the hospital; *all nurses would be educated on head to toe assessments; *CNAs would be in-serviced regarding identifying early risk of significant changes and the "stop and watch tool"; and *all current residents would be assessed. The physician would be consulted on any out of parameters change of condition. The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Fourteen CNAs were interviewed and said they had recently been in-serviced regarding changes in resident condition and used the "stop and watch" tool. Five nurses were interviewed and said they had recently been in-serviced regarding physician consultation with significant change of condition and assessment and documentation. The new undated policy for notification of changes in condition with residents with a history or [DIAGNOSES REDACTED]. The new physician notification log was reviewed and the following parameters were included: "If the systolic blood pressure drops 30 points EXP: ,[DATE] then drops to ,[DATE]; If the diastolic blood pressure drops 15 points EXP: ,[DATE] then drops to ,[DATE]; and If pulse increases by 20 beats per minute EXP: 80 bpm to 100 bpm the MD needs to be notified of change of condition for medical intervention". On [DATE] at 9:20 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Physician orders [REDACTED]. Resident #11 was to receive [MEDICATION NAME] 325 mg ,[DATE] tablets every 4 hours as needed for pain, [MEDICATION NAME] 50 mg every 4 hours as needed for pain, Tylenol 325 mg every 4 hours as needed for pain, and [MEDICATION NAME] 25 mcg/hr patch every 3 days for pain. The most recent MDS dated [DATE] indicated Resident #11 required the extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Resident #11 was always incontinent of bladder, frequently incontinent of bowel, did not resist care, and was able to understand others and make herself understood. The MDS pain assessment indicated Resident #11 had frequent and severe pain. An undated care plan indicated Resident #11 was at risk or had actual pain. The goals noted pain would be relieved or reduced within 40 minutes of an intervention. Interventions included: *monitor for verbal/nonverbal indications of discomfort; *reassure resident that comfort measures will be implemented; *ensure an environment conducive to comfort (quiet/music/lighting/aroma/etc.); *assess need for preventive measures prior to ADLs, treatments, exercise, etc; *position with pillows (devices as ordered) to promote comfort; and *use (medication/prescriptive measure, warm/cool compresses, other) to treat/prevent pain. A pain evaluation dated [DATE] indicated Resident #11's resident profile, pain history, evaluation, and education sections were blank. The narrative note of the pain evaluation noted, "Resident complains of no pain at this time, will continue to monitor". Resident #11 did not have additional pain evaluations. The pain evaluation did not address type, characteristics, frequency, intensity, or interventions to manage Resident #11's pain. During the following observations, Resident #11 was in bed lying on her back on a without pillows or other pain relieving devices: *[DATE] at 2:33 p.m. *[DATE] at 5:30 p.m. *[DATE] at 8:10 a.m. *[DATE] at 6:05 p.m. During an interview on [DATE] at 11:18 a.m., the ADON said Resident #11 was cognitive with occasional confusion and complained of pain often. During an interview on [DATE] at 5:15 p.m., Resident #11 was in bed lying on her back. She did not have pillows or other pain relieving devices. Resident #11 said her bottom was sore due to having to "wear a diaper and using bathroom on myself". She said she did not sleep well because she was always in pain. She said she often did not go to activities because she had back pain. She said she told CNAs and nurses when she experienced pain, but it seemed they did not "take time to listen or pay attention to me". During an observation on [DATE] at 9:59 a.m., CNAs B and C provided incontinent care for Resident #11. Resident #11 had an open area on her right buttock and in her gluteal fold. Resident #11 complained of "burning" pain as CNA B cleaned her buttocks. CNA B continued to clean without acknowledging Resident #11's pain. Resident #11 said "my butt is hurting". CNA B replied, "We are fixing to get you up; hopefully after we get you up, it will stop hurting". CNA B continued to clean Resident #11 without addressing her pain. Resident #11 said, "Oh, that hurts my tailbone and my butt". During an interview on [DATE] at 11:10 a.m., the DON said Resident #11 complained of pain often and received routine and PRN pain medications. During an interview on [DATE] at 11:11 a.m., Resident #11 was in her wheelchair without a pressure relieving cushion. She said her bottom still hurt. During an interview on [DATE] at 1:36 p.m., Resident #11 said her bottom hurt at a "5" on a scale of ,[DATE] (0 = no pain, 10 = severe/excruciating pain). She said on the night prior, she hurt so bad she could not sleep. During an interview on [DATE] at 1:43 p.m., LVN A said she was the charge nurse for Resident #11. She said she was responsible for administering PRN pain medication. She said she was not aware Resident #11 had complained of pain today. She said Resident #11 had not received any PRN pain medication today. LVN A said Resident #11 received a [MEDICATION NAME] every three days. The February MAR for [DATE] through [DATE] indicated Resident #11's routine pain medication, a [MEDICATION NAME], was administered as following: *[DATE] at 8:15 a.m. "was not administered" *[DATE] at 9:16 a.m. administered A medication error report dated [DATE] indicated Resident #11 did not receive her scheduled pain patch on [DATE]. A reason for the missed dose was not given. The February 2013 MAR indicated [REDACTED]. The MAR indicated signs and symptoms of pain or expresses of discomfort 0 =no pain 1=yes". Resident #11's pain was documented as "0" [DATE] through [DATE]. During an observation with the treatment nurse on [DATE] at 2:15 p.m., Resident #11 was lying on her back. She did not have pillows or other pain reliving devices in place. During an interview on [DATE] at 3:20 a.m., CNA W said Resident #11 complained of pain often. She said if a resident complained of pain, she reported it to the charge nurse. CNA W said she was not aware of interventions to address Resident #11's pain. During an interview on [DATE] at 3:25 a.m., CNA V said Resident #11 complained of pain often. She said if a resident complained of pain, she reported it to the charge nurse. CNA V said she was not aware of interventions to address Resident #11's pain. During an interview on [DATE] at 3:30 a.m., CNA X said prior to today she had been instructed to use pillows to eliminate pain for Resident #11. During an interview on [DATE] at 3:35 p.m., CNA Y said Resident #11 had recently complained of pain to her tailbone and legs. CNA Y said Resident #11 said it was painful to be on her back, so pillows were used to eliminate the pain. CNA Y said the pain complaints were reported to LVN R. During an interview on [DATE] at 3:40 p.m., the AD said Resident #11 stopped participating in activities as often during the past ,[DATE] months. She said Resident #11 often told her she did not want to go to activities because she was in pain. The AD said she did not notify anyone of Resident #11's lack of participation or pain because it was "discussed in a care plan meeting". The AD said she was not aware of pain interventions to address Resident #11's pain. During an observation and interview on [DATE] at 8:40 a.m., Resident #11 was in bed on a low air loss mattress. She said a new mattress was put on her bed at approximately 5:30 a.m. and she felt "a lot better" and her bottom was not hurting as bad as before. During an interview on [DATE] at 9:12 a.m., CNA B said Resident #11 was able to verbalize pain. CNA B said Resident #11 complained of pain the day before during incontinent care due to a pressure sore on her bottom. CNA B said she did not notify the nurse of Resident #11's pain. CNA B said if Resident #11 complained of pain from something other than a pressure sore, she might report to the charge nurse. During an interview on [DATE] at 9:45 a.m., the DON said Resident #11 did not receive her scheduled pain patch on [DATE] due to a medication error. During an interview on [DATE] at 10:40 a.m., MA Z said Resident #11 complained of pain every day. 3. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #13 was cognitively intact and required extensive assistance with transfers. The care plan dated [DATE] indicated Resident #13 required staff assistance with mobility. The care plan approaches indicated Resident #13 was unable to transfer independently and required extensive assistance of two staff members with all transfers. The care plan indicated Resident #13 was at risk for pain in her left hip, but did not address pain during transfers. During an observation on [DATE] at 11:40 a.m., CNAs T and U were using a sit-to-stand mechanical lift to transfer Resident #13. CNAs T and U placed straps on Resident #13, sat her up on the side of the bed and secured her to the mechanical lift. CNA T walked to the end of Resident #13's bed and stood by the wheel chair. CNA U stepped away from Resident #13's side to operate the lift. CNA U began to raise Resident #13 off the bed and Resident #13 said, "That scares me. It hurts." CNA U continued to lift Resident #13 and replied, "Don't be scared just trust me." Resident #13 continued to tell CNA U she was scared and the straps were hurting her arms. CNAs T and U did not address Resident #13's complaints of pain. After surveyor intervention, CNAs T and U stopped the transfer and asked the ADON for assistance. During an interview on [DATE] at 11:45 a.m., CNA U said she should have put Resident #13 back on her bed if she was scared or complained of pain during a transfer. During an interview on [DATE] at 11:50 a.m., CNA T said Resident #13 always said she hurt while being transferred with the mechanical lift. She said when Resident #13 complained of pain, they continued the transfer. She said when Resident #13 was placed in her wheelchair, she would calm down. During an interview on [DATE] at 11:55 a.m., the ADON said she was not aware Resident #13 hurt during transfers. During an interview on [DATE] at 10:40 a.m., Resident #13 said the sit-to-stand lift always hurt her shoulders when she was transferred. During an interview on [DATE] at 10:45 a.m., the DON said she was not aware of any residents who hurt while being transferred with the sit-to-stand lift. The mechanical lift program, tender lift and care, dated [DATE] indicated the purpose of the policy was to provide residents with the safe assistance by mechanical lifts and eliminate unnecessary and possible unsafe manual lifting, transferring and repositioning by employees. The program indicated the sit-to-stand lift would be used for residents who can bear 50% weight and offer assistance with transfers/lifts and have the ability to follow simple commands. The policy did not address what to do if residents complained of pain during a transfer. The pain management and assessment policy dated [DATE] indicated adequate treatment of [REDACTED]. The policy indicated residents would be evaluated for pain upon admission and with a new complaint of pain, quarterly and with a significant change in condition, and on the day of discharge. The policy described pain as an unpleasant sensory and emotional experience that can be acute, recurrent, or persistent. The policy's procedure to be followed for pain included evaluation, pain management addressed in resident's care plan, treatment and documentation, pharmacist's consultation and physician review. The policy noted all pain evaluations would be placed in the medical record. The policy did not address pain during transfers. During an interview on [DATE] at 9:30 a.m. the administrator provided an undated list of 36 residents currently experiencing a change of condition. During an interview on [DATE] at 12:37 p.m., the DON said 51 residents received pain management.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development and worsening of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. (Resident #11) Resident #11 was admitted without a pressure ulcer and developed a Stage II pressure ulcer that worsened to an un-stageable pressure ulcer. The facility did not provide accurate assessment, nutritional interventions and pressure relieving devices. This failure contributed to the development and worsening of a pressure ulcer for Resident #11 and could place 10 residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers. Findings included: Physician orders [REDACTED]. The care plan dated 12/13/12 indicated Resident #11 had a history of [REDACTED]. The care plan approaches included: *food intake would be monitored and reported to physician and dietician if any decline; *pillows, air mattress, and other supportive devices would be used for positioning; *out of bed activities would be encouraged; *peri cleanser would be used following every incontinent episode; and *lab work would be monitored and reported to physician and dietician as needed. The most current RD evaluation dated 12/14/12 indicated Resident #11 had a decreased appetite and was at risk for weight loss, skin breakdown, and dehydration. The MDS dated [DATE] indicated Resident #11 required extensive assistance with all ADLs except eating, was frequently incontinent of bowel, and always incontinent of bladder. The MDS indicated Resident #11 did not have pressure ulcers, but was at risk for developing pressure ulcers. Body audit reports for Resident #11 indicated the following: *1/21/13 no pressure ulcers; *1/28/13 on the right buttock a .25 cm x .25 cm x 1 cm scratch and mild redness around the coccyx; and *2/4/13 the scratch noted on 1/28/13 was documented as a 2 cm x 2 cm x .1 cm Stage II to the right buttock. The pressure ulcer evaluation dated 1/28/13 indicated Resident #11 did not have any wounds. The narrative indicated Resident #11 had a .25 cm round scratch to the right buttock which had a thin layer of skin covering the site. The evaluation indicated staff would use Sensi-Care (protective skin barrier) as preventative measures after pericare. The pressure ulcer evaluation dated 2/2/13 indicated Resident #11 had a 2 cm x 2 cm x .1 cm Stage II pressure ulcer on her right buttock. The wound bed was pink/red. The narrative note indicated the resident was encouraged to turn side to side to relieve pressure. The evaluation indicated treatment would include Sensi-Care to be applied to the area twice a day and as needed. The skin risk assessment dated [DATE] indicated Resident #11 was at high risk for developing pressure ulcers. The assessment indicated preventative measures included: pressure relieving mattress to the bed; pressure relieving cushion to chair, and turning and repositioning every 2 hours and as needed. A telephone order dated 2/4/13 indicated Resident #11's right buttock was to be treated with Sensi-Care twice a day and as needed for a Stage II pressure ulcer. The updated care plan dated 2/4/13 indicated Resident #11 had a 2 cm x 2 cm x .1 cm pressure ulcer on her right buttock. "Sensi-Care" was written on the bottom of the page. The care plan approaches included: *perform treatment per order, if no improvement within two weeks report to physician; *encourage oral fluid intake within dietary limits; *keep family/responsible party and physician informed of resident's progress; *assist with turning and repositioning every 2 hours and as needed; *use padding between pressure areas and positioning devices for proper body alignment; and *provide pressure relieving device for bed and wheel chair. During an interview on 2/4/13 at 11:18 a.m., the ADON said Resident #11 had a "red spot" on her buttocks, but it was not a pressure ulcer. During the following observations, Resident #11 was in bed lying on her back on a regular mattress without pillows or other pressure relieving devices: *2/4/13 at 2:33 p.m., *2/4/13 at 5:30 p.m., *2/5/13 at 8:10 a.m., and *2/5/13 at 6:05 p.m. On 2/7/13 at 12:30 p.m., the DON provided a copy of the manufacturer information for the mattress Resident #11 was using prior to surveyor intervention. The undated information indicated the mattress "may be appropriate through Stage II wounds ...Resident specific assessment could alter your particular usage of these mattresses". During an observation and interview on 2/5/13 at 5:15 p.m., Resident #11 was in bed lying on her back. She was on a regular mattress. She did not have pillows or other pressure relieving devices. She said she required help with all ADLs, including rolling over, and was incontinent. Resident #11 said she was afraid of getting "bed sores" and her bottom was sore. She said she told CNAs and nurses about the pain to her bottom. During an observation and interview on 2/6/13 at 9:59 a.m., CNAs B and C provided incontinent care for Resident #11. Resident #11 had an approximate 4 cm x 2 cm open wound on her right buttock with a dark red/purple area to the upper portion of the wound bed. Resident #11 complained of "burning" pain to the area. CNA B said Resident #11 had a really small "pin-point" area on her bottom when she came back from the hospital, but "it is much worse now". The CNAs applied barrier cream and transferred Resident #11 to her wheelchair. The wheelchair did not have a pressure relieving/reducing device. During an observation and interview on 2/6/13 at 11:11 a.m., Resident #11 was sitting in a wheelchair. The wheelchair did not have a pressure relieving/reducing device. She said her bottom hurt. During an interview on 2/6/13 at 1:36 p.m., Resident #11 was in her room sitting in her wheel chair without a pressure relieving/reducing device. During an observation and interview with the treatment nurse on 2/6/13 at 2:15 p.m., Resident #11 was lying on her back on a regular mattress. She did not have pillows or other pressure reliving devices in place. Resident #11 had a 4 cm x 2 cm open wound with a 2 cm x 2 cm area of yellow tissue to the upper half of the wound bed. The tissue surrounding the wound was red and non-blanchable. The treatment nurse said the yellow tissue was not easily removable from the wound bed. She said she noticed the yellow the day before, but had not consulted with the physician. The website <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/> accessed 2/12/13 indicated: Pressure Ulcer Stages Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (a layer or mass of yellow/cream colored dead tissue separated from surrounding living tissue). Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. The updated care plan dated 2/6/13, after surveyor intervention, indicated Resident #11 had a Stage II pressure ulcer on her coccyx. The care plan indicated Sensi-Care would be applied twice daily. All approaches from prior care plan remained in place. physician progress notes [REDACTED]. *on 1/29/13 abdominal pain and "bottom is raw"; and *on 2/6/13 4 cm x 3 cm Stage II opened area dried crust in center. During an interview on 2/6/13 at 3:30 p.m., CNA X said Resident #11 was unable to turn herself over in bed. CNA X said Resident #11 could use her trapeze bar to slide over a little. During an interview on 2/6/13 at 3:35 p.m., CNA Y said Resident #11 had complained of pain to her tailbone for the past 3-4 days. During an observation on 2/6/13 at 4:00 p.m., following survey intervention, Resident #11 had a pressure relieving pad in her wheel chair. She said her bottom did not hurt as bad since the pad had been placed in her chair. During an interview on 2/6/13 at 4:15 p.m., the DON said she did not have a protocol for interventions based on pressure ulcer risk assessment. During an observation and interview on 2/7/13 at 8:40 a.m., Resident #11 was in bed on a low air loss mattress. She said a new mattress was put on her bed at approximately 5:30 a.m. and she felt "a lot better". She said her bottom was not hurting as bad. During an interview on 2/7/13 at 9:00 a.m., the RD said she had not evaluated Resident #11 since 12/14/12. The RD said if she had been aware of Resident #11's declined appetite and pressure ulcer, she would have treated her more aggressively. The undated facility pressure ulcer prevention guidelines indicated a pressure reducing mattress and wheel chair cushion would be utilized for those identified at high risk. The guidelines indicated a plan for nutritional support would be established for residents at risk of developing pressure sores within seventy-two hours of admission. The facility treatment guidelines for skin/wound management policy dated 3/1/06 indicated the following: *prior to admission an assessment would be completed; *upon admission a risk assessment would be completed per protocol; *upon admission nursing, nutritional and therapy assessments would be completed and a visual skin assessment would be completed; The policy indicated a Stage II pressure ulcer would be treated with a transparent or [MEDICATION NAME] dressing (interacts with wound to absorb exudate). The CMS 672 dated 2/4/13 indicated there were 10 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to implement interventions to address self-injurious behavior for 1 of 5 residents sampled for behaviors. (Resident #1) Resident #1 had a known history of picking at her eyes, nose and mouth and had a prior corneal implant to her right eye. On 1/1/11, the resident picked at her eye and ruptured her eyeball. Resident #1's right eyeball had to be removed. The facility did not implement interventions to protect the resident's eye. These failures contributed to the necessity of surgical removal of Resident #1's right eyeball and could place 45 residents with behavior symptoms at risk of harm. Findings included: Consolidated physician orders [REDACTED]. Her [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] indicated Resident #1 rarely made herself understood and rarely understood others. Her cognitive skills for daily decision making were severely impaired. A care plan dated 11/9/10 indicated Resident #1 had a history of [REDACTED]. Staff were to monitor the resident's actions that could cause injury: *picking at her face, eyebrows, nose or eyes. *frequency of behavior of picking and report to nurse and physician and *make referrals to psychiatric services if indicated or if behaviors warrant. An incident report statement dated 1/1/11 written by LVN W indicated Resident #1 was found in bed with dried blood on her hands and a large amount of clotted blood coming from her right eye. Blood was also noted under the resident's head and neck. A post status incident report dated 1/1/11 indicated Resident #1 required total assistance with all needs related to advanced dementia. She had a history of [REDACTED]. Resident #1 had a prior corneal implant. At 11:00 p.m., the resident was bleeding from her right eye with blood under her fingernails, on her hands, and under her head and neck. A provider investigation report dated 1/3/11 indicated Resident #1 had a history of [REDACTED]." The resident's daughter confirmed these past behaviors and said the resident had a corneal implant "some years back". The resident's daughter said the ophthalmologist stated he felt the resident caught her finger on the healed suture line and caused the injury. The resident received aspirin therapy, [MEDICATION NAME] for anxiety and [MEDICATION NAME] for [MEDICAL CONDITION]. The resident was sent to the emergency room for evaluation and treatment. Surgery was scheduled for 1/5/11 for the removal of the eyeball. During an observation on 1/25/11 at 8:30 a.m., Resident #1 was in the TV room. Resident #1's right eyeball had been removed. In an interview on 1/25/11 at 9:50 a.m., the DON said Resident #1 had always picked at her nose, eye brows, and face. A statement written by CNA X on 1/26/11 indicated on the afternoon of 1/1/11 Resident #1 had pink fluid coming from her right eye. CNA X took the resident to charge nurse LVN Y. CNA X said the nurse said it looked like the resident had scratched her eye. After supper CNA X assisted the resident to bed and the resident still had fluid coming from her right eye. When CNA X last saw the resident that night, the resident still had fluid draining from her eye. Resident #1 had a behavior monitoring sheet dated 10/2010 for depression and anxiety. The next behavior monitoring sheet was dated January 2011 with an initial date of 1/26/11. The behaviors to be monitored were picking, scratching and rubbing. On 1/25/11 at 1:46 p.m., during an interview, LVN W said Resident #1 constantly picked at her eyebrows and would pick her nose until it bled. On the night of 1/1/11 she was called to the room by CNA Z. Resident #1 had blood on her hands and neck and her eye was bleeding. LVN W said the resident did not appear to be in pain. Resident #1 did not have any special precautions in place at that time. On 1/25/11 at 2:03 p.m., during an interview, CNA X said on 1/1/11 around 3:15 p.m. Resident #1's eye was red and had pink fluid running from her right eye. She took the resident to the charge nurse and the nurse said she would call the physician. She said she had last seen the resident on 1/1/11 around 9:00 p.m. Resident #1's eye was still red and had a small amount of drainage. On 1/25/11 at 3:17 p.m., during an interview, LVN Y, charge nurse, said CNA X brought Resident #1 to her with concerns about her eye. The LVN said the right eye was red. She did not recall any drainage. It looked like something may have been in the resident's eye. LVN Y said she had flushed the resident's eye with normal saline. She had not called the physician. The resident was always picking her nose,and would pick it until it bled. The LVN said she had checked the resident again about seven and she was asleep. The undated facility 802 form received 1/24/11 indicated 45 residents had behavior symptoms. The facility was given the opportunity to provide additional information during the exit conference. No information was provided.