Every finding on record at Briarcliff Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 (Resident #1) of 5 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication Haldol (Haloperidol Decanoate) (an antipsychotic) for Resident #1 with a diagnosis of dementia. This failure could put residents at risk of chemical restraint, adverse reactions or harmful side effects. The findings included: Record review of Resident #1's admission record dated 08/19/2026, revealed a [AGE] year-old male with an admission date of 08/05/2025. Resident #1's diagnoses included dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) severe, with psychotic disturbance (often called dementia-related psychosis - occurs when a person with a cognitive decline also experiences false beliefs, known as delusions, or senses thing that are not there, known as hallucinations [a sensory experience - such as seeing, hearing, smelling, tasting, or feeling something - that feels completely real but is created by the mind without any actual external stimulus]) and unspecified psychosis (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality) not due to a substance or known physiological condition. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 04, indicating severe cognitive impairment. Resident #1 had no potential indicators of psychosis such as hallucinations or delusions (a firm, fixed belief that was not true and did not change even when clear facts or proof show it was wrong). Resident #1 received antipsychotics on a routine basis. Record review of Resident #1's care plan, dated 08/05/2026, revealed FOCUS: [Resident #1] has impaired cognitive function/dementia or impaired thought processes r/t Dementia, Psychosis. Date Initiated: 08/06/2025 Revision on: 09/15/2025. [sic] FOCUS: [Resident #1] uses psychotropic medications (Haldol) r/t psychosis agitation and Keppra for mood disorder. Date Initiated: 08/06/2025 Revision on: 08/18/2026. [sic] INTERVENTIONS/TASKS: Haldol Injection Solution Black Box Warning Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Haloperidol is not approved for the treatment of patients with dementia-related psychosis. Date Initiated: 09/15/2025 Revision on: 12/16/2025. Record review of Resident #1's Physician's order dated 03/25/2026 revealed Haloperidol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate). Inject 1 dose intramuscularly one time a day starting on the 28th and ending on the 28th every month related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Record review of Resident #1's pharmacy recommendation on 06/26/2026 revealed, Antipsychotic Gradual Dose Reduction Attempt - Haloperidol 50 mg monthly. All agents following within the psychoactive category (without regard to indication) fall under gradual dose reduction guidelines. Please address the appropriate response below: 1.X Please change order to: Haloperidol 37.5 mg IM monthly on the 28th. Signed by MH NP 06/29/3026. Record review of Resident #1's Physician's order written by MHNP dated 06/29/2026 revealed Haldol Decanoate Intramuscular Solution (Haloperidol Decanoate). Inject 37.5 mg intramuscularly one time a day starting on the 28th and ending on the 28th every month related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Record review of Resident #1's June 2026 MAR revealed Resident #1 was administered Haloperidol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 1 dose intramuscularly one time a day starting on the 28th and ending on the 28th every month related to unspecified psychosis, not due to a substance or physiological condition on 06/28/2026 at 06:00 a.m. Record review of Resident #1's July 2026 MAR revealed Resident #1 was administered Haloperidol Decanoate Intramuscular Solution (Haloperidol Decanoate) Inject 37.5 mg intramuscularly one time a day starting on the 28th and ending on the 28th every month related to unspecified psychosis, not due to a substance or physiological condition on 07/28/2026. During an interview on 08/19/2026 at 04:35 p.m., Resident #1 stated he was sad because he lost his suitcase that had suits in it. He said he did not know where it was and he was grieved. During an interview on 08/19/2026 at 05:00 p.m., ADON B stated she had spoken to MHNP before about antipsychotics and she said some residents with Alzheimer's/Dementia needed antipsychotics and if they were not given the antipsychotics, they would not be helped. During an interview on 08/20/26 at 01:08 p.m., Medical Director stated psychosis was not an appropriate indication for Haldol when a resident had Alzheimer's or dementia. He said if they did not have an appropriate indication for Haldol for Resident #1, he should not be getting the antipsychotic. Medical Director stated he would be going to the facility tomorrow (08/21/2026) and he would review Resident #1's medication and if Haldol especially the Haldol was being given with the indication of psychosis, he would discontinue the Haldol and notify the PCP why he discontinued it. During an interview on 08/20/2026 at 01:40 p.m., ADON C stated Resident #1 had a history of behaviors and delusions. ADON C stated she had never seen Resident #1 agitated. ADON C stated when she would receive an order for an antipsychotic for a resident with Alzheimer's or dementia, the order would be given by the MHNP. ADON C stated the indication on Resident #1's Haldol was psychosis. She said she just follows the doctor's order. She said she knew (regulatory) did not want antipsychotics given with an inappropriate indication. She said she had to follow the doctor's order. She said she was aware of the black box warning for Haldol and that could be the negative effect. ADON C stated they had been in-serviced on antipsychotics within the last three months or so. During an interview on 08/20/2026 at 03:45 p.m., Pharmacist stated antipsychotics ordered for Alzheimer's/dementia residents were reviewed monthly for each resident. He stated indications for antipsychotics were checked by pharmacy. He said for short-term usage of Haldol, psychosis would be an appropriate indication. He said antipsychotics could not be stopped abruptly. During an interview on 08/20/26 at 05:07 p.m., the DON stated Resident #1 had delusions. She stated a resident with Alzheimer's/Dementia should not be given antipsychotic with an indication of psychosis. The DON stated the negative effect of giving an antipsychotic to a resident with diagnosis of Alzheimer's/Dementia with an inappropriate indication could be the black box warning said it increased their mortality rate. Record review of facility's Use of Psychotropic Medication(s) Policy dated 03/05/2025 revealed, Record review of the facility's Psychotropic Drug Use policy dated 03/05/2025 reflected Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. Definitions:'Adequate indications for use' refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treaments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indications for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. [sic] 'Chemical restraint' refers to any drug used for discipline or makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated because they are less dangerous to a resident's health and safety. Policy Explanation and Compliance Guidelines:1.A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2.Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #1) reviewed for accuracy and completeness of clinical records.The facility failed to ensure MA documented Resident #1's blood pressure on the eMAR when Resident #1's metoprolol (blood pressure medication) was held on July 4th of 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included:Record review of Resident #1's face sheet dated 07/29/26 revealed an [AGE] year-old female with an original admission date of 03/14/26 and a current admission date of 11/14/24. Diagnosis included Essential Primary Hypertension (chronic high blood pressure with no single, identifiable cause, developing slowly over time). Record review of Resident #1's Quarterly MDS Assessment with an unknown date revealed a BIMs score of 0 which indicated severe cognitive impairment. Record review of Resident #1's Comprehensive Care Plan dated 07/29/26 revealed the problem [Resident #1] has hypertension (HTN) and Hyperlipidemia (elevated cholesterol), at risk for elevated blood pressure and other complications initiated on 04/02/24. An intervention listed for the problem included Obtain blood pressure readings as ordered initiated on 04/02/24. Record review of Resident #1's order summary dated 07/29/26 revealed an active order for metoprolol 50 MG give 1 tablet by mouth one time a day for HTN Hold for SBP (top blood pressure number) Less 110 or HR Less than 60 initiated on 10/08/25 Record review of Resident #1's eMAR for July 2026 revealed no blood pressure was recorded on the morning of 07/04/26. Further review revealed MA did not administer metoprolol to Resident #1 on the morning of 07/04/26 because her blood pressure was outside the physician's parameters. During an interview at 3:26 PM on 07/29/26, MA stated before administering a blood pressure altering medication she always checked the resident's blood pressure to ensure it was inside the physician's parameters. The MA stated she forgot to add in Resident #1's blood pressure to the eMAR when she held the metoprolol on the morning of 07/04/26. The MA stated there was no way to prove she held the medication appropriately. The MA stated it was important to document the blood pressure, so the doctor had a record to review and find any patterns to alter the dosage of the medication. The MA stated holding a blood pressure medication inappropriately could result in hypertension in the residents. During an interview at 4:20 PM on 07/29/26, the DON stated nurses and medication aides should always check the resident's blood pressure and pulse as needed per physician's orders. The DON stated she was unable to find any documentation in Resident #1's electronic health record stating what her blood pressure was when MA held the metoprolol on the morning of 07/04/26. The DON stated there was no proof MA held the metoprolol appropriately on the morning of 07/04/26. The DON stated it was important to document blood pressures to keep a record for the doctor so they could look at it and adjust the dose as needed. Record review of the facility policy Medication Administration dated 10/24/22 revealed the following: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 3 (Resident #1) residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN A accurately documented his findings on Resident #1's Initial Nursing Evaluation on 06/04/26. This failure could place residents at risk of a health decline. Findings included:Record review of Resident #1's admission record, dated 06/16/26, reflected an [AGE] year-old female re-admitted on [DATE], and an original admission date of 08/16/22. Her relevant diagnoses included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple tasks), dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, communication, and reasoning), senile degeneration of brain (age-related cognitive decline), and glaucoma (a group of eye diseases that damage the optic nerve, typically due to a buildup of fluid and pressure inside the eye.)Record review of Resident #1's quarterly MDS assessment, dated 04/24/26, reflected a BIMS score of 99, which indicated her cognition was severely impaired.Record review of Resident #1's Initial Nursing Evaluation, dated 6/04/26, authored by LVN A reflected he had documented in Section D. Oral/Nutrition that Resident #1 did not have any broken or carious (decayed or affected by cavities) teeth.During an observation and attempted interview on 06/16/26 at 3:30 p.m., Resident #1 was observed lying in bed awake. Resident #1 refused to be interviewed and shouted to get out of her room. During an interview on 06/16/26 at 3:44 p.m., CNA B said she had provided care to Resident #1 since her admission to the facility. She said Resident #1 used to be in the facility's memory unit and before her Alzheimer's progressed, Resident #1 would allow her to perform oral care. She said she had observed Resident #1 had multiple broken upper front teeth.During an interview and observation on 06/16/26 at 3:55 p.m., LVN A said Resident #1 was re-admitted on [DATE] after a brief hospital stay. LVN A was observed as he reviewed Resident #1's electronic medical record and said he was her admitting nurse on 06/04/26. LVN A said during Resident #1's Initial Nursing Evaluation done on 06/04/26, he observed Resident #1 had multiple broken upper front teeth. LVN A said he had erroneously documented Resident #1 did not have any broken or carious teeth. LVN A said there were no negative outcomes to Resident #1 not having her Initial Nursing Evaluation correctly documented. During an observation on 06/17/26 at 8:30 a.m., CNA C fed Resident #1 her breakfast. Observation revealed Resident #1 had multiple broken upper front teeth while eating. After breakfast, CNA C was observed as she attempted to perform oral care on Resident #1 but she refused. CNA C said Resident #1 had some natural teeth but had multiple broken upper front teeth. During an interview and observation on 06/17/26 at 3:30 p.m., the DON said Resident #1 had multiple broken upper front teeth since her admission to the facility. She was observed as she reviewed Resident #1's electronic medical record and said LVN A was Resident #1's admitting nurse on 06/04/26. She said LVN A had erroneously documented Resident #1 did not have broken or carious teeth. The DON said LVN A should have documented yes to having broken or carious teeth. The DON said there were no negative outcomes to Resident #1 not having her Initial Nursing Evaluation completed accurately on 06/04/26, because it was more of a documentation issue because LVN A knew Resident #1 had multiple upper from teeth missing. Record review of the facility's Documentation in Medical Record policy, dated 10/24/22, reflected:Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1.Licensed staff and interdisciplinary team members shall document all assessment, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 3.Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interviews, observations and record review, the facility failed to ensure the resident had the right to personal privacy during medical treatment for 4 (Resident #156, Resident #52, Resident #71, and Resident #133) of 7 residents reviewed for resident rights. The facility failed to ensure MA A closed the door or the curtain during medication administration for (Resident #156, Resident #52, Resident #71, and Resident #133) on 05/12/2026. This failure could place residents at risk of not having their personal privacy maintained during medical treatment.Findings included: During an observation on 05/13/2026 at 7:20 a.m., MA A kept the door and the curtain open while administering medications to Resident #156. During an observation on 05/13/2026 at 7:30 a.m., MA A kept the door and the curtain open while administering medications to Resident #52. During an observation on 05/13/2026 at 7:37 a.m., MA A kept the door and the curtain open while checking Residents #71's blood pressure. She then proceeded to administer medications which included ophthalmic (eye) medication. During an observation on 05/13/2026 at 7:49 a.m., MA A kept the door and the curtain open while checking Resident #133's blood pressure. She then proceeded to administer medications. In an interview on 05/13/2026 at 8:00 a.m., MA A stated that she was supposed to close the door and the curtain before checking the blood pressures and administering medications to Resident #156, Resident #52, Resident #71, and Resident #133. She stated that she forgot to do it. MA A stated that closing the door and the curtain was important to provide the residents with privacy. In an interview on 05/13/2026 at 8:47 a.m., ADON B stated that staff did not need to provide privacy when checking blood pressure because it was not considered invasive. She also stated that she did not believe the door or curtain needed to have been closed when administering oral medications. However, ADON B stated that privacy should have been provided, especially when administering eye drops. She stated that providing privacy was important to promote resident dignity. ADON B stated that the last in-service training regarding medication administration had been completed approximately 4-6 weeks prior. In an interview on 05/13/2026 at 2:06 p.m., the DON stated that MA A should have closed the door, the curtain, and the blinds prior to administering medications to residents unless the residents specifically requested otherwise. She stated that if resident had requested otherwise, staff ensured that it was care planned. The DON stated staff should have provided privacy when administering medications to promote dignity, as it was their right. She stated that the staff had recently been trained on medication administration and had completed a return demonstration. Record review of the facility's policy, Medication Administration dated 10/24/2022, revealed: Policy Explanation and Compliance Guidelines: 6. Explain Purpose of Visit 7. Provide Privacy 8. Obtain and record vital signs, when applicable or per physician orders. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program, to keep the facility free of pests for 2 (Resident #83 and Resident #57) of 8 residents reviewed for pests. The facility failed to ensure Resident #83 and Resident #57's room was free from roaches. This failure could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.Findings included: Record review of Resident #83's face sheet dated 05/13/2026 revealed an [AGE] year-old female admitted on [DATE] with a diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Senile Degeneration of Brain, Dysphagia, Unspecified Psychosis, Legal Blindness, Delusional Disorders, Hypertension(high blood pressure) and Muscle wasting and Atrophy, not elsewhere classified. Record review of Resident #57's face sheet dated 05/13/2026 revealed an [AGE] year-old female admitted on [DATE] with a diagnosis of Alzheimer's Disease, Vascular Dementia, Radiculopathy Lumbar Region, Depression, Unspecified Psychosis, Dysphagia, Hypertension (high blood pressure) and Muscle wasting and Atrophy, not elsewhere classified. During an observation on 05/11/2026 at 2:58 p.m., revealed a live roach on the floor in Resident #83 and Resident #57's restroom. This observation was pointed out to LVN F, by the time she got to the restroom it was no longer visible. In an interview on 05/11/2026 at 2:58 p.m., LVN F stated pest control came last week and sprayed for pests. She stated that she rounds every two hours and has not seen roaches. LVN F stated that roaches could be an infection control issue for the residents. In an interview on 05/11/2025 at 3:20 p.m., CNA H stated that when she first began working at this facility approximately five years ago, she would see roaches in the facility. However, she has not seen them anymore. She stated that roaches were a concern because they could negatively affect residents with respiratory issues. CNA H further stated that roaches could crawl on residents and create an infection control issue. She stated that she had not seen pest control services during her shift. In an interview on 05/11/2026 at 3:29 p.m., CNA J stated that she had not seen any roaches or other bugs in the facility. She stated that she had not seen pest control services and believed they may come during another shift. CNA J stated that it was important for the facility to not have roaches for the safety of residents because roaches carry bacteria. In an interview on 05/11/2026 at 3:34 p.m., LVN K stated that she had not seen any roaches or bugs in the facility. She stated that she had not seen pest control services. LVN K stated that it was important for the facility to remain free of roaches because it was unhygienic and unsanitary. She further stated the residents in the unit were not fully aware, and she was unsure how they would respond if they were to see a bug. In an interview on 05/13/2026 at 10:44 a.m., Maintenance Director stated that roaches or any other pests have not been an issue. He stated that it depends on the weather, and that it had been raining over the past couple of days. The Maintenance Director stated pest control had informed him that when it rains, there were usually more roaches and ants, but would go away once the rain stops. He stated he had seen the black sugar ants and roaches primarily in the 100, 200, and 600 halls, but indicated that different residents had occupied those rooms at that time. The Maintenance Director stated that one resident was dirty, and he had seen ants in his food. He stated the CNAs, nurses and other staff members were responsible for documenting sightings in the pest control binder. The Maintenance Director stated that if a resident voices a sighting he would notify the aide and the aide would document it. He stated that pest control services came every month and treated both the inside and outside of the building. The Maintenance Director stated that it was important for there not to be any roaches because they could enter through the sewage pipes or dry wall insulation and potentially come into contact with residents. In an interview on 05/13/2026 at 2:25 p.m., the administrator stated that to her knowledge, there was not a pest control issue at the facility. She stated that pest control services were scheduled for once a month, but if needed, they would come more frequently. The administrator stated that if there were any random pest sightings, staff would document them in the pest control book. She stated that there was a book at each nurse's station. She stated that it was important for the facility to remain free of roaches or any bugs because that was infection control issue. The Administrator stated on 05/13/2026 at 11:25 a.m. that the facility did not have a Pest Control Policy, only the contract. Record review of Pest Control sighting logbooks revealed 2 entries for the month of 05/11/2026- roach in room [ROOM NUMBER] and roach in the 500-shower room. There were 7 entries for the month of April 2026-noted roaches in rooms 104, 105, 108, 110, 301, in the 300 hall, in the 500 hall, and 3 large roaches in room [ROOM NUMBER]. Record review of Pest Control Invoice, dated 04/02/2026, revealed the following services, Regular Pest Service and Flying Insect Program. Under General Comments/Instructions: Talked to contact, looked over sighting log and inspected and treated rooms 301, 108, 104, 105, and 108. Interior . Inspected and treated all common areas, kitchen, laundry, offices, dining, employees area, hallways cleaned and replaced glue in MCTs and ILT. Exterior .Inspected and treated perimeter of building and replaced baits in rodent bait stations. Record review of the Pest Control Sales Agreement dated September 2022, revealed the following: Covered pests are cockroaches, rats, mice, and ants (exclude pharaoh, fire and carpenter ants). Exterior treatments for covered ant species are limited .The initial term of the agreements is 3 years from the date hereof and shall automatically renew for additional terms of one year thereafter.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Residents #2) reviewed for dignity. The facility failed to ensure Resident #2 was provided oral care on a regular basis.This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.Findings included:Record review of Resident #2's face sheet dated 03/27/26 reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Diagnoses included encephalopathy (a change in how the brain functions, including confusion or agitation. It can be temporary, or it could permanently damage the brain. It can be caused by an infection or an underlying condition. Treatment depends on the cause), altered mental status, high blood pressure, abdominal mass, kidney failure, left kidney cancer, urine retention due to obstruction, prostate enlargement, and diabetes. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected the resident had active diagnoses including stroke, non-Traumatic and traumatic spinal cord and Brain Dysfunction, progressive Neurological Conditions, Hip and Knee Replacement, Fractures and Other Multiple Trauma, cancer, anemia, high blood pressure, kidney failure, diabetes, dementia, depression, and malnutrition. Resident #2 's BIMS score of 01 indicated severe cognitive impairment.Record review of Resident #2's care plan dated 10/07/25 reflected he was admitted to hospice on 04/04/26. The goal was shift focus to achieving quality of life rather than restoration of health with intervention ordered. Interventions were Assess for pain-Provide pain management as per MD. Date Initiated: 04/04/2026. Assess, support, and be sensitive to personal, cultural and religious values, beliefs, and practices. Date Initiated: 04/04/2026. Bedside comfort case: focus all care on patient comfort. Vital signs, daily personal care, assist with ADL's provide quiet, calm environment. Acknowledge resident, speak to resident. Date Initiated: 04/04/2026. Resident #2 has an ADL self-care performance deficit r/t limited mobility, metabolic encephalopathy, hydronephrosis (kidney disease), after a motor vehicle accident. Date Initiated: 10/07/2025.Interventions included, is dependent on staff for oral hygiene. Date Initiated: 04/06/2026 Revision on: 04/06/2026 , and The resident requires (total assistance) by (X1) staff with personal hygiene and oral care. Date Initiated: 04/06/2026 Revision on: 04/06/26.Observations of Resident #2 on 05/11/26 at 3:22 pm revealed he was not responsive to voice. His eyes were closed and respirations were even and unlabored. He was wearing humidified oxygen at 2 liters per minute via nasal cannula. His mouth was partially open and had a crusted substance over his tongue and connecting his upper and lower lips. The substance was clear/brown in color. (see IMG)In an interview with CNA F and CNA G on 05/11/26 at 3:27 pm, both CNAs said hospice came in daily, had been at the facility today, and the hospice nurse was responsible for oral care. They did not know what time hospice was at the facility, who the hospice nurse was, or what the name of the hospice company was. Together, they looked at Resident #2's crusty mouth and said it did not look like his mouth had been cleaned for a while. CNA G said she thought they should clean his mouth. They said he was on hospice for a couple of months. Then CNA G said she was sure the CNAs should clean mouths.Record review of the facility policy dated 05/26/23, titled, Activities of Daily Living (ADLs) under Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 (Resident #28) of 8 residents reviewed for respect and dignity. The facility failed to get Residents #28's consent to search personal possessions, resulting in confiscating items without notice. This failure placed residents at risk of anxiety, frustration, and decreased quality of life. The findings included:Record review of Resident #28's face sheet dated 2/18/26 reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Diagnoses included diabetes, high blood pressure, morbid obesity, eye problems related to diabetes, urine retention due to obstruction, and prostate enlargement. Record review of Resident #28's quarterly MDS assessment dated [DATE] reflected the resident had behavioral symptoms including rejection of care that occurred 4 to 6 days, but less than daily. His BIMS score was 15, indicating he was cognitively intact, and was on a regular diet. Record review of Resident #28's care plan dated 05/08/22, reflected he had access to order items from an on-line store and received packages from the on-line store almost daily. Interventions included, Resident #28's preferences will be respected. Date Initiated: 12/22/23. Resident #28 receives daily to QOD (four times a day) packages from an on-line store with various (unable to determine items) due to residents' privacy of mail. Date Initiated: 02/19/26. Resident #28 may at times refuse to allow staff to do room safety checks or go through his belongings Date Initiated: 07/24/25. Resident #28 wishes to be discharged to an Assisted Living facility although, discharge date more than 3 months away. Date Initiated: 05/11/2026.Record review of a grievance written by Resident #28 dated 04/16/26 reflected he was upset during a care plan meeting because his glass olive oil bottle was confiscated in early March, 2026. The item was removed without prior notification. The AA informed him the glass container was not permitted due to safety concerns. He voiced not being notified in advance of this change in regulations and requested better communication. Facility follow-up dated 04/16/26: Resident #28's olive oil was returned to him after it was poured into a plastic container. Record review of Resident #28's progress note dated 04/17/26 at 10:03 am: Note Text: Care Plan meeting held today with resident and IDT, reviewed code status, diagnoses, diet, weight, therapy, and activities. Also reviewed items he can and cannot have in his room. He had some concerns and voiced wanting to relocate to an assisted living. Record review of progress notes dated 04/01/26 to 05/12/26 revealed Resident #28 often refused care and changed appointments on his own. Observation and interview on 05/12/26 at 8:59 a.m., Resident #28 was in his room, the walls were filled with shelves loaded with various items from top to bottom. The floor was sticky and the room smelled of urine and body odor. He said he liked his room, the food, the staff, and the facility. He said the food had improved a great deal. In an interview with Resident #28 on 05/12/26 at 3:11 pm, he said he was ok with the memo about contraband but was more upset about them going through his grocery bag without his consent. He said he did not get the prohibited items list until after the facility confiscated his olive oil that was in a glass bottle in a plastic grocery bag. He said the prohibited items list was posted in the facility by the ADM on March 1, 2026. He said he placed a grocery order on March 4, 2026, that was delivered to the front desk the same day. He said he did not know about the list because he was bed bound at the time and no one told him about it or gave him a copy of it. He said no reimbursement or replacement was offered at the time. He said a month or so later, during a care plan meeting, he got the oil back after they poured it into a plastic jar he bought. He said he would have wanted to be present during the search and would have told them they could not search his bags. In an interview with the ADM on 05/13/2026 at 10:00 am, she provided an in-service sheet dated 02/10/26 titled Resident Education on prohibited items. Resident #28's name was not on the list. She said the flyer was posted on the front board after letting the residents know about the prohibited items list. She said they sent a media alert (not sure when) to inform the rest of the residents and a letter to families today (05/12/26). She said the poster and letter was initiated because another resident had a large glass globe he left in the dining room during an event and she was fearful it would get broken or used as a potential weapon. She said she suggested Resident #28 write a grievance regarding his concern about his groceries. She said the AA received the open plastic bag of groceries and when she set it down, she heard something that sounded like glass and could see it was a glass bottle. She said the AA removed the glass bottle (before) she took Resident #28 his grocery bags and gave the bottle to her (ADM). She said she immediately spoke with Resident #28 and he was not overly upset. She said they (Resident #28 and herself) discussed items about safety. She said he expressed being upset about the product being removed from his grocery bag without asking him first. She said she told staff not to remove items from open bags but to let her know of any questionable or contraband items. She said the product that was removed from Resident #28's grocery bag should not have been removed because it was his privacy and personal items. She said she did not remember how long it took to get the product back to him- maybe that afternoon. In an interview with the AA on 05/13/2026 at 10:27 am, she said she was asked by the receptionist to take the delivery to the resident. She said she saw through the plastic bag that there was a green glass bottle in it. She said she took out the glass bottle and told the nurse (unknown) because the residents were not supposed to have glass. She said she let Resident #28 know she removed the glass bottle and gave him a copy of 'the list' (the contraband/prohibited items list). She said he told her it was the first time he saw the list. She said he was upset by the tone of his voice. She said he said something to her about reimbursement and that was when she told the ADM. She said Resident #28 wanted to speak with her again because he was upset about the olive oil in a green glass bottle. She said she told him she took it out of the plastic grocery bag and reminded him of contraband and then he wanted reimbursement. The ADM had already been informed by the nurse and the ADM was already on her way to talk to him. She said she had taken him mail several times after that, but he never brought it up again. Record review of an in-service sign-in sheet dated 02/10/26, titled, Resident education on prohibited items did not include Resident #28's name on it. Record review of the facility's undated Prohibited Items List included: Medications (prescribed and over the counter), Sharp items (knives, blades, razors, nail clippers, etc., Cigarettes, Vapes, Cigarettes, Cigars, Hookah, and Tobacco products, Matches and lighters, Alcohol products (rubbing or drinking), Aerosol cans (Lysol, body sprays, glade, etc.), Glass items (vases, picture frames, colognes and perfumes), Weapons (guns), Laundry/Housekeeping items (Clorox, etc.), Extension cords, appliances (microwave, coffee makers, Keurig, etc.), Plug in air fresheners, no flammable items, no items to be placed on the overhead light. This list is not inclusive, and the facility has the right to remove items deemed hazardous. Facility staff will notify the responsible party when prohibited items are removed. Record review of the facility's Resident Rights manual revised 07/14/20 under Statement of Resident Rights:You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Human Services by calling [PHONE NUMBER]. You have a right to: (4) be treated with courtesy, consideration, and respect; (13) access money and property you have deposited with the facility and to an accounting of your money and property that are deposited with the facility and of all financial transactions made with or on behalf of you; (14) keep and use personal property, secure from theft or loss.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #11) reviewed for resident rights. The facility did not ensure Resident #11's toilet was free from stains on 05/13/26. This failure could place residents at risk for an unsafe environment and unsanitary environment. Findings included: Record review Resident #11's admission record, dated 05/13/26, reflected a [AGE] year-old male with a readmission date of 01/19/26 and an admission date of 03/11/22. His relevant diagnoses included metabolic encephalopathy (a syndrome of global brain dysfunction caused by an underlying systemic or chemical imbalance in the body), type 2 diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), and glaucomatous optic atrophy (a group of eye diseases that damage the optic nerve). Record review of Resident #11's quarterly MDS assessment, dated 04/23/26, reflected a BIMS score of 12, which reflected his cognition was moderately impaired. Record review of Resident #11's quarterly care plan, dated 05/06/26, reflected a problem [Resident #11] has an ADL self-care performance deficit r/t confusion, weakness, hx of falls, and osteopathy d/t hx of polio to left leg. Date initiated 01/14/24 and revised 01/20/26. Interventions included functional performance: personal hygiene: [Resident #11] requires supervision or touching assistance for personal hygiene. During an interview and observation on 05/13/26 at 10:00 a.m., Resident #11 was observed sitting in wheelchair. Resident #11 said the only concern he had was that his toilet was not clean. He said he had already complained to the housekeeping staff, but the problem continued. Resident #11 said he had noticed housekeeping was not cleaning the toilet for about one week ago. Resident #11 said it frustrated him having to see his toilet dirty. With Resident #11's permission, this surveyor inspected his restroom. The toilet bowl had black spots around the rim, one side of the base had yellow stains, hair, and was missing a bolt cover. During an interview and observation on 05/13/26 at 10:23 a.m., CNA O said would round residents every two hours and during her rounds she would ensure the residents' restrooms were clean. She said she would check to make sure there were no sharps, no spills on the floor, and that the toilet bowl and floor were clean. CNA O was observed as she looked inside Resident #11's toilet bowl and base and said, I will call the housekeeper to come clean it. CNA O said, the housekeeper had just cleaned Resident #11's room. CNA O said had not seen Resident #1's toilet dirty in the past few days. CNA O said a negative outcome to Resident #11 having a dirty toilet would be an infection control issue. During an interview and observation on 05/13/26 at 10:30 a.m., Housekeeper P said she had been assigned to Resident #11's hall on 05/12/26 and 05/13/26. She said she had just cleaned Resident #11's room, but since he was asleep, she did not clean his restroom because she did not want to wake him up. Housekeeper P did not remember if she cleaned the toilet on 05/12/26 and on 05/13/26. She first said she had not wanted to wake him up and then added that she had not been feeling well and might have forgotten to clean his toilet on 05/12/26 and 05/13/26. Housekeeper P said she had not received any complaints from Resident #11. Housekeeper P said a negative outcome to Resident #11 would be that he would complain. During an interview on 05/13/26 at 11:00 a.m., the Housekeeping Supervisor said it was his responsibility to ensure all resident's rooms were thoroughly cleaned and disinfected on a daily basis. He said he would randomly inspect resident's rooms to ensure housekeepers were doing what they were supposed to do. He said he had not checked Resident #11's room himself and had not received any complaints from him about the cleanliness of his restroom. The Housekeeping Supervisor said a negative outcome to Resident #11 would be infection control. During an interview on 05/13/26 at 11:15 a.m., the Administrator said it was the responsibility of housekeepers to ensure the residents' rooms were cleaned and disinfected daily. The Administrator said it was the housekeeper supervisor to ensure the housekeepers were doing their job. She said she had not received any complaints from Resident #11 about the cleanliness of his room. She said a negative outcome to Resident #11 not having a clean toilet would be infection control. The Administrator said the facility did not have a policy related to housekeeping. She provided undated General Housekeeping Procedure used by the housekeeping department. Record review of the facility's General Housekeeping Procedure undated reflected: . 7-Step Cleaning Process:Step 5: Clean and disinfect toilet, includes the tank, seat, bowl, and base.Use a separate rag with disinfectant to wife down every areaUse [NAME] mop to disinfect inside of the bowlUse bowl cleaner only on the insure of the bowl.

Based on interviews and record review, the facility failed to ensure an assessment accurately reflected the resident's status for 1 (Resident #84) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #84 MDS assessment was accurately coded for Hospice Care. This failure could place residents at risk for receiving inappropriate care due to an inaccurate assessment data not reflecting their actual status and needs. Findings Included: Record review of Resident #84's face sheet dated 05/13/2026 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Pertinent diagnoses included: Alzheimer's Disease, Type 2 Diabetes (high levels of sugar in blood), Hypertension (high blood pressure), Unspecified Dementia, Anxiety Disorder, Mood Disorders. Record review of Resident #84's Comprehensive MDS assessment dated [DATE] revealed: BIMS score of 00 indicating Resident #84's cognition was severely impaired. Section O0110 - Special treatments, procedures, and programs - section K1 Hospice Care was not marked as being received. Record review of Resident #84's care plan initiated on 03/06/2026 reflected Resident #84 was under Hospice Care. Interventions included assess coping strategies and respect resident wishes, consult with physician and social services to have Hospice care for resident in the facility, and encourage support system of family and friends. Record review of Resident #84's Order Summary printed on 05/13/2026 reflected an order for Hospice Care dated 03/06/2026. In an interview on 05/12/2026 at 6:21 p.m. with MDS N, she stated that she and another MDS nurse share the responsibility for completing the facility's MDS assessments. She confirmed that she was the one who completed the MDS assessment for Resident #84 dated 03/09/2026. MDS N verified that Hospice Care was not marked on Resident #84's MDS assessment. She stated that it had been an oversight on her part. She stated that it was important for the MDS assessment to be completed accurately because it affected Hospice reimbursement and reflected that the resident was receiving Hospice services. In an interview on 05/13/2026 at 2:06 p.m., the DON stated that she had two full time MDS nurses and one part time who oversaw completion of the MDS assessments for the facility. She stated that there was oversight in place to ensure MDS assessments were completed accurately. She has quality managers review the MDS assessments to verify that no coding items were missed. The DON stated that Hospice services were discussed prior to the resident's admission. She further stated that stand up meetings were conducted at the end of the day to triple check the MDS assessments. The DON stated the MDS assessment should be completed accurately to ensure appropriate overall resident care. Record review of CMS's RAI version 1.17.1 dated October 2019 revealed section: O0110: Special Treatments, Procedures, and Programs a. On admission b. while a resident c. at discharge K: Hospice care O0100K, Hospice care Code residents identified as been in the hospice program for terminally ill persons where an array of services is provided where the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

Based on interviews 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) for 1 (200-hall binder) of 6 controlled medication binders reviewed for pharmacy services. The facility failed to ensure controlled medications were accurately accounted for when LVN Q failed to sign the narcotic medication count sheet during shift change on 05/12/2026. This failure could place residents receiving controlled medications at risk of medication discrepancies, diversion, medication errors, and lack of accountability for controlled substances. Findings Included: Record review of the 200-hall medication aide cart-controlled substance binder revealed LVN Q failed to sign the narcotic medication count sheet during shift change (2p.m-10p.m.) on 05/12/2026 at 3:30 p.m. In an interview on 05/12/2026 at 3:40 p.m., LVN Q stated that she was responsible for signing on and off on the narcotic count sheet at the beginning and end of her shift when she received and hands off the controlled medications. She stated that two nurses were required to sign during shift change to verify reconciliation of the controlled medication count. LVN Q confirmed that her signature was missing today, 05/12/2026 on the count sheet and stated she forgot to sign it. She stated that the signatures were important to ensure accountability and verification that the controlled medications were counted by both oncoming and off-going nurses. LVN Q stated if a discrepancy was identified and she did not document that the count was completed, responsibility could fall on her. She acknowledged that failure to sign the narcotic sheet prevents an accurate audit trail for controlled medications. LVN Q also stated that she had training on documentation of controlled substances about a month ago. In an interview on 05/13/2026 at 8:47 a.m., ADON B stated that she does oversee the narcotic book and reviews it periodically, approximately a couple of times per month, while checking medication carts. She stated that staff received education regarding controlled medication documentation upon hire and during medication administration training. She said she also conducts ongoing checks year-round to ensure staff correctly log controlled medications in and out of the narcotic book. ADON B stated that maintaining accurate controlled medication counts and identifying if any medications were missing. She further stated that discrepancies could indicate possible drug diversion and would require investigation. ADON B stated that staff were instructed to count the controlled medications before accepting the medication cart and to avoid correcting discrepancies prior to verifying the count themselves. In an interview on 05/13/2026 at 2:06 p.m., the DON stated the ADONs oversee the controlled medications books and routinely monitor them throughout the day. She stated the nurses were instructed not to leave their shift until the controlled medication count has been completed. The DON stated that the facility operates on three shifts and that whichever nurse assumes responsibility for the medication cart was required to sign the controlled medication book when taking over and handing off the cart. She stated the policy emphasizes the importance of completing and documenting the narcotic count to ensure the count was properly performed and verified. The DON stated that if the count was not signed, it would be considered incomplete. She stated that LVN Q was new but knows that she was required to sign the narcotic count sheet. She stated that signatures were important because they provide proof that the controlled medication count was completed. Record review of the facility's policy titled Documentation of Controlled Substance dated 10/01/2019 revealed Policy: Medications included In the Drug Enforcement Administration (DEA), classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Controlled Substances Record documentation will be maintained accurately. Definition: The controlled substances record refers to the document(s) utilized to track controlled substances on a shift-to-shift basis from the point of receipt through destruction/discharge. These documents may also be referred to as controlled substance book or proof of use sheet. Procedure: 4. Medications listed in Schedule II, III, IV, and V, are stored under double lock in a locked cabinet, medication cart drawer, or safe designated for that purpose, separate from all other medications. Controlled substance keys are kept on a separate key ring and are always in the possession of the Licensed Nurse or Certified Medical Aide who has been designated responsible for medication administration and signed for those controlled substances and the Controlled Substances Record at the change of shift. 7. Two Licensed nurses or Medical Aide or combination thereof, are responsible to complete a count of all controlled substances at the change of shift or any time that the narcotic keys are surrendered from one nurse to another. 8. A licensed nurse or medical aide on the shift reporting for duty counts all medication with the licensed nurse or medical aide going off duty. The nurse coming on duty should be overseeing both the Controlled Substances Record and each sealed unit dose card The licensed nurse or medical aide on both shifts will ocunt and sign the Controlled Substances Record in each others presence. If there is a discrepancy in the count, DO NOT SIGN the record. Report the discrepancy to the supervisor or the Director of Nursing immediately. 9. THE LAST SIGNATURE IN THE CONTROLLED SUBSTANCES RECORD WAS RESPONSIBLE FOR THE COUNT.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored securely, maintained within their expiration dates, and labeled properly in accordance with currently accepted professional principles and standards for 1 of 2 medication carts (500 Hall Medication Cart) and 2 of 2 medication storage rooms (500 Hall Medication Storage Room and 600 Hall Medication Storage Room) reviewed for labeling and storage. The facility failed to dispose of a bottle of over the counter (OTC) anti-acid tablets from the 500 Hall Medication Cart which had an open date of 05/02/25. The facility failed to properly label a vial of lidocaine (local anesthetic medication used to induce temporary numbness or loss of feeling in specific skin areas) with an open or expiration date from the 500 Hall Medication Cart. The facility failed to ensure expired medications that were to be disposed of were placed in a locked cabinet from the 500 Hall Medication Storage Room. The facility failed to properly label a box of opened OTC sore throat lozenges and an opened box of OTC anti-diarrhea tablets with open dates from the 600 Hall Medication Storage Room. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them and place the facility at risk of drug diversion. Findings included: In an observation and interview on 05/12/26 at 3:06pm of the 500 Hall Medication Cart, a bottle of OTC anti-acid tablets was discovered to have an open date of 05/02/25. RN D stated medication carts should not have any expired medications in them. RN D stated that the carts should have been reviewed at the beginning and end of each shift. RN D stated it was important not to have expired medications in the cart because medications could have been given to residents, and it could have damaged their health. In an observation and interview on 05/12/26 at 3:09pm of the 500 Hall Medication Cart, a vial of lidocaine was discovered not to have an open date or an expiration date. RN D stated that the lidocaine vial should have been placed in a box or clear bag with a label on it. RN D stated it was important to properly label medications with open or expiration dates because it placed residents at risk of receiving expired medications and could have caused harm. In an observation and interview on 05/12/26 at 3:18pm in the 500 Hall Medication Storage Room, there was an unlocked cabinet which contained expired medications. RN D stated the medications were expired medications that needed to be disposed of. RN D stated he knew medications were supposed to be locked but did not know why they were not in the indicated locked cabinet. RN D stated it was important to have expired medications locked because nurses could accidentally administer those medications to residents, which in turn could have harmed residents. In an observation and interview on 05/12/26 at 3:29pm in the 600 Hall Medication Storage Room, there was an open box of OTC sore throat lozenges with no open date and an open box of OTC anti-diarrhea tablets with no open date. RN E stated he was unaware of the opened boxes. RN E stated it was important to have open dates because one needed to know the shelf life of the medication. RN E stated that an effect on not having an open date on medications was that the medication could be expired and if given to residents, residents could have a decline in their health. RN E stated medications rooms were checked and cleaned out monthly. During an interview on 05/13/26 at 9:55am ADON C stated she oversaw Hall 500 and Hall 600. ADON C stated OTC anti-acids were good for a year after an open date, then they needed to be discarded. ADON C stated that all medications that were for destruction had to be under lock and key. ADON C stated that all medications had to have an open date at the time the medication was opened. ADON C stated medication carts get checked for expired and unlabeled medications on a weekly basis. ADON C stated it was the responsibility of all the nurses to check for those things. ADON C stated that the medication rooms were also checked on a weekly basis to keep it as clear as possible. ADON C stated nurses were frequently reminded to check for expired medications and medications not labeled properly. During an interview on 05/13/26 at 1:50pm the DON stated medication carts and medication rooms are constantly being checked. The DON stated that the pharmacist and the pharmacist technician also assist with checking. The DON stated that the manager on duty checked and logged whatever needed to be discarded and placed it into the proper cabinet. The DON stated in-services (teachings) had already been started on checking for expired medications and ensuring all medications were properly labeled. Record review of the facility's Expiration Dating and Expired Medications policy, dated revised 10/01/19, revealed Procedure 1. All medications received from the pharmacy will have an expiration or beyond use date clearly stated on the label or medication container. 5. For multi-dose vials of injectable drugs: A. Date and initialed when opened 8. It is the responsibility of all nurses who administer medications to monitor for the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per Facility policy. Record Review of the facility's Discontinued Medications policy, dated revised 03/22/23, revealed Procedure 2. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until disposed of or returned to the pharmacy if credit is allowed. Medications are removed from medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #2 and #4) of 8 residents reviewed for infection control practices. The facility failed to ensure: CNA F and CNA G performed hand washing or change gloves during peri care on Resident #2. -oxygen tubing and humidifier bottle was labeled, dated, in a protective sheath, and kept off the floor for Resident #2. -foley bags were kept off the floor for Resident #2 and Resident #4. These failures could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. The findings included:1.Record review of Resident #2's face sheet dated 03/27/26 reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Diagnoses included encephalopathy (a change in how the brain functions, including confusion or agitation. It can be temporary, or it could permanently damage the brain. It can be caused by an infection or an underlying condition. Treatment depends on the cause), altered mental status, high blood pressure, abdominal mass, kidney failure, left kidney cancer, urine retention due to obstruction, prostate enlargement, and diabetes. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected the resident had active diagnoses including stroke, non-Traumatic and traumatic spinal cord and Brain Dysfunction, progressive Neurological Conditions, Hip and Knee Replacement, Fractures and Other Multiple Trauma, cancer, anemia, high blood pressure, kidney failure, diabetes, dementia, depression, and malnutrition. Resident #2's BIMS score of 01 indicated severe cognitive impairment. Record review of Resident #2's care plan dated 10/07/25 reflected the following care areas:-Resident #2 has an ADL self-care performance deficit r/t limited mobility, metabolic encephalopathy, hydronephrosis (kidney disease), after a motor vehicle accident. Date Initiated: 10/07/2025. Interventions included, The Resident is dependent on staff for personal hygiene. Date Initiated: 04/06/2026. -Resident #2 has the need for Enhanced Barrier Precautions due to: (Foley catheter) Assist with ADL care as indicated Date Initiated: 10/28/2025.Interventions included, Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated. Date Initiated: 10/28/2025 -Resident #2 has infection bacterial MRSA (Methicillin-resistant staphylococcus aureus-a type of staph bacteria resistant to several common antibiotics.MRSA is very contagious, spreading through skin-to-skin contact or touching contaminated objects, surfaces, and personal items, affecting both patients and healthy individuals) Date Initiated: 04/02/2026 Revision on: 04/06/2026. -Resident #2 has a (Foley) Catheter: Terminal condition Grade 4 clear cell renal cell carcinoma/Urinary retention/BPH.Date Initiated: 10/17/2025 Revision on: 01/09/2026Interventions included, Position catheter bag and tubing below the level of the bladder and away from entrance room door.Date Initiated: 10/17/2025-Resident #2 is at risk for shortness of breath (SOB) r/t Anxiety, Decreased energy and fatigue, Decreased lungExpansion Date Initiated: 04/06/2026Interventions included Admin O2 as ordered to maintain o2 saturation at or above 92% Date Initiated: 05/11/2026.Record review of Resident #2's active physician orders dated 03/27/26 documented: -Change O2 tubing every week on Sunday and PRN.-03/27/26: Monitor that collection bag is off the floor and hung below bladder level every shift. -- Observations on 05/11/26 at 3:22 pm, revealed Resident #2 was in his room in bed, unsheathed oxygen tubing was on the floor attached to the resident via nasal cannula. The oxygen concentrator had a bottle for humidification. Neither the oxygen tubing nor the humidifier bottle was labeled, dated, or initialed. Resident #2's foley catheter bag was lying on the floor, next to and slightly under the bed. CNA F and CNA G were starting incontinent care on Resident #2. CNA G slid the foley bag out of her way. Neither of them washed their hands prior to donning gowns & gloves per EBP guidelines. Using his drawsheet, Resident #2 was turned to his left side by CNA F. CNA G performed peri care using single wipes x4. She did not change her gloves after discarding the soiled wipes. Utilizing his drawsheet, Resident #2 was turned to his right side by CNA G. CNA F gathered and discarded Resident #2's soiled brief and without changing gloves, she placed a clean brief under Resident #2. Resident #2 was returned to his back by CNA G. Still using his same drawsheet, Resident #2 was repositioned up in his bed by both CNAs. They touched his pillow, smoothed his clothing, and replaced his bed covers while still wearing soiled gloves. In an interview with CNA F and CNA G on 05/11/26 at 3:27 pm, CNA G said she was supposed to change her gloves. CNA F said she did not change gloves either because they like to clean him quickly because he's on oxygen. Neither could verbalize the process required for peri care. CNA G said she did not notice the foley catheter bag on the floor. CNA F said the O2 tubing was supposed to be in a bag, and off the floor, because of contamination. They said Resident #2 was on hospice for a couple of months. They both said they received training for peri care and neither could say when their most recent training was. 2. Record review of Resident #4's face sheet dated 04/19/26 reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Diagnosis included urine retention. Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected the resident had an active diagnosis of in-dwelling foley catheter due to obstructive uropathy Resident #4's BIMS score of 09 indicated moderate cognitive impairment. Record review of Resident #4's care plan dated 05/02/22 reflected he was dependent on staff for all ADL's. Resident #4 has an Indwelling Foley Catheter r/t Urinary Retention and Obstructive Uropathy. Date Initiated: 04/20/2026 Revision on: 05/06/2026. Record review of Resident #4's active physician orders dated 04/20/26 indicated: *Indwelling Urinary Catheter: Irrigate catheter with (30mls) of NS as needed, Indwelling Urinary Catheter: Change 18F catheter as needed, insert Foley Catheter 16F with 30cc balloon every shift for urine retention related to retention of urine, monitor that collection bag is off the floor and hung below bladder level every shift. *Ciprofloxacin Tablet 500 MG (milligrams) Give 1 tablet via G-Tube every 12 hours for UTI (urinary tract infection) for 5 days 5/10/26. Observations and interview with Resident #4 in his room on 05/12/26 at 9:50 am, revealed his foley catheter collection bag was laying on the floor, and the privacy bag was hanging on the siderail of his bed. The collection bag was in view of the hallway through the door. Resident #4 was unable to describe why or how long he had a foley catheter. Resident #4 had an IV (intravenous catheter) in his left wrist for antibiotics due to an URI (upper respiratory infection) and was receiving another antibiotic via PEG for a UTI (urinary tract infection). In an interview with ADON C on 05/13/2026 at 11:20 am, she said she had been the ICP (Infection Control Preventionist) at this facility since Feb. 2026. She said O2 should never be on the floor, should always have a sheath, and always be labeled and dated. She said they only changed humidifiers before they were empty, but they should always be dated. She said both enteral feeding and the water had to be dated and labeled. She said every 2 halls had an ADON and everyone was responsible for labeling and dating tubing. She said the managers did rounds every morning; 4 ADON's, 1 DON, ADM, MDS, SW. She said she was assigned to the 600 hall and she checked infection control. She said she should be checking the entire facility-IV's, Foley's, Tubing, oral care, privacy bags and collection bags, etc. She said the managers did check-offs on peri care about every three months. She said all staff had to change gloves in between clean & dirty areas. She said she trained staff upon hire and monthly. She said the facility did not have a policy regarding oxygen tubing. In-services for infection control were requested at this time but not received. In an interview with LVN L and LVN M on 05/13/26 at 1:38 pm, LVN L said she was the full-time treatment nurse at the facility. LVN L and LVN M both said they were not involved in training staff for infection control. They said staff received in-services from ADON C regarding infection control, but did not know how often or when the most recent training occurred. They both said staff should at least follow the guidelines for infection control when performing peri care or anything else that required gloves, gowns, face shields; any kind of precautions; EBP or isolation. They both said dirty or soiled gloves should never be used-they should be discarded and depending on the level of soil on the dirty gloves, alcohol based hand rub could be used or soap and water hand washing per standards (meaning >20 seconds). Record review of the undated facility document titled, [NAME] Nursing Procedures, eighth edition, Evidence-Based Bedside Care page 360, Special Considerations for humidifiers. Replace a bedside humidifier unit every 7 days or as determined by your facility.page 387, Indwelling urinary catheter care. Do not place the drainage bag on the floor, to reduce the risk of contamination and subsequent UTI. Record review of the facility policy dated 11/24/25, titled, Enhanced Barrier Precautions under Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions:Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.4. High-contact resident care activities include: d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: .urinary catheters.h. Wound care: any skin opening requiring a dressing. 9. Additional epidemiologically important MDROs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA). Record review of the facility policy dated 10/24/22, titled, Perineal Care under Policy Explanation and Compliance Guidelines:6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. Record review of the facility policy dated 05/13/23, titled, Infection Prevention and Control Program under Policy Explanation and Compliance Guidelines: l. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 4. a All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed accordance with our facility's established hand hygiene procedures. Record review of the facility policy dated 10/24/22, titled, Hand Hygiene under Policy: All staff will perform hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub. 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for Advance Directives. The facility failed to ensure Resident #1's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #1's electronic face sheet dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia (a general, non-normal aging term for the progressive decline of cognitive functions - memory, language, problem-solving, and thinking - severe enough to disrupt daily life), Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar to build up in the blood instead of entering cells for energy), orthopedic aftercare, nondisplaced fracture of lesser trochanter of left femur (a crack in the small bony protrusion of the inner, upper part of the left thigh bone), cerebral infarction affecting right dominant side (stroke), and heart disease. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she scored a 03 on her BIMS which reflected severe cognitive impairment. Record review of Resident #1's comprehensive care plan dated [DATE] reflected, Resident #1's Advanced Directives: Code Status: (DNR) Do Not Resuscitate Date Initiated: [DATE] with interventions: Ensure signed DNR is in medical record Date Initiated: [DATE] Revision on: [DATE] If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification Date Initiated: [DATE] Revision on: [DATE] Keep resident as comfortable as possible at all times Date Initiated: [DATE] Revision on: [DATE] Send copy of DNR paperwork upon transfer from facility Date Initiated: [DATE] Revision on: [DATE] Social services consult if resident/family want to change code status Date Initiated: [DATE] Revision on: [DATE] Record review of Resident #1's physician's order dated [DATE] reflected DNR (Do Not Resuscitate). Record review of Resident #1's OOH-DNR form dated [DATE] reflected the form was signed in section C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above person's: adult child. The OOH-DNR revealed the form was not signed by the attending physician below section E, Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician did not sign section F, All persons who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 03:57 pm SW B stated she would review the advanced directives with the family. She said she was responsible for getting the family's signature and then the OOH-DNR was given to MR C. SW B stated MR C was the one who was responsible for obtaining the doctor's signature. SW B stated as soon as they got the family's signature, the DON and staff were notified. In an interview on [DATE] at 04:05 pm, MR C stated the SW would scan OOH-DNRs to her and she would email the doctor requesting their signature. She stated normally the doctor signed the OOH-DNR within a day or two. She said she had sent Resident #1's DNR to the doctor's office. She said the doctor's signature was delayed by his office. MR C stated Resident #1's OOH-DNR was signed by the doctor on Friday, [DATE]. In an interview on [DATE] at 04:55 pm the DON stated Resident #1's DNR had been signed on [DATE]. She said she was not sure how the DNR was not signed by the physician before that. She said it had been care planned and there was an order for it, but the DNR had not been signed by the physician. Record review of the facility's Residents' Rights Regarding Treatment and Advanced Directives policy dated [DATE], revealed: Policy:It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical and surgical treatment and to formulate an advance directive.Policy Explanation and Compliance Guidelines: 1.On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. 3.Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as communicated to the staff. Record review of the [DATE] OOH DNR Order instructions for issuing and OOH-DNR Order revealed: Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person attending physician will document the existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: . In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 2 (Resident #2 and Resident #3) of 6 residents reviewed for unnecessary medications. 1.The facility failed to have an adequate indication for the use of the medication Lurasidone (an antipsychotic) for Resident #2 before administering the medication with a black box warning. 2.The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) and Seroquel (an antipsychotic) for Resident #3 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: Record review of Resident #2's admission record dated 03/03/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's Disease (a progressive, irreversible neurodegenerative brain disorder that destroys memory, thinking, skills, and eventually the ability to perform daily tasks), hypertension (high blood pressure), and Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar to build up in the blood instead of entering cells for energy). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Antipsychotics, antidepressants, anticoagulants (e.g. warfarin, heparin, or low-molecular weight heparin), antibiotics, and hypoglycemic (including insulin), and anticonvulsants were received on a routine basis. Record review of Resident #2's Care Plan dated 01/26/2026 revealed: FOCUS: (Resident #2) is resistive to care r/t Dementia, resident refuses showers, treatments, ADL care at times. (Resident #2) is refusing in/out catheterizations ordered by urologist, refuses treatments/ medications Date Initiated: 12/09/2025 Revision on: 12/09/2025. FOCUS: (Resident #2) has impaired cognitive function or impaired thought processes r/t Dx. Alzheimer's and Dementia. Date Initiated: 01/18/2025 Revision on: 02/13/2025. : (Resident #2) uses antipsychotic medications latuda/topamax r/t mood disorder and psychosis. Date Initiated: 12/13/2025 Revision on: 03/03/2026.INTERVENTIONS/TASKS: Latuda Oral Tablet Black Box Warning Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Lurasidone is not approved for the treatment of patients with dementia-related psychosis.() Suicidal thoughts and behaviors Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Date Initiated: 01/21/2026 LN RN Monitor for adverse reactions. Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 12/13/2025 Revision on: 03/03/2026 LN RN Monitor vital signs as ordered by MD and PRN Date Initiated: 03/03/2026 LN. Record review of Resident #2's Physician's Order dated 02/27/2026, revealed Order Summary: Lurasidone HCl Oral Tablet 40 MG (Lurasidone HCl)Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29). Black Box Warning:Increased mortality in elderly patients with dementia-related psychosisElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Lurasidone is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #2's February 2026 MAR revealed Lurasidone HCl 40 mg tablet was administered daily on 02/28/2026. Record review of Resident #2's March 2026 MAR revealed Lurasidone 40 mg tablet was administered daily from 03/01/2026 through 03/03/2026. 2.Record review of Resident #3's admission record dated 03/03/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (a progressive, irreversible neurodegenerative brain disorder that destroys memory, thinking skills, and eventually the ability to perform daily tasks), early onset, heart disease, Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar to build up in the blood instead of entering cells for energy), hypertension (high blood pressure), bipolar disorder (a chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels), current episode mixed, severe, with psychotic features, intermittent explosive disorder, and mood disorder due to known physiological condition, and unspecified intellectual disabilities. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of blank, indicating Resident #3 had severe cognitive impairment. Resident #3 was rarely/never understood by others and rarely/never understood others. Resident #3 was dependent (Helper did ALL of the effort. Resident #3 did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity) for toileting, showering, and personal hygiene. Antipsychotics, antidepressants, antibiotics, and anticonvulsants were received on a routine basis. Record review of Resident #3's Care Plan dated 02/21/2026 revealed: FOCUS: (Resident #3) uses antipsychotic medications (Seroquel)and (Haldol) r/t Psychosis Targeted Behaviors: Agitation/Yelling/grabbing at other residents and/or staff. She uses an anticonvulsant for Labile Moods. Date Initiated: 03/11/2025 Revision on: 11/18/2025. Record review of Resident #3's Physician's Order 12/17/2025 revealed Order Summary: Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate)Inject 50 mg intramuscularly one time a day starting on the 1st and ending on the 1st every month for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) (Administer every last day of the of the month) Black Box Warning:Increased mortality in elderly patients with dementia-related psychosisElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of approximately 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #3's January 2026 MAR revealed Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 50 mg intramuscularly one time a day starting on the 1st and ending on the 1st every month for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) (Administer every last day of the of the month) was administered on 01/01/2026 in the morning. Record review of Resident #3's February 2026 MAR revealed Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 50 mg intramuscularly one time a day starting on the 1st and ending on the 1st every month for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) (Administer every last day of the of the month) was administered on 02/01/2026 in the morning. Record review of Resident #3's March 2026 MAR revealed Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 50 mg intramuscularly one time a day starting on the 1st and ending on the 1st every month for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) (Administer every last day of the of the month) was administered on 03/01/2026 in the morning. Record review of Resident #3's Physician's Order dated 01/27/2024, revealed Order Summary: SEROquel Oral Tablet 300 MG (Quetiapine Fumarate)Give 2 tablet by mouth at bedtime for PSYCHOSIS related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Black Box Warning:Increased mortality in elderly patients with dementia-related psychosisElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of approximately 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #3's January 2026 MAR revealed 2 Seroquel 300 mg tablets were administered 01/27/2026 through 01/31/2026 at bedtime. Record review of Resident #3's February 2026 MAR revealed 2 Seroquel 300 mg tablets were administered 02/01/2026 through 02/28/2026 at bedtime. Record review of Resident #3's March 2026 MAR revealed 2 Seroquel 300 mg tablets were administered 03/01/2026 through 03/04/2026 at bedtime. Record review of Resident #3's Physician's Order dated 02/19/2026 revealed, Order Summary: SEROquel Oral Tablet 300 MG (Quetiapine Fumarate)Give 1 tablet by mouth one time a day for PSYCHOSIS related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Black Box Warning:Increased mortality in elderly patients with dementia-related psychosisElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of approximately 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #3's February 2026 MAR revealed 1 Seroquel 300 mg tablet was administered 02/19/2026 through 02/28/2026 daily in the morning. Record review of Resident #3's March 2026 MAR revealed 1 Seroquel 300 mg tablet was administered 03/01/2026 through 03/05/2026 daily in the morning. During an interview on 03/09/26 at 12:27 pm MHNP A stated psychosis is a proper diagnosis for some residents. She said over 50% of dementia residents in nursing homes are psychotic and need antipsychotics. She said, What if all the people in nursing homes who were psychotic did not get medications? She said over half the residents would be crawling on the floor, aggressive, and all would have to live with a brain imbalance. She said if she did not medicate them, then she would get tagged for not medicating and she would be tagged for putting psychosis as the indication for an antipsychotic. She said to not treat psychosis would be like hanging someone from a tree. MHNP stated she had been doing this for 40 years. She said she wished she could educate CMS about antipsychotics. She said with the black box warning showing there was a risk of death for a dementia resident receiving Seroquel or any other antipsychotic with a diagnosis of psychosis was not pertinent because we were all going to die sometime. She said she did not believe the risk of death with geriatrics and antipsychotics was increased. She said by the time someone was a geriatric, they already had other issues like cardiovascular, kidneys, liver problems, etc. She said the right medication can pinpoint the area in the dementia resident's brain that helps calm them. During an interview on 03/09/26 at 02:14 pm LVN D stated they would call the doctor if a resident had behaviors like crawling on the floor, yelling out during the night, being aggressive with staff or other residents, or just being agitated. He gave an example of agitation as when the resident verbalizes anything against anyone. He said the doctor will order medication. LVN D stated they sometimes had to ask the provider for the indication for the medication. LVN D stated he did not know that for a resident who had dementia or Alzheimer's, psychosis was not a proper indication for an antipsychotic. He said the doctor or NP gave an order and nurses followed the order given by the doctor. He said as long as they had consents signed for antipsychotics, it was ok to give the antipsychotic. LVN D stated if the resident had any symptoms of the medication making behaviors worse, he would notify the doctor who gave the antipsychotic order. During an interview on 03/09/26 at 02:44 pm NP E stated Resident #2 was her patient and Resident #2 had aggressive dementia which meant she was verbally and physically aggressive. She said Resident #2 was placed in the secure until due to wandering behaviors. She said until she went into the secure unit it was mostly verbal aggression. NP E stated she believed Resident #2 was still having intermittent behaviors since she had started on Latuda. She said the pharmacy would send GDR recommendations. She said she knew CMS did not like antipsychotics being given to residents with diagnosis of Alzheimer's/dementia with an inappropriate indication for the antipsychotic. During an interview on 03/09/26 at 04:55 pm The DON stated the facility had 37 active antipsychotic orders. She stated that psychosis was not an appropriate indication for an antipsychotic for a resident who had the diagnosis of Alzheimer's or dementia. The DON stated for residents with new behaviors, they would notify the physician of the new behaviors, have labs drawn, and have non-pharmacological interventions in place. The DON stated they had IDT meetings twice a week going over the antipsychotics for each resident to ensure it was working for the resident or if behavior was getting worse or stabilizing. She stated that sometimes the family does not want an antipsychotic for their loved one. She said sometimes the resident will come in from the hospital with an antipsychotic and diagnosis. She said when the doctor or NP writes an order, they cannot refuse to give the medication even if it has an indication that was inappropriate. She said some doctors or NPs would not change the indication. Record review of the facility's Psychotropic Drug Use policy dated 03/05/2025 reflected Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Definitions Chemical restraint refers to any drug used for discipline or makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated because they are less dangerous to a resident's health and safety. Policy Explanation and Compliance Guidelines:1.A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2.Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for five residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 10 residents reviewed for abuse. Resident #2 sustained facial injuries from an altercation with resident #4 on 05/27/25 7:59 PM as they passed each other in the 600 hall. Resident #3 sustained facial injuries from being hit in the face by Resident #2 on 05/19/25 @1:30 PM in Resident #3's room. \Resident #5 was slapped in the face by Resident #6 as she was trying to get by Resident #6. Resident #6 was scratched by resident #5 in retaliation for being slapped in the face by Resident #5 on 06/19/25 @4:39 PM. These failures have the potential to result in serious injury. Findings include: Resident#2 Record Review of Resident#2's face sheet dated 10/21/25 revealed a [AGE] year-old male initially admitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Depression (a group of conditions associated with the elevation or lowering of a person's mood), Bipolar Disorder (A chronic mental health condition characterized by extreme mood swings between mania and depression), Altered Mental Status (a change in a person's Level of consciousness, alertness, and cognitive Function, Hostility (hostile behavior unfriendliness, or opposition), Mood Disorder (A group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), and unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #2's MDS dated [DATE] had a BIMS Score of 04-severe cognitive impairment and needed extensive assistance with all ADLs. Behavioral symptoms included other behavioral symptoms not directed toward others like pacing, and rejection of care occurred 1 to 3 days out of the week, and wandering. A record review of Resident #2's Care Plan dated 03/27/25 revealed Resident #2 wandered into another resident's room resulting in discoloration to bilateral hands and abrasion to chin due to altercation with resident. Resident #2's wandered in hall grabbing another resident by arm resulting in altercation with laceration to left lower jaw to resident. Resident #2 has a behavior problem (Wandering) related to Diagnosis of Alzheimer Disease and Dementia. Resident#2 has impaired cognitive function or impaired thought processes related to Alzheimer's Disease and Dementia. Resident #2 has a psychosocial well-being problem (potential) related to Cognitive deficits. Interventions included speaking calmly, moving slowly towards residents, and explained all procedures and why residents were being re-directed at an appropriate date and initiated 05/19/2025. Observe and monitor for signs and symptoms of changes in mental status. Per family, the resident becomes more confused, agitated, or aggressive when he has UTI. Resident #2 was currently on antibiotics for Urinary Tract Infection. Resident #2 was to be redirected positively when seen entering another resident's room. Resident#2 was monitored with a one-to-one care for three days after the incident. Record review of Resident #2's Progress Notes Dated 04/19/2025 to 06/22/25 revealed on 05/19/25 Nursing staff reported Resident #2 had an altercation with Resident #3 after wandering into Residents #3's room. Resident #2 was to continue on neuro checks; continued follow up for physical aggression towards staffs and new order day 2 Keppra (is anti-seizure medication) that include drowsiness increased to 1000 mg 1 tab take by mouth twice a day and Haldis (a powerful antipsychotic medication with a wide range of potential side effects) 5mg/ml inject 2ml every 12 hours as needed for 5 days. On 05/19/25 Resident #2 was in hallway attempting to grab another resident from arm, when alleged Resident #4 began to get physical towards resident. The staff member was unable to arrive on time, and the other resident was able to strike other residents on the face. Nursing staff immediately separated both residents from each other. Resident #2 was assessed; a laceration was noted to lower left jaw line. The nurse practitioner was called and notified. Per the nurse practitioner the wound was to be cleansed in the area with wound cleanser, and applied a steri-strip, the nurse practitioner will be doing an in-house visit later today. The family member of Resident #2 was called and notified of the incident. and could conducted and a follow-up visit for new order of Haldol Dec increased to 100mg intermuscular daily for 14 days for severe psychosis, orders carried out, nursing care on going. Patient continued a follow up check for post resident-to-resident conflict. Resident #2 required constant redirection throughout this shift to prevent the resident from entering other patients' rooms. Resident #2 continued with new orders to add Zolpidem (sedative-hypnotic medication used for the short-term treatment of insomnia) 10 mg tablets by mouth every night at bedtime and change trazadone to 50mg as needed each morning and 100MG as needed each evening. Resident #2 was to be continued to be monitored and redirected; nursing care was going with no discomfort noted. Record review of Resident #2's Head-to-toe dated 05-19-25 assessment noted purple discolorations to bilateral hand, upon resident-to-resident confrontation, noted during nursing assessment. A new order as follows: cleanse with wound cleanser and apply steri-strips to area; orders carried out. Residen#2 was placed on a one to one for closer observation for 3 days. Record review of Resident #2's dated 05/19/25 Skin assessment revealed Resident#2 had an abrasion to the chin, applied topical antiseptic ointment, resident monitored for discoloration to hands and abrasions to the chin area; and continued to be monitored. Had continued with weekly and as needed skin evaluations. Resident #2 altercation with Resident #3, a skin & wound evaluation was completed and noted with abrasion to left medial jaw & laceration to the left lateral jaw. First aid rendered, orders received for wound care to site from NP orders noted. On 5/26/25 skin evaluation completed, abrasion to the chin area was resolved. Resident monitored for discoloration to hands and abrasions to chin area; skin intact and no signs of infection noted, no drainage noted and no redness around wound area. Record review of Resident #2 incident report dated 05/19/25 conducted by ADON-B On 05/19/2025revealed; Resident #2 (BIMs 4) entered Resident #3 room telling Resident #2 to get out of his room. Resident #3 asked Resident #2 to leave his room. As Resident#2 was leaving, he swung at Resident #3 making contact with his left forehead resulting in skin tear. CNA heard yelling and immediately ran to Resident #3 room separating residents. The charge nurse called to the room and performed a head-to-toe assessment of #3 with noted skin tear to left upper forehead and abrasion to the left eyebrow. The physician advised new orders for Haldol Deaconate 5mg/ml inject 2 ml every 12 hours as needed for 5 days and increase in Keppra to 1000mg 1 tab by mouth at bedtime as ordered. The incident was reported to local authorities. Police report filed and case number was provided. Resident #2 was placed on a one-to-one monitoring. Record review of Resident#2's pain evaluation conducted by the ADON B revealed the Resident #2 had no pain reported by resident at the time of incident. Resident #2 was not observed due to his passing 10/13/2025 in the facility at the time of the investigation not related to incident. Resident # 3 Record review of Resident #3's face sheet dated 05/22/25 revealed a 66- year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of traumatic hemorrhage of cerebrum (a bleeding within the brain tissue, cerebrum, caused by an injury to the head) and altered mental status (a change in a person's level of consciousness, alertness, and cognitive function.) Resident #3 was not observed due to he no longer resided in the facility at the time of the investigation was discharged [DATE]. Record review of Resident #3's quarterly MDS dated [DATE] indicated a BIMS score of 10- which indicated moderate cognitive impairment and may need extra assistance with activities of daily life. Resident#3 had difficulty focusing and had disorganized thinking no behaviors were noted. Record review of Resident #3's Care Plan revised on 05/19/2025 revealed Resident #3 with a skin tear to the left upper front of forehead as a result of an altercation with another resident entering his room. Monitor left upper forehead for redness swelling further skin breakdown. Resident #4 has potential to be physically aggressive when touched or when another resident comes close to him. When the resident becomes agitated: Engage Calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Ask residents whether he wants the door open or closed after any entrance to his room. Record review of Resident #3's progress notes dated 05/19/25 revealed continues on discoloration and swelling to right index finger, no complaint of pain; will continue to monitor any changes throughout all shifts. Resident with follow up for resident-to-resident altercation and with injury with skin tear to left forehead and abrasion to be left eyebrow. No pain or discomfort voiced this shift to staff. Continuing with neuro check, monitoring discoloration and swelling to right index finger no complaint of pain. Patients continue with skin tears to the left of the forehead and abrasion to be left eyebrow. No signs or symptoms of infection. The right index finger continues with purple discoloration swelling resolved. Denies any pain or discomfort. Patients also continue to me monitored for follow up post resident to resident incident. Patients show no signs of pain, distress, or discomfort. Patients demonstrated a good appetite on this shift consuming 75%-100% of his dinner. Will continue to monitor.'' Resident #4 Record review of Resident #4's face sheet dated 05/25/25 revealed a [AGE] year-old male admitted on [DATE] with a diagnoses of Vascular Dementia (a type of dementia caused by damage to the blood vessels in the brain), and bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania and depression). Record Review of Resident's #4's MDS dated [DATE] revealed a BIMS score of 10 which indicated moderate cognitive impairment and may need extra assistance with activities of daily life. Resident#4 has difficulty focusing and disorganized thinking. Resident #4 was not noted for any behaviors. Review of Resident #4's care plan dated 08/25/25 revealed Resident #4 was involved in a resident-to-resident altercation in which he struck the other resident. Interventions included monitoring and a visit with the social worker, and no distress was noted or voiced. Resident #4 has potential to be physically aggressive when touched. When another resident comes to close to him. Record review of Resident #4's progress notes dated 05/27/25 revealed Resident #4 was involved in a resident-to-resident altercation in which he struck the other resident. Following the altercation, the charge nurse performed a head-to-toe assessment. No skin tears or bruising was noted. On 05/27/25 to 05/29/25 Resident #4 was monitored, and no distress nor latent injuries were noted. No previous incidents of aggression or altercations were noted to have occurred. Record review of Resident #4's Incident Report dated 5/27/2025 conducted by ADON B revealed, Incident Description: On 05/27/25 both residents were ambulating down the hallway Resident #2 attempted to grab Resident #4 by the arm to ask a question. At that time Resident #4 pushed him away. The CNA attempted to verbally redirect both residents and simultaneously tried to physically intervene. During this interaction, Resident #2 attempted to grab Resident #4's arm. In response, Resident #4 kicked and struck Resident #2 on the left lower jaw line. Resident #5 Record review of Resident#5's face sheet dated 05/27/25 revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Mood Disorder (A group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), and Major Depressive Disorder (A common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in previously enjoyable activities). Record review of Resident #5's MDS Quarterly dated 08/27/2025 revealed Resident #05 had a BIMS Score of 01 which indicated -severe cognitive impairment and needed extensive assistance with all ADLs. Behaviors included hallucinations, delusions, and pacing which occurred 4 to 6 days but less than daily. Rejection of care occurred 1 to 3 days and wandering 4 to 6 days, but less than daily. Record review of Resident #5's care plan dated 03-19-25 revealed she used antipsychotic medications to Abilify for Aggression/Agitation Date Behaviors included hallucinations, delusions, and pacing which occurred 4 to 6 days but less than daily. Rejection of care occurred 1 to 3 days and wandering 4 to 6 days, but less than daily Initiated: 03/12/2025. Record review of Resident #5's progress note dated 06/19/25 revealed Resident approached another resident while trying to ambulate with walker, this resident scream at other resident and slap her on the face, other resident responded scratching this resident in right arm. Resident restless and pacing hall crying, Pain medication administered Tylenol 325mg 2tabs as needed for pain. Cleanse abrasion made to right arm with Normal Saline, apply topical antibiotic ointment only. Residents was on a 1:1 supervision for aggressive behavior. Record review of Resident #5's incident report dated 06/19/25 revealed 06/19/25 at 4:39 PM, Resident#5 exhibited a sudden episode of agitation, approached another resident in an aggressive manner, and struck her in the face with an open hand. In response, the other resident stuck back and caused a scratch to Resident #5's right arm. Local police were contacted, and a report was made. Record review of Resident #5's Skin and Wound assessment dated [DATE] revealed An abrasion located on the right inner forearm was acquired in house. Measurements of the wound were documented as 0.4 cm x1.6 cm X 0.4 cm. treatment included to cleanse with normal saline. Resident #6 Record review of Resident#6's face sheet dated 05/22/25 revealed an [AGE] year-old female initially admitted on [DATE], and readmitted on [DATE] with diagnoses of Depression (a group of conditions associated with the elevation or lowering of a person's mood), Vascular Dementia (a type of dementia caused by damage to the blood vessels in the brain), Altered Mental Status (a change in a person's Level of consciousness, alertness, and cognitive function). Resident #6 was not observed due to he no longer resided in the facility at the time of the investigation and was discharged [DATE] to another facility. Record review of Resident #6's MDS Quarterly dated 06/06/2025 revealed Resident #6 had a BIMS Score of 03 which indicated -severe cognitive impairment and needed extensive assistance with all ADLs. Cognitive patterns of inattention and disorganized thinking were present behaviors. Residents' mood revealed feelings of feeling down, depressed or hopeless. Behaviors of hallucinations and delusions were present and behaviors hitting scratching and self-pacing were noted. Functional abilities revealed Residents #6 needed supervision for touching and partial to moderate supervision needed for activities of daily life. Record review of Resident #6's care plan dated 06/19/25 revealed Resident #6 is an elopement risk; wanderer related to impaired safety awareness due to her Dementia. The resident was in women's secured unit the resident had the potential to be verbally aggressive, and the intervention was to analyze key times, places circumstances, triggers and what deescalates behavior and document. Needed to be in a structured environment in secure unit related to cognitive deficit. The resident was resistive to care; refused to be rendered ADL care, toileting, incontinent care, showers, medication, treatments, nail care. The resident had a behavior problem; many at times exhibit behaviors such as labile moods, remove brief, urinates on the floor, restlessness, aggression, yelling, irritability, sundowning. The intervention was to discuss behavior with the residents and explain also reinforce why this behavior is inappropriate and unacceptable. Record review of Resident #6's progress notes dated 06/19/25 while this resident was trying to ambulate with walker, another resident approached and slapped her, this resident responder scratched other resident in right arm. Pain was assessed and the resident denied any pain and skin was intact. This Social worker followed up with Resident #6 due to resident-to-resident altercation. The residents had no recollection of events with another resident. Day 1 after 06/20/25 resident to resident altercation Resident #6 was noted with no pain and no injuries was calm with no emotional distress. Day 2 06/21/25 after resident-to-resident altercation Resident #6 was noted with no pain and no injuries. Resident #6 was calm with no emotional distress. Resident#6 was discharged to another facility on 06/23/25. Record review of Resident #6's incident report revealed on 06/19/25 at 4:39pm. Resident #5 exhibited a sudden episode of agitation, approached Resident #6 in an aggressive manner, and struck her in the face with an open hand. In response, the other Resident #6 struck back and caused a scratch to Resident #5's right arm. The police were contacted, and a report was made. Observation on 10/22/25 at 11:41 AM of Resident #4 revealed he was located inside the 600 Hall men locked unit sitting in a chair and had a drink. Resident #4 stated he could not remember any incident and did not want to talk to the state surveyor. Observation and attempted interview with Resident #5 revealed she was sitting with her family member asleep on his shoulder in the front lobby of the facility. The family member stated she could not talk and did not have a good memory and would not be able to say or remember what happened. Resident #5 woke up and seemed incoherent and confused. Resident #5 could not speak, made mumbling sounds. The surveyor attempted to ask Resident #5 if she remembered the incident and Resident #5 did not make eye contact and did not say a word. The state surveyor discontinued the interview at that time. In an interview on 10/22/25 at 8:54 AM with CNA C she said when she arrived at the altercation with Resident #2 and Resident #3 both residents were already separated inside Resident #3's room. CNA C said she saw Resident #3 at the door and heard him screaming to get Resident #2 out of his room. CNA C said Resident#3 had blood and a scratch to his forehead with slight bleeding. CNA C said Resident #2 hit him in the face. CNA C said Resident #2 had no injuries noticed at the time of the altercation. CNA C said Resident #2 thought he was in his room then realized it wasn't his room and wanted to leave to his room. CNA C said Resident #2 was always going into other Residents rooms thinking it was his room. CNA C said Resident #2 was put on a 1 to 1 monitoring for 3 days. CNA C said Resident #3 was not an aggressive person and did not want to get in trouble and just wanted to go home. Resident #3 felt that he was defending himself. CNA C said no other altercation occurred between Resident#2 and Resident #3 or with any other residents. CNA C said her last training was this week on abuse and neglect and had one right after the incident with Resident #2 and Resident#3. CNA C stated the administrator is the abuse coordinator and could state all types of abuse physical, mental, sexual, and verbal. In an interview on 10/22/25 at 10:18 AM with the SW she said Resident #3 was in his room and Resident #2 had entered his room and Resident #3 asked him to leave. The SW said Resident#2 struck Resident#3 causing an injury to Resident#3's forehead. The SW said she had done a follow up with both residents several days following the incident, and Resident#2 had a medication review to adjust his medication that helped with his mental status at the time. The SW said she could not recall many details about this incident. The SW stated she did not have many notes, so she could not recall what interventions had been put in place for either resident. The SW said she did recall both residents were wandering residents, and the facility had plenty of intervention for those types of residents in the facility. In an interview on 10/22/25 at 11:37 AM with CNA D said she did not witness the altercation between Resident #2 and Resident #3 but did assist in keeping them apart by staying at the nurse's station to monitor other residents out of their rooms as other staff went to assist in the altercation. CNA D said she worked in hall 600 and was familiar with Resident #2 he always wandered the hall and often went into the room of Resident #3 thinking it was his room. CNA D said Resident #3 was quiet and reserved, who mainly kept to himself. Resident #2 was more aggressive and was always confused about where his room was located. CNA D did not see Resident #3 afterward and did not know of injuries that he had sustained. CNA D could only say she heard the shouting from Resident #3's Room. CNA D stated Resident#2 was always going to Resident #3 room and never had an altercation before this one. CNA D said Resident#2 was put on a 1 to 1 and after the incident occurred. CNA D said the staff became more aware of Resident #2's whereabouts in the hall and redirected him away from other residents' rooms. CNA D said no other altercations occurred between Resident #2 and Resident #3 or with any other resident. CNA D stated she had just received training on abuse, neglect, and the next day after the incident between Resident #2 and Resident #3 occurred. CNA D stated any verbal, physical, sexual, and mental abuse occurrence must be reported immediately to the abuse coordinator and charge nurse. In an interview with ADON-B on 10/22/25 at 9:31 AM she said the incident between Resident #2 and Resident #3 occurred on 05/27/25 at 7:59 AM in the 600 hallway. ADON B stated the Resident#2 and Resident #4 were walking in the hallway and Resident #2 tried to grab the arm of Resident #4. ADON B said Resident #4 pushed Resident #2 away and Resident #2 tried again to grab Resident #4's arm and Resident #4 punched and kicked Resident #2. ADON B stated both residents did not need to be sent out for their injuries and were taken care of in-house. Resident #2 sustained a laceration to the left jaw and an abrasion to left middle jaw. ADON B said Resident#2 was monitored for 3 days on a 1 to 1 and Resident #4 was monitored for the same number of days by the staff on duty at every shift. Resident #2 was under psych eval since 04/25, and his medications and care plan were reviewed and modified by his nurse practitioner and physician. ADON B said a meeting was set up with family to discuss individual activities and redirections. ADON B stated the nurse practitioners' orders were to monitor injury sight for changes and notify him of any changes in behavior. ADON B said the residents were not moved to different rooms as the altercation happened in the hallway. When asked why the incident between Resident #2 and Resident #4 was not reported to local authorities, ADON B said the altercation was not considered abuse because it was a witnessed altercation. ADON B said reportable abuse incidents are on a case-by-case basis. ADON B said an abuse incident had to be suspicious, or something out of the ordinary like misappropriation of property and Injury of unknown origin. ADON B could not remember if the incident was reported, and there were no notes to show it had been reported. ADON B said because the incident was witnessed, the incident was not questionable and not considered abuse. ADON B said this incident was not considered an incident of abuse. ADON B stated the incident between resident #3 and Resident #4 was a willful act. ADON B would not say that this incident was a willful act as Resident #4 was defending himself and only reacted. In an interview with 10/22/25 at 10:27 AM LVN E stated Resident #2 was required to be on a 1 to 1 because of aggressive behavior with residents and staff members. LVN E said Resident #4 was grabbed by Resident#2, and he was pushed, hit, and kicked by Resident #4. Resident #2 was very confused and always going into the outer residents' rooms. The LVN said Resident #2 was also inappropriate with female staff members at times. LVN E said the incident occurred in the hallway as Resident #4 was coming out of his room and Resident #2 had grabbed Resident by the arm then Resident #4 then hit Resident #2 in the face. LVN E said it was a busy time for the staff members around the time the incident occurred as staff were attending to residents with breakfast and getting residents out of bed. LVN E said RN F had done the skin assessments and Resident #2 had a small wound to the lower cheek and a small laceration, but it not swollen. LVN E said Resident#4 was put on a 1 to 1 along with Resident #2. LVN E said Resident #2 was monitored more thoroughly after the 1 to 1 was over her shift and Resident #4 never got near Resident #2 after altercation. LVN E stated staff received abuse, neglect, and dementia care in service after the altercation between Resident #2 and Resident #4. LVN stated the most current in service on abuse and neglect was last week. In an interview on 10/22/25 at 8:30 AM with RN F, she said she conducted the skin assessment for the incident between Resident#2 and Resident #4. RN F said Resident #2 was wandering down the hall and got too close to Resident #4. RN F said then Resident #4 threw a punch as he was reacting to Resident #2 who got too close to him. RN F said Resident #2 had a small laceration to the cheek area and an abrasion and had done wound care. RN F got orders from the physican for a steri-strip to help the wound heal because it had minimal bleeding. RN F said Resident #4 had a bruise on his hand and could not recall any x-rays being done. RN F said both residents were wandering around the hallway that morning. RN F said Resident #4 did not like anybody in his personal space. RN F said they were kept separated and could not recall if either one was on a 1 to 1. RN F said no other incident occurred between Resident#2 and Resident #4. RN F said the abuse and neglect were given at least annually as incidents occurred. RN F said the Abuse Coordinator was The Administrator. In an interview on 08/22/25 1:30 PM with LVN I said she did the head-to-toe assessment for Resident #5, and she just had a scratch on her hand with slight blood. Resident # 5 did not have any marks on her face and could not remember any of the incident. LVN I said there were follow-ups for the next couple of days, and neither resident could remember what had happened. Resident#6 did not have a history of aggression towards others. LVN I said Resident #5 was aggressive at the beginning of her stay in the facility and now she just slightly poked staff and other residents in their stomachs. LVN I said Resident #5 did this playing around meaning no harm. LVN I said before this incident Resident 5 nor Resident #6 had any other altercation with each other or any other residents in the facility. No other incidents occurred between Resident #5 and Resident #6 before or after this incident. In an interview with ADON H 10/22/25 2:16 PM she said when she followed up with Resident #2, he could respond but he was not comprehensive. ADON H said Resident #4 was able to recall the incident, and she gave resident #4 council on what not to do to other residents while out of his room. ADON H said Resident #2 had never been aggressive with other residents but did have other incidents with staff members which was sexual in nature often touching female staff members. ADON H said he would often confuse female staff members as his wife and gabbed when in a sexual manner. ADON H said the incident between Resident#2 and Resident #3 occurred in a locked unit in the hallway and could only remember speaking to them days after the incident. ADON H said Resident #2 had received social services with the SW and the SW did follow up visits for a few days after. ADON H said Resident #2 was put on 1:1; medication was reviewed and reeducated on behaviors. ADON H said Resident #4 was reeducated on behavior outside of his room with other residents. ADON H said she did not think this was abuse case Resident #4 was just reacting to Resident #2. ADON H said after the definition of willful and abuse was given to her to read she agreed the right to be free from abuse was violated and the incident was considered abuse. ADON H said the Administrator is the Abuse Coordinator and said they were provided with training last week on abuse and neglect. In an interview on 10/22/25 at 2:36 PM with ADON H she said Resident #5 and Resident #6 were in a resident-to-resident altercation where Resident #6 was slapped by Resident #5. ADON H said Resident #5 struggled trying to get by Resident #6's walker and Resident #5 got frustrated and slapped Resident #6. ADON H said Resident#6 in turn scratched the hand of Resident#5. Resident #5 was put on a 1 to 1 and Resident #6 was to be monitored with supervision from staff. ADON H said there was a charge nurse, and 2 CNA's who were witnesses to the altercation. The Incident was reported to police by the abuse coordinator. ADON H, she said they had dementia care and abuse, neglect, and dementia care in services last week. In an interview on 10/22/25 at 3:30 PM with the Administrator/ Abuse coordinator she said all altercations were taken seriously and were reported immediately to state and local authorities if the altercation was considered a crime like theft, sexual in nature or if injury occurred to any party involved in the incident. The Administrator said these types of incidents must be reported within the proper time allowed, which is 2 hours. The Administrator stated every resident has the right to be free from all forms of abuse, and that was the main concern when any type of alteration occurs with a resident in the facility. The administrator said interventions should be put in place immediately after an incident of abuse occurred, residents are to be monitored with a 1 to 1 for three days minimum, medication should be reevaluated so that the behavior of the resident could be controlled. The administrator said residents seen wandering and entering a room that was not theirs's should be redirected by all staff members.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 2 out of 10 residents (Resident #1 and Resident #2) reviewed for reporting of abuse/neglect. 1. The facility failed to report to the local law enforcement agency a resident-to-resident physical altercation involving Resident #2 and Resident #4 resulting in minor injuries that occurred on 05/27/25. 2. The facility failed to report an allegation of abuse of Resident #1 within 2 hours that occurred on 04/12/25 at around 1:00 PM. These failures could place residents at risk for potential abuse. The findings included:1. Record Review of Resident#2's face sheet dated 10/21/25 revealed a [AGE] year-old male initially admitted on [DATE] with the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Depression (a group of conditions associated with the elevation or lowering of a person's mood), Bipolar Disorder (A chronic mental health condition characterized by extreme mood swings between mania and depression), Altered Mental Status (a change in a person's Level of consciousness, alertness, and cognitive Function, Hostility (hostile behavior unfriendliness, or opposition), Mood Disorder (A group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), and unspecified Psychosis not due to a substance or known physiological condition. Record review of Resident #2's MDS dated [DATE] had a BIMS Score of 04-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #2's Care Plan dated 03/27/25 revealed Resident #2 wandered into another resident's room resulting with discoloration to bilateral hands and abrasion to chin d/t altercation with resident. Resident #2 wandering in hall grabbing another resident by arm resulting in altercation with laceration to left lower jaw to resident. Resident #2 has a behavior problem (Wandering) related to Diagnosis of Alzheimer Disease and Dementia. Resident#2 has impaired cognitive function or impaired thought processes related to Alzheimer's Disease and Dementia. Resident #2 has a psychosocial well-being problem (potential) related to Cognitive deficits. Interventions included to speak calmly, to move slowly towards resident, and explain all procedures and why resident was being re-directed when appropriate date and initiated 05/19/2025. Observe and monitor for signs and symptoms of changes in mental status. Per family, the resident becomes more confused, agitated, or aggressive when he has a urinary tract infection Resident #2 was currently on antibiotics for Urinary Tract Infection. Resident #2 was to be redirected positively when seen entering another resident's room. Resident#2 was monitored with a 1:1 care for three days after the incident. Record review of Resident #2's Progress Notes dated 04/19/2025 to 06/22/25 indicated Nursing staff report Resident #2 had an altercation with Resident #3 after wandering into Residents #3's room. The head-to-toe assessment noted purple discolorations to bilateral hand., upon resident-to-resident confrontation, noted during nursing assessment. The Nurse practitioner and daughter were called and notified. A new order as follows: cleanse with wound cleanser and apply steri-strips to area; orders carried out. Resident #2 was placed on a one-to-one for closer observation for 3 days. Resident#2 had an abrasion to the chin, applied topical antiseptic ointment, and continued to be monitored. Resident monitored for discoloration to hands and abrasions to chin area; continued on neuro checks; continued follow up for physical aggression towards staffs and new order day 2 Keppra increased to 1000 mg 1 tab take by mouth twice a day and Haldo 5mg/ml inject 2ml every 12 hours as needed for 5 days. 05/26/25 Skin evaluation completed, abrasion to chin area resolved, skin intact, no signs of infection noted, no drainage noted and no redness around wound area. On 05/27/25 Resident#2 in hallway attempting to grab another resident from arm, when alleged Resident#4 began to get physical towards resident. The staff member was unable to reach the residents in time to prevent the altercation. Record review of Resident #4's face sheet dated 10/22/25 revealed a [AGE] year-old male admitted on [DATE] with a diagnosis of Vascular Dementia (a type of dementia caused by damage to the blood vessels in the brain), and bipolar disorder (A chronic mental health condition characterized by extreme mood swings between mania and depression). Record Review of Resident #4 quarterly MDS revealed a BIMS score of 10 indicates moderate cognitive impairment and may need extra assistance with activities of daily life. Resident#4 had difficulty focusing and disorganized thinking. Review of Resident #4 care plan dated 08/25/25 revealed Resident #4 was in a resident-to-resident altercation in which he struck the other resident. Interventions included monitoring and a visit with the social worker. Resident #4 did not have any previous resident to resident altercations Record review of Resident #4's progress notes dated 05/27/25 revealed Resident #4 was involved in a resident-to-resident altercation in which he struck the other resident. Following the altercation, the charge nurse performed a head-to-toe assessment. No skin tears or bruising was noted. On 05/27/25 to 05/29/25 Resident #4 was monitored, and no distress nor latent injuries were noted. Resident #2 was not observed due to his passing 10/13/2025 in the facility at the time of the investigation. Record review of Resident #4's incident report dated 5/27/2025 conducted by ADON B revealed, Incident Description: On 05/27/25 both residents were ambulating down the hallway. Resident #2 attempted to grab Resident #4 by the arm to ask a question. At that time Resident #4 pushed him away. The CNA attempted to verbally redirect both residents and simultaneously tried to physically intervene. During this interaction, Resident #2 attempted to grab Resident #4. In response, Resident #4 kicked and struck Resident #2 on the left lower jaw line. Observation on 10/22/25 at 11:41 AM of resident #4 revealed he was located inside the 600 Hall men's locked unit sitting in a chair and had a drink. Resident #2 stated he could not remember any incident and did not want to talk to the state surveyor. In an interview on 10/22/25 at 9:30 AM with ADON B, she said abuse cases were reported to local authorities on a case-by-case basis. ADON B said if she suspected something out of the ordinary, she would have reported it to local authorities. ADON B said she could not remember if she had reported the incident to the local authorities, and there was no case number to show it had been reported. ADON B said the incident altercation between Resident #2 and Resident #4 was not an abuse case because it was witnessed, and it was not a questionable incident. ADON B said she had not considered this incident to meet the definition of abuse because Resident #4 was defending himself. ADON B said this was not a willful act because both residents had mental i ADON illnesses. ADON B stated she did not report this incident to the local authority because the two residents had mental illness and dementia and the altercation was not a will full act. In an interview with the Administrator/ Abuse Coordinator 10/22/25 at 3:27 PM she said all altercations were taken seriously and were reported immediately to state and local authorities if the altercation is considered a crime like theft, sexual in nature or if injury occurred to any party involved in the incident. The Administrator stated these types of incidents must be reported within the proper time allowed, which is 2 hours. The Administrator stated every resident has the right to be free from all forms of abuse, and that is the main concern when any type of alteration occurs with a resident in the facility. The Administrator said all altercations in the facility are to be reported immediately to the charge nurse and the abuse coordinator. 2. Record review of Resident #1's face sheet dated 10/22/25 revealed a [AGE] year-old female with an original admission date of 03/29/12 and a current admission date of 01/01/20. Resident #1's pertinent diagnosis included hemiplegia (paralysis of one side of the body). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's comprehensive care plan dated 10/22/25 did not reveal any instructions related to reporting of alleged abuse. In an interview with CNA A on 10/21/25 at 1:35 PM, CNA A stated she observed NA L make comments to Resident #1 asking if she was a lesbian at around 1:00 PM on 04/12/25. CNA A stated she observed NA L tell Resident #1 that she was too heavy. CNA A stated she did not report this immediately to the administrator because LVN G was in the room as well and she thought he would report it. CNA A stated she was not the one that reported this incident to the administrator. CNA A stated it was important to report any possible abuse to the administrator to keep the residents safe. In an interview with Resident #1 on 10/21/25 at 4:14 PM, Resident #1 stated one employee did call her fat around April 12th, 2025. Resident #1 stated CNA A stated she should go and report NA L's behavior. Resident #1 stated her feelings were not hurt she NA L called her fat, and that it went in one ear and out the other. In an interview with the DON on 10/22/25 at 9:59 AM, the DON stated CNA A should have reported the incident to the administrator immediately after the incident on 04/12/25. The DON stated she did not hear about the incident until the ombudsman told her a few days later. The DON stated it was important to report instances of suspected abuse immediately to keep the residents safe. In an interview with the ADM on 10/22/25 at 10:24 AM, the ADM stated CNA A should have called her immediately after she witnessed possible abuse on 04/12/25. The ADM stated if an employee had any doubt that abuse or neglect may have occurred they should report it to her. The ADM stated it was important to report all abuse allegations to HHSC within 2 hours to ensure residents were protected. The ADM stated both staff members involved in this incident were no longer employed at the facility. The ADM stated the incident was reported to the HHSC on 04/15/25, after the ombudsman interviewed Resident #1 and reported the allegation to the facility. In an interview with LVN G on 10/23/25 at 9:32 AM, LVN G stated he was not in the room during the alleged abuse. LVN G stated he had been in their earlier, but he did not witness any staff member say Resident #1 was fat or ask if she was a lesbian. LVN G stated he did not know why CNA A thought he was in the room at the time of the incident. LVN G stated if he had witnessed any possible abuse he would have reported it to the administrator immediately. An interview was attempted with NA L on 10/22/25 at 2:49 PM but she did not answer the phone call. Record review of the facility's Abuse and Neglect and Exploitation Policy and Procedure dated 07/11/2025 indicated Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident properties. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes:a. a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan to include Resident #1's behaviors and interventions. This failure could place residents at risk of not receiving safe and appropriate care. The findings include: Record review of Resident #1's face sheet, dated 11/20/25, revealed an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce or block blood flow to the brain), moderate with mood disturbance, obstructive (blockage that prevents urine from flowing out of the body) and reflux uropathy (urine flows backwards from the bladder) , unspecified, and retention of urine (inability to completely empty the bladder), unspecified. Record review of Resident #1's quarterly Minimum Data Set assessment, dated 09/29/25, revealed Resident #1 had a BIMS score of 03, which indicated he was severely cognitively impaired. Resident #1's MDS did not indicate any behaviors. Record review of Resident #1's care plan retrieved on 11/14/25 did not include any documentation related Resident #1's behavior of urinating in trash cans or on the floor in his room. Record review of Resident #1's care plan retrieved on 11/20/25 included a problem of, [Resident #1] has episodes of urinating in inappropriate areas (wastebasket, floor) and is at high risk for falls related toincontinence and wet floor hazards. With an initiated date of 11/19/25. During a record review and interview with the DON on 11/20/25 at 5:07pm she stated Resident #1 had a behavior of urinating in the trash bins in his room and restroom. The DON stated Residents #1's behavior of urinating in the trash cans started about 6 months prior to November 2025. The DON stated staff had never physically seen Resident #1 urinating in the trash cans, but they had found yellow liquid in the trash cans that smells. The DON stated herself, SW A and ADON B were responsible for adding these behaviors to Resident #1's care plan. The DON stated she had been aware of the behavior previously and had discussed these behaviors with both SW A and ADON B. The DON stated SW A had told her the behavior had been care planned. The DON stated this kind of behavior should be included on the residents care plan to make sure everyone was aware and to make sure they were checking the trash liners and taking them out. The DON stated she had reviewed Resident #1's care plan after this surveyor asked questions on 11/19/25 regarding Resident #1's behaviors and did not see his behaviors care planned and stated they added Resident #1's behaviors afterwards on 11/19/25. The DON stated it was important to include behaviors on the care plan because it was the plan of care and communication from staff to staff. The DON stated the interdisciplinary team reviewed care plans for all required information including behaviors quarterly and as needed. The DON stated they did this by reviewing 24 hour reports and 72 hour reports to review for any documented behaviors from staff and then determined what the behavior was and have it reflected on their care plan so everyone was aware and would be aware of the interventions to try to minimize those behaviors. The DON stated both her and SW A have been trained over developing a care plan and what should be included. The DON stated the facility policy regarding care plans stated it should include residents behaviors and changes should be made as needed ad were on going. The DON stated this policy was not followed due to Residents #1's care plan not being updated. The DON stated not including residents behaviors on their care plan could impact the communication among direct care staff. During an interview with SW A on 11/20/25 at 5:59pm SW A stated from what she was aware of Resident #1 did not urinate outside of the restroom and stated based off her previous interviews Resident #1 always urinated in the restroom and stated that was the room she checked and had never seen urine outside of the restroom. SW A stated Resident #1 may miss the toilet and get urine on the floor in the restroom but that was it. SW A stated nothing had been reported to her that it was a behavior Resident #1 had. During an interview with ADON B on 11/20/25 at 7:32pm stated you could smell urine and see it in the trash cans but stated she had never seen him physically do it. ADON B stated she did not recall when Resident #1 started urinating in the trash can but states leadership had been aware and had discusses it in the morning meetings and had discussed it with both the DON and SW A. ADON B stated no one had seen Resident #1 urinate in the room and never reported seeing it either but had only found urine in the trash can. ADON B stated generally SW A was responsible for adding behaviors such as urinating in the room on the care plans and stated ultimately everyone was. ADON B stated she reviewed Residents #1's care plan on 11/19/25 after this surveyor spoke to staff about the behavior and ADON B stated she had not seen anything on there regarding urinating. ADON B stated she did not know why the Resident #1's behavior was not on his care plan. ADON B stated from what she was aware of SW A had reviewed the care plan previously and had said it was on there, ADON B stated it was oversight. ADON B stated it was important for behaviors to be on the care plan so that staff would be aware of how to address, redirect the behaviors and how to implement intervention. ADON B stated the interdisciplinary team would review and monitor the care plans to ensure they had all required information including behaviors and stated they did this during their morning meetings and meetings at 3:30pm and stated they would go over anything new and would update the care plan and add interventions. ADON B stated staff had been trained over developing the care plan and what should be included. ADON B stated without looking at it she could not recall what the facilities policy stated in regards to including behaviors on the care plan. ADON B stated she felt staff did not follow their facility care plan policy when it came to Resident #1. ADON B stated not including residents behaviors on their care plan could negatively impact them because staff would not be able to implement the interventions. Record review of facility in-service training report dated 01/31/25 that covered comprehensive care plans reflected, the DON, SW A and ADON B had all received the training. Record review of the facility's policy titled, Comprehensive Care Plans with an implemented date of 10/24/22 stated, The comprehensive care plan will describe, at a minimum, the following:The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #101) reviewed for abuse. The facility failed to ensure Resident #101 was free from abuse. CNA H slapped Resident #101 on the face on 8/1/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/01/24 and ended on 08/01/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 3/26/2025 at 12:32pm. This failure affected one resident and placed additional 9 residents who were on the memory unit at risk of abuse. Findings included: Record review of Resident#101's admission record dated 3/25/2025 reflected an [AGE] year-old female initially admitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), cognitive communication deficit (difficulties with communication arising from problems with cognitive process like, attention, memory, or reasoning, rather than speech or language difficulties themselves), dementia (a general term for a group of brain disorders that cause a progressive decline in cognitive abilities, memory and behavior). Record review of Resident #101's comprehensive care plan dated 5/9/2022 indicated she had a history of physical aggression and agitation/combative behavior towards staff and other residents. Resident #101 had severe cognitive impairment and needed moderate assistance with all ADLs. Record review of Resident #101's quarterly MDS dated [DATE] reflected a BIMS score of 00, indicating Resident #101 was severely cognitively impaired and had a wandering behavior that occurred daily. Record Review of Resident #101's incident report dated 8/1/24 reflected she had been slapped on the face by CNA H. The incident was witnessed by CNA I and RN J. The incident occurred while CNA H and CNA I tried to render care to Resident #101. Resident #101 became agitated and hit CNA H, and in response CNA H slapped Resident#101. The incident report revealed that the facility's investigation was confirmed for abuse. During an observation on 3/24/25 at 10:00 am, Resident #101 was in the dining room watching television and eating a snack. During an observation on 3/25/25 at 11:25 am, Resident #101 was in the dining room eating a snack. During an observation on 3/26/25 at 12:10 pm, Resident #101was in the dining room eating lunch. During an interview on 3/24/25 at 10:00 am Resident #101 was not able to recall the incident. In a telephone interview on 3/24/25 at 4:00 PM, CNA H denied that she had slapped Resident#101 on the face. CNA H said that she simply raised her hand to scare her. CNA H said RN J immediately intervened and instructed her to report to the Administrator's office. CNA H said the Administrator immediately suspended her and later terminated her. Record Review of CNA H's written statement (not dated) reflected in part that Resident #101 hit my face with force and I instantly hit her back not hard. I know it was wrong, but it was instinct. In an interview on 3/25/25 at 10:26 AM, CNA I said the incident occurred while she tried to convince Resident#101 to go back to her room to render perineal care. CNA I said Resident#101 refused and became agitated. CNA I said she went to ask CNA H for assistance. CNA I said Resident #101 followed her and at that time CNA H and CNA I tried to redirect Resident#101 back to her room. CNA I said Resident #101 became physically combative and suddenly slapped CNA H on the face. CNA I said CNA H reacted by slapping Resident #101 on the face. CNA I said the incident was witnessed by RN J who immediately protected Resident#101 and instructed CNA H to report to the Administrator's office. In an interview on 3/25/25 at 10:35 AM, RN J said she heard Resident#101 yelling at CNA H and CNA I while they tried to redirect her back to her room. RN J said that she immediately went to check on Resident #101. RN J said she observed CNA H slap Resident#101 on the face. RN J said that she immediately separated Resident #101, and CNA H. RN J said she instructed CNA H to exit the memory unit and report to the Administrator's office. RN J said she immediately a head to toe assessment was done for Resident#101 for any physical injuries and then reported the incident to the Administrator. RN J said that CNA H was removed from the facility after the incident. In an interview on 3/25/25 at 11:00 AM, the DON said that after the 8/1/24 incident CNA H was immediately suspended, and later terminated. The DON said all staff were in-serviced on 8/1/24 on of the topics of Dealing with challenging residents; Abuse Prohibition Policy. The DON said the following interventions were initiated: Resident #101 was closely monitored by staff and to monitor for any psychosocial behaviors. In an interview on 3/25/25 at 11:15 AM, the Administrator said that when CNA H reported to her office on 8/1/24 she was immediately suspended and instructed to leave the facility. The Administrator said she immediately reported the incident to the state. The Administrator said after the investigation the facility confirmed the allegation of abuse and CNA H was terminated. It was determined these failures placed Resident #101 in an Immediate Jeopardy situation on 08/01/24. The facility had corrected the noncompliance before the survey began. Record Review of the facility resident report dated 8/1/2024 of the following interventions were put in place: 1. Resident #101 was immediately protected by RN J. In an interview on 3/25/25 at 10:35 AM, RN J said she heard Resident#101 yelling at CNA H and CNA I while they tried to redirect her back to her room. RN J said that she immediately went to check on Resident #101. RN J said she observed CNA H slap Resident#101 on the face. RN J said that she immediately separated Resident #101, and CNA H. RN J said she instructed CNA H to exit the memory unit and report to the Administrator's office. RN J said she immediately a head to toe assessment was done for Resident#101 for any physical injuries and then reported the incident to the Administrator. RN J said that CNA H was removed from the facility after the incident. 2. CNA H was immediately removed from the facility. Record reveiw of incident report dated 8/1/24 revealed resident was suspended on 8/1/24. Record Review of incident report dated 8/1/24 CNA H was terminated on 8/6/24. 3. A head-to-toe assessment was conducted on Resident #101 on 8/1/24. Record review dated 8/1/24 of resident assessment revealed no physical harm, pain or mental anguish. 4. The facility's social worker assessed Resident #101 for signs of psychosocial harm on 8/1/24 and later referred Resident#101 to counseling. Interview with social worker revealed that she assessed the resident and there were not signs of psychosocial harm and was referred for counseling evaluation on 8/1/24. Record review dated 8/1/24 revealed social worker had done an assessment and referred resident for counseling. 5. Staff were in-serviced on 8/1/24 on the topics of Dealing with challenging residents and Abuse Prohibition Policy. Record review dated 8/1/24 revealed all staff were in-serviced on dealing with challenging residents and abuse prohibition policy. 6. All residents in the memory unit were interviewed and observed for abuse on 8/1/24 with no concerns mentioned. 7. Staff in the memory unit were interviewed on 3/24/25, 3/25/25 and 3/26/25 and all were familiar with the facility's protocol when dealing with residents with cognition impairment and aggressive behaviors and abuse prohibition policy. 4 CNAs were interviewed from different shifts, 3 License Vocational Nurses and 1 registered nurse. 3/24/25 at 1:39 PM, CNA EE 3/25/25 at 10:35 AM, RN J 3/25/25 at 10:26 AM, CNA I 3/25/25 at 1:34 PM, LVN F 3/25/25 at 1:49 PM, CNA DD 3/25/25 at 2:48 PM, ADON 3/25/25 at 2:25 PM, LVN CC 3/26/25 at 10:49 AM, CNA S Record Review of the facility's policy titled abuse, neglect and exploitation, date implemented 8/15/22, stated It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, biting, and kicking. It also includes controlling behavior through corporal punishment.

48278 Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 6 (Resident #119, Resident #124, and Resident #205) and 1 shower bed (hall 300) out of 4 that were reviewed for safe environment. 1. The facility failed to ensure bathroom sinks' hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #119, Resident #124, and Resident #205. 2. The facility failed to ensure the shower bed in Hall 300 shower room was in good condition. These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. Findings Included: During an observation on 03/24/2025 at 04:14 p.m. with the Maintenance Director and using the maintenance director's digital thermometer, the bathroom sink hot water temperatures were: 1.Resident #119's bathroom sink hot water temperature was 124 degrees Fahrenheit, Resident #124's hot water temperature was 118 degrees Fahrenheit and Resident #205's hot water temperature was 116 degrees Fahrenheit. Record review of Resident #119's face sheet dated 03/24/2025 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with original admitted [DATE]. His pertinent diagnoses included Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Mood Disorder, Muscle wasting and Atrophy (loss of muscle tissue), Peripheral Vascular Disease (reduced circulation of blood to a body part, other than the brain or heart), Essential Hypertension (high blood pressure). Record review of Resident #119's quarterly MDS assessment, dated 03/06/2025 revealed a BIMS score of 05, indicating Resident #119 was severely cognitively impaired. He required minimal assistance for mobility. Record review of Resident #119's care plan revised dated 03/11/2025 revealed he had limited physical mobility. Interventions: The resident was able to ambulate self with a walker. Record review of Resident #124's face sheet dated 03/26/2025 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE], with original admitted [DATE]. His pertinent diagnoses included Vascular Dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Essential Hypertension (high blood pressure), Anxiety Disorder. Record review of Resident #124's quarterly MDS assessment, dated 01/25/2025 revealed a BIMS score of 03, indicating Resident #124 was severely cognitively impaired. He required supervision for mobility. Record review of Resident #124's care plan revision dated 08/05/2024 revealed he had Alzheimer's. Interventions: the resident requires supervision for toileting hygiene. Record review of Resident #205's face sheet dated 03/24/25 reflected the resident was a [AGE] year-old female with an admission of 01/15/24 and initial admitted [DATE]. Her relevant diagnoses included need for assistance with personal care, and lack of coordination. Record review of Resident #205's quarterly MDS dated [DATE] reflected she had a BIMS score of 14, which revealed her cognition was intact. In an interview on 3/24/2025 at 4:20 p.m. with the Maintenance Director, he stated that he has a maintenance assistant who does rounds every day in the morning. His assistant was not working this afternoon. He stated the assistant checks the water temperatures at least one room in each hall every day and the last time he checked them was this morning (3/24/2025). The Maintenance Director stated that his assistant documented the temperature readings on a paper, and he received it on Fridays. He stated if they were not within range, that he would get notified right away. The Maintenance Director stated the hot water temperature should be between 100-110 degrees Fahrenheit. The Maintenance Director stated the negative outcome of the water temperature being too hot in the resident's restroom was that the residents can get burned since they have thinner skin. In an interview on 03/24/2025 at 5:02 p.m. with Resident #124, he stated that he does use the restroom sink and he has not been burned. He stated that he adjusted the water temperature before he used it. In an interview on 03/24/25 at 5:30 p.m., Resident #205 said she used the sink in her restroom daily but had not sustained any burns. She said she would open the cold and hot water at the same time to wash her hands. In an interview on 03/25/2025 at 2:08 p.m. with the maintenance assistant, he stated that he checks the water temperatures every day. He stated that he checks one room in each hall randomly. He then documents these temperatures in a paper log. He enters this information in TELS on Fridays. He gives this log to his supervisor, the maintenance director, at the end of the week. He stated if he gets an out-of-range reading, he calls his supervisor right away at the time. He stated the hot water temperature should be between 100-105 degrees Fahrenheit. He checked them yesterday, 03/24/2025 in the morning and the temperature was within range. He stated the hot water does not come out hot right away, but the residents can get burned. In an interview on 03/26/2025 at 1:45 p.m. with Resident #119, he stated that he does use the restroom sink to wash his hands. He stated he had not been burned. In an interview on 03/27/2025 at 10:10 a.m. with the Administrator, she stated that the maintenance assistant randomly checked the water temperatures daily and enters the temperatures weekly in TELS. She stated that she does not look at these temperatures unless she receives an alert. The alert would be triggered when the temperature was out of range. The range should be between 100 -110 degrees Fahrenheit. The administrator stated there had not been any residents burned by hot water in their rooms. She stated the plumber was here on Tuesday, 03/25/2025, troubleshooted the water heater and tested the room temperatures. She stated the negative outcome of the hot water being too hot was that the resident's skin could be affected. Record Review of the Water Temperature Log dated 03/24/2025 revealed residents' rooms were within normal range between 106 to 110 degrees Fahrenheit. Further review of the TELS Logbook documentation for the week of 03/17/2025-03/21/2025 revealed minimal variation of temperature between 101 to 105 degrees Fahrenheit. Review of facility's incident and accidents logs dated 01/2025, 02/2025, and 03/2025 did not reveal any injuries to residents due to hot water. Review of the facility's Grievance logs dated 01/2025, 02/2025, and 03/2025 did not reveal any complaints of water temperature being too hot. 2. In an observation on 03/25/25 at 5:45 p.m., the shower bed in Hall 300 made of pvc (polyvinyl chloride) and a blue mesh fabric. It had a have a white and black film in the middle of the shower bed that extended from the top to the bottom of the bed. Parts of the mesh were worn out and frayed throughout the shower bed. In an observation and interview on 03/25/25 at 5:00 p.m., with the Central Supply Director as he inspected the shower bed in the Hall 300 shower room. He said the mesh on the sides were frayed and could potentially cause the mesh to tear. He described the middle part of the shower bed as having mold, dirty and frayed. He said the bottom pan of the shower bed had water residue. He said it was the CNA's responsibility to inspect the shower beds as they were the ones that used them on a daily basis. He said in his opinion, the shower bed needed to be replaced. The Central Supply Director said no one had told him that particular shower bed had signs of wear and tear. He said if the Administrator approved a new shower bed he would be responsible for ordering one. The Central Supply Director was not able to say what negative outcome that shower bed would have on the residents. In an observation and interview on 03/25/25 at 6:00 PM, the DON was observed as she inspected the shower bed. The first thing the DON said when she saw the shower bed was, oh it needs to be sanitized. She was not able to say what if anything was the negative outcome to the residents in hall 300 for having a shower bed with frayed and dirty mesh. She said it was the responsibility of the CNAs to report any wear and tear to the administration. The DON said she had not been informed by any staff member that the shower bed was not in good condition. In an observation and interview on 03/25/25 at 6:07 p.m., the Administrator said after seeing the shower bed that it needed to be taken out of commission and replaced. She said the frayed mesh needed to be replaced. She said she would be authorizing the Central Supply Director to order a new shower bed immediately. The Administrator said she had not been informed by any staff member that the shower bed was showing signs of wear and tear. She was not able to say if there were any negative outcomes to residents for having a shower bed that needed to be replaced. The Administrator said the facility did not have a policy related to shower beds. In an interview on 03/26/25 at 8:15 am, CNA P said she used the shower room in hall 300. She said she had not noticed the shower bed needed repair. She said if she had noticed the shower bed needed repairs she would have immediately reported it to her charge nurse or the DON. She said she was regularly in-serviced on the topic of reporting anything that needed to be repaired as soon as possible to her charge nurse or administration in order to avoid resident accidents. Review of the facility's Instructions Direct Supply TELS provided the following information: 1. Ensure patient room water temperatures are between 100 degrees and 110 degrees Fahrenheit or as specified by state requirement). Texas 100-110 degrees Fahrenheit 5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. Record results in the water temperature log 1. Note any discrepancies 2. Adjust water heater setting as required 3. Retest as necessary

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding. 2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings include: Record review of Resident #101's face sheet, dated 3/25/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #101 had a diagnosis which included: Vascular Dementia (a type of cognitive decline caused by damaged to the blood vessels in the brain), Alzheimer's disease (caused by problems with blood supply to the brain, leading to damage and impaired function, and often involves difficulties with thinking, planning and problem solving), Needs assistance with personal care. Record review of Resident #101's Care Plan initiated on 5/11/23 reflected she has an ADL self-care deficit related to decreased cognition secondary to Alzheimer's Dementia, and Amnesia. Resident #101's functional performance with eating: the Resident requires (supervision/or touching assistance) for eating. Record review of Resident #101's quarterly MDS assessment, dated 1/30/25, reflected a BIMS score of 00, which indicated Resident #00's cognition was severely impaired. Eating assistance was marked on the MDS as 04 which indicated supervision or touching assistance (helper provides verbal cues and/or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. During an observation on 3/24/25 at 12:00PM Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding. During an observation on 3/25/25 at 5:00PM, Resident #101 was in the dining room, CNA was sitting next to resident and was assisting with feeding. During an interview on 3/24/25 at 4:00PM with CNA I stated that Resident #101 needs assistance with feeding because she was not able to feed by herself because of the resident's had Alzheimer's. CNA I stated Resident #101 did not know how to use the utensils. CNA I stated resident had been fed with all meals. During an interview on 3/26/25 at 11:35AM with RN L stated Resident #101 needed total assistance with feeding with all her meals because of the resident's Alzheimer's disease. RN L stated that a negative outcome of care plan not been accurate could place Resident#101 at risk for weight loss. During an interview on 3/26/25 at 10:00 AM with LVN K, MDS nurse, stated that the resident was able to grab finger food. LVN K, MDS nurse stated that she did not know that resident needed a lot of assistance. LVN K, MDS nurse stated that she did not update the care plan because she was not aware that resident was being assisted with feeding every meal. During an interview on 3/26/25 at 4:40 PM, the DON said she was not aware that resident was needing total assistance with feedings. DON said Resident#101's care plan had to be accurate and this way all staff could know what the resident needed. 2. Record review of Resident #82's face sheet dated 03/27/25 reflected resident was a [AGE] year-old male admitted to the facility on [DATE] with original admitted [DATE]. His pertinent diagnoses included post-traumatic stress disorder (mental condition that develops after experiencing or witnessing a traumatic event, war, violent crime, or personal loss), bipolar (a disorder associated with episode of mood swings ranging from depressive to manic highs), dementia (a group of thinking and social symptoms that interferes with daily function), cognitive communication deficit (a group of conditions that affect a person's ability to communicate effectively due to underlying cognitive impairments), major depressive disorder ( mental condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), delusional disorder (mental illness that caused people to have unshakeable false beliefs for at least a month), and schizoaffective disorder (disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #82's quarterly MDS assessment dated [DATE] reflected his BIMS score question was left blank, indicating his cognition was severely impaired. His active psychiatric/mood disorder diagnoses included depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and psychotic disorder (mental disorder characterized by a disconnection from reality). It further reflected he had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal (threatening others, screaming at others, cursing at others) and other behavioral (not directed towards others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) symptoms that occurred 1 to 3 days during the review period. Record review of Resident #82's order summary reflected he had a diagnosis of post-traumatic stress disorder effective 03/25/21. Record review of Resident #82's quarterly comprehensive care plan dated 03/06/25 reflected he: 1. used to be a boxer and suffered from post-traumatic stress disorder (date initiated/revised 08/25/23). His interventions included to administer medications as ordered, behavioral health consults as needed, monitor/document/report PRN any risk for harm to self (date initiated 01/10/24), monitor/record/report to MD prn mood patters signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols (date initiated 11/24/23 and revised 11/25/23) and monitor/record/report to MD prn risk for harming other, increased anger, labile mood ( a neurological condition that involves rapid and exaggerated mood changes) or agitation, feels threatened by others or thoughts of harming someone (date initiated 01/10/24 2. had a psychosocial well-being problem related to post-traumatic disorder, bipolar disorder, dementia, and schizoaffective disorder (dated initiated/revised 11/19/24). Interventions included to encourage participation from resident who depended on others to make his own decisions, increased communication between resident/family/caregivers about care and living arrangements, provide opportunities for the resident and family to participle in care, should conflict arise, remove resident to a calm safe environment and allow to vent/share feelings. In an observation on 03/24/25 at 10:35 a.m., Resident #82 was observed lying in bed awake and mumbling to himself with a blank stare. In an interview on 03/25/25 at 10:00 a.m., the SW said when a resident was admitted , they were screened for any trauma. She said Resident #82 was admitted to the facility on [DATE] and diagnosed with post-traumatic stress disorder on 03/25/21. She said she would have to review her records to see if he had any identifiable triggers. In an interview on 03/26/25 at 8:00 a.m., CNA R said she had cared for Resident #82 for almost one year. She said since she had cared for him he had not displayed any behaviors. She said he was bed bound, required total assistance for all ADLs, and was not able to communicate. CNA R said she would round Resident #82 more frequently because he was not able to communicate or use the call light. She said by rounding more often than every 2 hours, staff could anticipate his needs better. In an observation and interview on 03/26/25 at 8:11 a.m., LVN F said Resident #82 used to be a hospice patient but had recently been discharged from hospice. She said for the most part his way to communicate was to moan. LVN F said, it was rare but there had been times in which Resident #82 was able to answer yes or no but for the most part he would just moan. She said staff were able to meet his needs by making more rounds to his room and trying to anticipate his needs better. LVN F said Resident #82 had a diagnosis of post-traumatic disorder. She was observed as she reviewed Resident #82's care plan and said she was not able to find any triggers listed under his problem of post-traumatic stress disorder. She said CNAs and nursing staff would constantly monitor Resident #82 for any signs or symptoms of any behaviors not only because of his diagnosis of post-traumatic stress disorder but for all his other mental disorders. She said in her experience as a nurse, Resident #82 had not displayed any behaviors that she could identify as triggers. She said there were no negative outcome for Resident #82 not having any triggers identified on his care plan because staff were monitoring all his behaviors because of his overall mental disorders. LVN F said she would be in-serviced at least every 12 months on the topic of post-traumatic disorder. In an interview on 03/26/25 at 10:30 a.m., LVN S-MDS said Resident #82 was the only resident in the facility with an active diagnosis of post-traumatic stress disorder. She said she had not included any triggers because there were no identifiable triggers for him. She said in her opinion, if a resident with an active diagnosis of post-traumatic disorder did not have any identifiable triggers their care plan should include a statement that reflected no identifiable triggers, which she acknowledged Resident #82's care plan did not. She said there were no negative outcome to Resident #82 not having triggers listed on his care plan, because he was being monitored for all his other mental disorders which included post-traumatic stress disorder. In an interview on 03/26/25 at 4:08 p.m., the Social Worker said she had reviewed Resident #82' progress notes and his counseling notes but had not found any documentation that identified any triggers for his post-traumatic stress disorder. She said Resident #82 had been referred to counseling in the past for his diagnosis of bipolar. She said when Resident #82 was initially admitted , he had behavior problems like wanting to punch staff and other residents. She said since his admission, Resident #82's health had declined and at one point he was under hospice. She said he was no longer under hospice, but his health continued declining. She said Resident #82 was not able to communicate, was bed bound. She said she had not been told by staff Resident #82 displayed any behaviors that could be identified as triggers. She said when Resident #82 was initially admitted , he was in the secure unit. She said since his health declined, he was transferred to a regular room as he was no longer displaying any behaviors or able to ambulate. In an interview on 03/26/25 at 4:27 pm the DON said the care Resident #82 received was based on his current physical status/psychosocial status. She said his diagnosis of post-traumatic stress disorder did not infringe in the care he received. She said there were no negative outcome to Resident #82 not having triggers identified on his care plan because his dementia was too advanced, and he was being monitored for any behavior issues. In an interview on 03/27/25 at 8:45 am, the Nurse Practitioner (Psychiatry) said when Resident #82 had initially been admitted to the facility, staff had a very hard time trying to diagnose him. She said Resident #82 was very aggressive, agitated, and difficult to manage. She Resident #82 was not a very good historian and it had taken a long time to stabilize him. She said she diagnosed Resident #82 with post-traumatic stress disorder along with other mental issues after his admission. She said at the time of his diagnosis, she was not able to identify any triggers and focused on his other more severe mental disorders. She explained Resident #82 had been a boxer in his younger years and had also been kidnapped for several weeks and severely beaten up in another country. She said the resident has had a rapid decline in health and in her medical opinion, he is beyond the point of having identifiable triggers because his dementia is too advanced. Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 50487

Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #5) reviewed for abuse. 1)The facility failed to ensure CNA F communicated Resident #5's allegation of abuse on 11/17/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/20/24 and ended on 11/20/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. The findings included: Record review of Resident #5's admission record dated 1/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (when blood flow to the brain is disrupted, which can lead to brain cell death), aphasia (a neurological disorder that impairs a person ' s ability to communicate), and mild intellectual disabilities. Resident #5 was discharged home with home health on 01/14/2025. Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected she had short-term memory problem and cognitive skills for daily decision making were severely impaired. Record review of intake investigation worksheet, for Resident #5 revealed On 11/17/24 at about 8-9 am CNA F when into resident's room to pick up breakfast tray and saw that resident seemed sad. Asked her how it went when she went out on pass with her sister. Resident began to cry and stated that she was hit while out on pass by her nephews. Did not go into detail about incident. When asked if she wanted to speak with someone, she stated no. During the rest of the shift resident remained sad. During incontinent care and care CNA did not see any visible injuries. Facility made aware of allegation on 11/20/24 and resident is currently out on pass with sister. Family to be called to have resident return to facility. Upon arrival, police will be called, head to toe assessment will be conducted, interview to be done with resident. In an interview on 1/29/25 at 11:30 am with the police officer, he said no crime was discovered. He said they spoke to the resident, resident's family and staff and found that the resident may have referred to an incident that happened years ago, nothing recent. In an interview on 1/29/25 at 12:30 pm with the facility's Social Services, she said she recalls CNA F reported to a nurse when CNA F returned to work on 11/20/24 and the nurse told her to talk to me. CNA F said she did not tell anyone because she was doing work and while she was off, she thought about it, and she told the nurse when she returned. Social Services said she called the administrator, and she took over from there. She said Resident #5 was out on pass so could not interview her. Social Services said she called the family member to bring the resident back so they could assess her. Social Services said she asked the family member if any males were around the resident and the family member denied. The family member said Resident #5 was never alone, she was always with the family member. Social Services said they called the PD, and they took a statement from Resident #5. Social Services said the resident denied allegations of abuse to police and the family also denied. Social Services said Resident #5 also denied allegations to her. Social Services said the police talked to the family, RP, resident, and staff. Social Services said she completed the one-to-one with CNA F. In an interview on 1/29/25 at 5:54 pm with CNA F she said Resident #5 had gone on pass with a family member on 11/17/24. When Resident #5 returned, CNA F said she asked how it went, and Resident #5 began to cry. CNA F said Resident #5 said someone hit her while out on pass. She said it was the sobrinos (nephews). CNA F said after Resident #5 reported that to her, she never commented on it again. CNA F said Resident #5 went out on pass again on 11/20/24 with family and everything was normal. CNA F said she did not report to anyone at the time because it was a Sunday, and no one was there except a new nurse. CNA F said she got busy after she came out of the resident ' s room, so she forgot to report. She said after work that day she was off. CNA F said when she returned to work, she reported it to the nurse and then it was reported to the administrator. CNA F said she completed an Abuse, Neglect and Exploitation in-service after the incident, and they also completed a one-on-one. She said they ask them about the types of abuse and tell them who to report to. She said she should first report to the administrator. She said they tell them to report immediately. She said they tell them if the administrator is not there, they must report to Social Services or a nurse. She said allegations of abuse were not reported; she could lose her certification. She said residents could also continue to get abused. In an interview on 1/30/25 at 11:05 am with LVN H, said she worked with resident the night shift of 11/17/24 to 11/18/24. She said Resident #5 did not voice complaints or show distress. She said Resident #5 was in good spirits and while she was awake, there were no concerns, reports of abuse, or any emotional distress noted LVN H said when an incident happens on the day shift, they pass on report to her and she follows up or monitors the resident. LVN H said during in-services, they were informed they must report physical, verbal, or sexual abuse. She said they must report any abnormalites or suspiciouns they of staff or family. She said they must report these examples to the Administrator as soon as they suspect. She said they are informed of alternative people to report to if the Administrator is not available such as the ADON or DON. In an interview on 1/30/25 at 1:56 with the DON, she said that prior to the incident they drilled staff on abuse, neglect and exploitation and the importance of reporting timely, so for her to have voiced it was because she was off after or whatever reason she gave made no sense. The DON said staff know the phone numbers for who they need to report to. The DON said they use alert media to inform staff of the importance of reporting abuse, how to report abuse, who to report it to and the importance of reporting immediately. The DON said they sent the staff the Ombudsman ' s number, and they provided staff the 1-800 number in case they wanted to report anonymously. DON said they also have people from outside the facility to come and do random interviews and ask questions about who the abuse coordinator was and how do they make a report, and they get back to the administration if anyone needs any intervention. The DON said they come in twice a week. The DON said they even printed out and laminated cards to place behind the staff ' s ID with all the information, along with the Recognize, Remove and Report card as well. The DON said on those cards it even says to report immediately. The DON said right after the incident, they in-serviced on abuse, neglect, and exploitation. In an interview on 1/30/25 at 3:10 pm with the Administrator, she said all she remembered was that there was no excuse for that, especially since Resident #5 went out on pass again and they weren't aware. The Administrator could recall the exact date she went on pass again. The administrator said they did a one-to-one with CNA F. When this was brought to their attention, the family was interviewed and they insisted Resident #5 was not around any males at the home. The Administrator was notified on 02/10/2025 at 11:15 am, that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. It was determined these failures placed Resident #5 in an Immediate Jeopardy situation on 11/17/24. The facility had corrected the noncompliance before survey began. Record review of continuing education transcript for CNA F revealed completion of Abuse and Neglect training and Incident Reporting on 6/20/24 and 7/24/24 and training on Reporting Abuse Attestation on 6/20/24. Record review of Staff Individual Inservice Record One to One (1:1) Procedure dated 11/20/24 revealed, Subject: Abuse, Neglect and Ex;loitation How to Correct Employee re-educated on ANE and the importance of reporting any allegations of abuse immediately to facilites abuse coordinator. Record review of In-Service Training Report dated 11/22/24 - ongoing for General Staff revealed, Topic Abuse, Neglect and Exploitation (ANE) training Contents or summary of training session . Re-educated staff on Abuse, Neglect and Exploitation (ANE training acts that constitute abuse, neglect, and exploitation, signs and symptoms of abuse, neglect, and exploitation, methods to prevent abuse, neglect, and exploitation, and how to report. Abuse Coordinator Three Rs: Recognize, Remove, Report. It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse 5. Verbal abuse of a resident overheard VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse for 1 of 32 residents (Resident #87) reviewed for abuse, in that: 1. The facility did not take measures to prevent verbal abuse of Resident #87 by LVN C. 2. The facility failed to implement measures, like identifying verbal abuse and handling residents with behaviors r/t PTSD, to protect residents from further abuse. 3. The facility failed to protect Resident #87 from having his mustache shaved against his will. 4. The facility failed to prevent LVN C from instructing staff to not give Resident #87 a blanket when Resident #87 complained of being cold. 5. The faciity failed to follow Resident #87's care plan in giving him fluids to prevent dehydration. 6. The facility failed to allow Resident #87 to have his meal tray in front of him for the entirety of his meal because he was eating quickly, instead of assisting Resident #87 per his care plan. 7. The facility failed to ensure that LVN C's abusive behavior was reported and corrected. An IJ was identified on 12/20/2023. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This failure could affect the residents at the facility and place residents at risk for physical, verbal, and/or psychosocial harm. The findings were: Record review of Resident #87's face sheet, dated 12/18/23 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), hemiplegia and hemiparesis (weakness or loss of strength on one side of the body), schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), major depressive disorder, and need for assistance with personal care. Record review of Resident #87's most recent MDS assessment, dated 11/29/2023, revealed a BIMS score of 9/15, signifying moderate cognitive impairment. The MDS assessment further revealed that it was known that Resident #87 had verbal behavioral symptoms directed towards others, such as threatening others, screaming at others, cursing at others. It was revealed that Ressident #87 needed supervision while eating. No pertinent information was revealed in Section K-Swalloing/Nutritional Status of the MDS assessment. Record review of Resident #87's comprehensive care plan revealed: Resident #87 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits, physical limitations, revised on 12/7/2023, with an intervention of all staff to converse with [Resident #87] while providing care. Resident #87 has an ADL self-care performance deficit r/t left sided hemiplegia and hemiparesis d/t CVA, revised 12/7/2023, with an intervention of EATING: The resident requires assistance b (1) staff to eat. Resident #87 is verbally aggressive with staff r/t poor impulse control and schizophrenia, revised 12/7/2023, with interventions of analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. And Provide positive feedback for good behavior. Emphasize positive aspects of compliance. And Psychiatric/Psychogeriatric consult as indicated. Resident #87 has impaired cognitive function or impaired thought processes r/t dementia, paranoid schizophrenia, anxiety, bipolar disorder, revised 12/7/2023, with an intervention of COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Resident #87 has a communication problem r/t impaired ability to understand and make self understood, revised 12/11/2023, with an intervention of Speak on an adult level, speaking clearly and slower than normal. Resident #87 needs assistance from staff for dehydration, at risk for dehydration, revised 12/7/2023, with an intervention of Encourage the resident to drink fluids of choice. Record Review on 12/19/23 of Resident #87's comprehensive care plan revealed that the facility revised Resident #87's care plan on 12/18/23. The updated comprehensive care plan revealed: Resident #87 has hx of torture, PTSD and active dx of paranoid schizophrenia., revised 12/19/2023, with interventions of Provide explanation when resident is denied an item he cannot have i.e. food not according to order., when redirecting resident maintain calm voice tone, look directly at resident, do not touch resident unless there is imminent danger to resident or others, maintain relaxed body posture. Resident #87 has Schizophrenia and Bipolar at risk for behavioral problems with an intervention of resident to see [counseling] per resident needs/prn Record Review of a nurse's progress note on 12/18/23 at 2:09 PM, author unknown, [Resident #87] was in dining room during lunch, claims charge nurse yelled at him. Feels that its abuse. Charge nurse was removed from schedule. Resident assessed for any signs of emotional distress. None noted at this time. Resident up to wheelchair at nurse's station. [NP] made aware. [Resident #87's RP] called but no response. During an observation on 12/18/2023 at 12:35 PM in the 600-hall dining room for lunch service, Resident #87 was coughing while eating his lunch meal. There were no drinks present on his lunch meal tray. Resident #87 was sitting by himself while LVN C was sitting at another table about 8 feet away, helping other residents eat. LVN C addressed Resident #87 in an elevated, derogatory voice, telling the resident to slow down while eating, multiple times. LVN C appeared to have her brow furrowed and with an upset expression on her face. After Resident #87 kept coughing while eating, LVN C told CNA E to take food away from the resident. CNA E took Resident #87's lunch meal tray away from him as he continued to cough, without telling the resident what she was going to do. Observation and interview 12/18/2023 at 12:40 PM, Resident #87 stated that LVN C was mean. During an observation and interview on 12/18/2023 at 12:41 PM, the RD had a surprised expression on her face and confirmed that LVN C was yelling at Resident #87 across the dining room. The RD was present during 12/18/23 lunch service and confirmed that there was no beverage present on Resident #87's lunch meal tray. The RD revealed that there should be a beverage on Resident #87's meal trays, and Resident #87 drank, ate quickly, and required cueing. During an interview on 12/18/2023 at 12:45 PM, the RD stated it was inappropriate for LVN C to be yelling across the room to Resident #87. The RD further stated that if LVN C was speaking to her like LVN C was speaking to Resident #87 she would not like it. The RD further stated LVN C should have spoken to Resident #87 in a more passive tone. During the interview with the RD, Resident #87 stated he did not get respect and wanted another staff member instead of LVN C to provide care for him. Resident #87 further stated LVN C was mean to him in the mornings as well. During an interview on 12/18/2023 at 1:12 PM, Resident #87 stated he had not reported that LVN C was mean to him to anyone else. Resident #87 was unable to quantify how long this was going on but that LVN C was always mean to him. During an interview on 12/18/23 at 1:38 PM, the RD stated she was going to report to the DON what happened to Resident #87 during lunch. During an interview on 12/18/2023 at 1:53 PM, CNA E revealed that she worked in the 600 hall for 3 months. CNA E was present during 12/18/2023 600-hall lunch service. CNA E stated that yelling at Resident #87 was the way LVN C talked to Resident #87 when he coughed at mealtimes. Resident #87 got his tray removed from him so he could calm down and stop coughing. CNA E stated they removed drinks from Resident #87's meals because he rushed to eat and drink. CNA E further stated she knew to care for Resident #87 from LVN C and not from a care plan. CNA E further stated when Resident #87 got cold LVN C would tell CNA E to not cover the resident because he would get a rash. CNA E further stated LVN C was rude and raised her voice at times but, that was the way she spoke. CNA E stated LVN C only treated Resident #87 like that. CNA E stated she would feel bad if she was treated how LVN C treated Resident #87. CNA E stated she did not recognize LVN C's behaviors as abuse. During an interview on 12/18/2023 at 2:11 PM, CNA CC stated LVN C would talk to Resident #87 with authority. CNA CC stated LVN C told nursing staff to give Resident #87 liquids after he ate so that he did not choke, even though Resident #87 would ask for his drinks during his meal. CNA CC was present during 12/18/2023 600-hall lunch service. CNA CC stated LVN C spoke loudly and raised her voice at Resident #87, however CNA CC would not say that LVN C yelled at Resident #87 during 12/18/2023 lunch service. CNA CC stated she would not feel welcome if LVN C spoke to her how LVN C spoke to Resident #87. During an interview on 12/18/2023 at 2:30 PM, Restorative Aide DD stated LVN C was strict, but it was best for the residents. Restorative Aide DD stated LVN C provided more focus on Resident #87, and further stated LVN C would speak in a loud tone but, can't tell if it's a yell or not. Restorative Aide DD stated no staff should be speaking loudly to residents and staff should be speaking calmly to residents. Restorative Aide DD stated he did not recognize LVN C's behaviors as abuse. During an interview on 12/18/23 at 5:33 PM, The PT/Rehab Director revealed that the last time Speech Therapy assessed Resident #87, they determined that Resident #87 was to eat 2-3 bites of food then drink some fluids throughout his meal. It was also revealed that Resident #87 should be fed by staff, however, staff reported that he did not want to be fed. During an interview on 12/19/23 at 11:49 AM, Resident #87's RP stated Resident #87 had complained about a nurse being in a bad mood when the resident would ask for something. Resident #87's RP stated they were concerned because the staff was paid for taking care of the residents at the facility. Resident #87's RP stated he had not reported it because he did not want to have problems with the facility because Resident #87 was by himself in the facility. Resident #87's RP stated he felt sad and hurt about Resident #87's experience. During an interview on 12/19/23 at 12:18 PM, the DON stated there were no concerns with LVN C, and further stated LVN C was previously educated on customer service because LVN C's tone had come off as aggressive versus stern in the past. The DON confirmed there were no other complaints about LVN C. During an interview and record review on 12/19/2023 at 12:26 PM, the DON revealed Resident #87 had a history of aggressive behavior towards staff, so that was expected from Resident #87. The DON further stated the facility was Resident #87's home and staff should treat the resident with dignity. The DON stated LVN C tried to make Resident #87 slow down while eating. The DON stated there was a way to redirect Resident #87 and to speak to Resident #87 in a calm tone. The DON stated LVN C had been educated on not having an aggressive tone of voice in the past. The DON further statedthat because Resident #87 had PTSD then LVN C's voice should not have been elevated. The DON read through various nurse's notes for Resident #87. Record review of a nursing note, authored by LVN C, on 9/19/2023 at 1:00PM revealed, [Resident #87] became combative when [CNA D] shaving mustache, punched him in the stomach, when nurse approached and explained keeping mustache not good hygiene due getting food stuck on it and stained with juice given to him, called nurse [expletive], reminded not to disrespect staff and [CNA D] only attempting to render care, reminders futile, will continue to monitor. The DON stated Resident #87 had the right to keep his mustache, if he wanted, because it was his right. The DON further stated Resident #87 should not be told what to do and the nursing staff should have adjusted the resident's care to his behaviors. During an interview on 12/19/23 at 1:16 PM, CNA F stated they had not worked at the facility since November 2023. CNA F worked since June 2023 with LVN C. CNA F stated most staff were kind of scared or concerned about working with LVN C because she could be very stern. CNA F stated Resident #87 would argue with LVN C. CNA F further stated LVN C would, not necessarily yell at him, but would speak in a, loud assertive voice,,then Resident #87 would yell back. CNA F stated that if Resident #87 was cold, he would not be given a blanket because LVN C stated it was a safety issue. CNA F stated at mealtimes they would let Resident #87 eat his food first and then let him drink fluids because he would rush to eat and choked. CNA F staed LVN C told staff to not give liquids to Resident #87 while he was eating, and further stated that was odd and would understand why Resident #87 would feel frustrated. CNA F did not think any of that behavior should be reported as abuse and that emotional abuse should be reported to the Administrator. During an interview on 12/19/23 at 1:51 PM, CNA D stated the plan of care for Resident #87 would be based off what LVN C told the other nursing staff to do. CNA D stated if Resident #87 asked for another drink when he already had one in front of him, they would not give him another one because he needed to drink one drink at a time. CNA D spoke about a time that Resident #87 refused to get his mustache shaved but LVN C told Resident #87 that he would have to have his mustache shaved because he got food in his mustache. CNA D stated it was easier to wash Resident #87's mustache than to shave his mustache. CNA D explained that abuse could be if Resident #87 was not able to do what he wanted to do. CNA stated that if he was treated like that, it, wouldn't go well if it happened to him, but did not identify that behavior as abuse. During an interview on 12/19/2023 at 5:00 PM, Resident #87 stated LVN C yelled at him all of the time and, you can see it in her eyes that she is angry with me. Resident #87 stated, she is bad, and there was, anger in face and eyes. Resident #87 stated one-time LVN C ordered for his mustache to be shave, and repeated that, she's [LVN C] mean. Resident #87 stated he had a mustache when he got to the facility and they wanted to shave it because food would get stuck in his mustache, but he did not want to have his mustache shaved. Resident #87 stated, I don't want them to do it, about not wanting his mustache shaved. Resident #87 stated CNA D was the CNA who had shaved his mustache and further stated, I got mad. Resident #87 stated the nursing staff would not give him beverages when he asked for them during mealtime. Resident #87 stated he did not want go into more detail about not having his beverages given to him. Resident #87 was unable to quantify how long this had been going on. During an interview on 12/20/2023 at 1:20 PM, LVN C stated Resident #87 was always choking while he had meals and LVN C was the one who had to redirect the resident because none of the other staff redirected him. LVN C stated she had asked CNA E to move Resident #87's tray during 12/18/2023 lunch because the resident was coughing. LVN C stated speech therapy had not advised nursing staff to move the tray from Resident #87 if he was coughing while he was eating, but that this was how they cared for Resident #87 during mealtimes. LVN C stated Resident #87 could have food then was given liquids after he was done with the food portion of his meal. LVN C stated she did not tell speech therapy about the interventions the nursing staff was doing for the resident. LVN C stated these interventions were not documented anywhere, and LVN C stated she did not read the resident's care plans. LVN C stated Resident #87 got mad at her because LVN C was the only one telling Resident #87 to slow down. LVN C further stated Resident #87 thought she was picking on him because she told him to slow down while eating, and further stated Resident #87 did not like to be told to slow down. LVN C stated when Resident #87 did not seem to want his mustache shaved but was okay after LVN C explained he needed to have his mustache shaved because a lot of food would remain in his hair. About the incident that occurred on 12/18/2023, LVN C stated she did not feel like she was yelling at Resident #87 because that was how she talked. LVN C revealed that she had been working with Resident #87 for several years, but the exact timeframe was unknown. During an interview on 12/22/23 at 5:48 PM. PT/Rehab Director revealed that Resident #87 could sip fluids fine throughout meals, but someone needed to sit with him and cue him while he ate. He revealed that you cannot cue a resident from across the room. Resident #87 was educated on how he had to eat to prevent coughing/choking and Resident #87 was able to learn quickly. The PT/Rehab Director further revealed that Resident #87 struggled with feeding himself at mealtime because he had a stroke. The PT/Rehab Director further revealed that mealtime should be enjoyable, and Resident #87 responded well to positive reinforcement. The PT/Rehab Director stated Resident #87 would have ongoing speech therapy and ensure that Resident #87's care plans would be updated so that other staff was aware of how to care for Residnet #87. During an interview on 12/22/2023 at 6:10 PM, the DON stated she had trained the facility staff to think about how they would treat their family members at the facility. The DON stated she wanted to make sure residents were safe. The DON stated Resident #87's care plan was updated to indicate his diagnosis of PTSD due to torture. The DON stated it was inappropriate to speak in a, raised, voice when speaking to a resident with PTSD. Record review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, implemented 1/13/23, revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Record review of facility policy Abuse, Neglect, and Exploitation, implemented 8/15/2022, revealed: III. Prevention of Abuse, Neglect, and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, register, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV. Identification of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying different types of abuse . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 5. Verbal abuse of a resident overheard 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as comfort safety, feeding, bathing, dressing, turning & positioning 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. This was determined to be an Immediate Jeopardy (IJ) on 12/20/2023 at 10:30 AM. The Administrator was notified and provided with the IJ template on 12/20/2023. The following Plan of Removal was accepted on 12/21/2023 at 7:01 PM. Immediate Jeopardy PLAN OF REMOVAL LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag 600: Abuse The facility failed to ensure the resident's right to be free from abuse and neglect. Done for those affected: - Resident #87 was assessed by facility social worker for psychosocial wellbeing on 12/20/23. - Resident #87 was assessed on 12/20/23 by ADON and there were no signs and symptoms of dehydration. On 12/18/23, the dietician evaluated for hydration needs and no additional recommendations were provided. - There was not a note from the RD, just the interview - Resident #87 Plan of Care was reviewed and updated on 12/20/23 to ensure appropriate interventions to assist the resident in attaining and maintaining the highest level of function are in place. - The alleged staff member was suspended on 12/18/23 and terminated on 12/20/23. Identify residents who could be affected: - On 12/20/23, the Facility Social Worker(s) completed 100% of interviews of residents to assess for potential abuse. No additional concerns were identified. - On 12/20/23, DON reviewed grievances in the last 30 days to ensure that concerns were addressed, and abuse allegations were reported per HHSC requirement. Systemic Process: - Effective immediately on 12/20/2023, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: - Abuse, Neglect & Exploitation - Assistance of Residents Activities of Daily Living Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated prior to the start of their next scheduled shift. - The facility will utilize the following processes if the resident or family is unable to or fearful of voicing concerns: - The Interdisciplinary Team (IDT) will review the Grievance Reporting process during the quarterly and annual IDT care plan meeting and will provide the resident and resident's representative with the Compliance Hotline number and the Ombudsman Information. - The Compliance Hotline and Ombudsman information will be provided to the resident's representative in the IDT mailed care plan meeting invitation. - On 12/21/23 the facility sent a Media Alert to facility staff and resident's representative with the Compliance Reporting Hotline: - If you have concerns about the care we provide or any compliance or legal concerns, please contact us at any time without fear of retaliation by calling our 3rd Party Compliance Hotline at [PHONE NUMBER]. - [Facility] is committed to honest and ethical behavior and conducting our business with integrity. - If you witness questionable activity or areas where we can improve our commitment to patient care, please tell us. - On 12/21/23 the facility sent a Media Alert to facility staff and resident's representatives with the Ombudsman Information: - If you have a concern or question, the Long-Term Care Ombudsman Program can help, confidentially and free of charge. Our local Ombudsman is [name redacted] and can be reached at: (956)682-3481 ext. 117 or [PHONE NUMBER] ext 117. - An Ombudsman helps, residents, family members, friends or facility staff members on behalf of a resident. - An Ombudsman will: - listen - protect your rights - offer ideas and options - help resolve concerns - support resident and family counsels - respect your choices - The facility maintains an onsite Weekend Manger and Nursing Supervisor that conduct rounds and may initiate and address resident grievances and may escalate to the appropriate administrative staff when required. The Administrator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. - To monitor, the Director of Nursing/ designee will review Grievances and resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. Grievances and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. - The Compliance Hotline and Ombudsman information will be reviewed at the Resident Council Meeting - The Administrator/designee will review new grievances and resident incidents daily Monday-Friday to insure concerns are addressed timely and if necessary reported per HHSC guidelines. - Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. - The facility has the Essential Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings will be reported during Morning Stand-up meetings to address and follow up on concerns/grievances. - The facility will place written information in each resident's room informing them how to file grievance and/or an allegation of abuse and neglect. The poster will contain the following: - Ombudsman name and contact information - Compliance Hotline number - Abuse Coordinator name and contact information Monitoring: - DON/designee will audit Grievances and residents' incidents for possible abuse/neglect/exploitation issues 3 times per week for 3 months. - Administrator/designee will present findings to the QAPI committee monthly for 3 months. The QAPI Committee will make recommendations accordingly. - An AdHoc QAPI was conducted on 12/20/23 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F tag 600 - Free from Abuse and Neglect and develop the above Action Plan Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12/20/2023. POR Verification During an interview with SW AA, SW RR, and the DON on 12/22/2023 at 10:02 a.m., SW AA, SW RR, and the DON confirmed that Resident #87 was assessed for psychosocial wellbeing. Record Review of Resident #87's clinical record as of 12/22/2023, revealed a progress note: New psychosocial intervention added - consult with psychologist for talk therapy in addition to services already in place from psychiatric NP. During an interview with ADON H on 12/22/2023 at 10:02 a.m., ADON H confirmed she assessed Resident #87 on 12/20/2023 and there were no signs of dehydration. During interview with the Consultant RD on 12/22/2023 at 10:15 a.m., the Consultant RD confirmed she evaluated Resident #87 for hydration needs and no additional recommendations were provided. Record Review of Resident #87's clinical record as of 12/22/2023 revealed a progress notes written by ADON H and dated 12/20/2023 which stated an assessment for dehydration had been completed. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed Resident #87 Plan of Care was reviewed and updated on 12/20/23 to ensure appropriate interventions to assist the resident in attaining and maintaining the highest level of function are in place. Record review of Resident #87's plan of care as of 12/22/2023 revealed it was updated on 12/20/2023. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed the alleged staff member was suspended on 12/18/23 and terminated on 12/20/23. Record review the alleged staff member's personnel file revealed Personnel Action Form dated 12/20/2023 which stated the staff member was terminated. During an interview with SW AA, SW RR, and the DON on 12/22/2023 at 10:02 a.m., SW AA, SW RR, and the DON confirmed that SW AA and SW RR interviewed 148 facility residents to assess for potential abuse with no additional concerns identified. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed she reviewed grievances in the last 30 days to ensure that concerns were addressed, and abuse allegations were reported per HHSC requirement. Record review of the grievance log book as of 12/22/2023 revealed no unresolved grievances. Record review of the HHSC intake system as of 12/22/2023 revealed no new incidents or complaints regarding abuse had been filed. A record review of the facility's nursing roster revealed a nursing staff of 100, to include RN's, LVN's, and CNA's. 26 staff were interviewed and a sample of the 26 from all 3 shifts were documented as follows: 08:00 AM to 05:00 PM shift: During an interview on 12/22/2023 at 9:57 AM, Van Driver YY stated she had received recent training on abuse, neglect, and exploitation. She was able to give examples of abuse and the abuse coordinator was the Administrator. During an interview on 12/22/2023 at 10:01 AM, Central Supply stated he had received recent training to include abuse, neglect, and exploitation. He was able to identify multiple examples. During an interview on 12/22/2023 at 10:02 AM, SW AA stated she received training to include abuse, neglect, exploitation. She was able to present several examples. During an interview on 12/22/2023 at 10:05 AM, the Maintenance Director and Maintenance assistant ZZ received recent training to include abuse, neglect, and exploitation and reported that the Administrator is the abuse coordinator. During an interview on 12/22/2023 at 10:07 AM, the DM and the food service department were interviewed, including dietary aides BBB/FFF/V and Cooks CCC/DDD/EEE/AAA/W. They received recent training that included abuse, neglect, and exploitation. During an interview on 12/22/2023 at 10:13 AM, the therapy department, including Speech Therapist GGG, Occupational Therapist HHH, PTA III, PTA JJJ, OT/Assistant Rehab Director, PT/Rehab Director. They received recent training that included abuse, neglect, and exploitation. 06:00 AM to 02:00 PM shift: During an interview on 12/22/2023 at 4:09 PM CNA TTT stated she had received recent training to include abuse, neglect, and exploitation. She was able to identify some examples and who to report to. During an interview on 12/22/2023 at 4:16 PM CNA UUU stated she had received recent training to include abuse, neglect, and exploitation. She was able to identify some examples and who to report to. 02:00 PM to 10:00 PM nursing shift: During an interview on 12/22/2023 at 2:28 PM, RN PPP, RN QQQ, CNA LLL, LVN RRR, and LVN SSS stated that they had received recent training to include abuse, neglect, and exploitation. They were able to give examples of these and knew who to report to. 10:00 PM to 06:00 AM nursing shift: During an interview on 12/22/2023 at 3:45 PM, CNA MMM stated that she had received recent training to include abuse, neglect, and exploitation. She was able to give examples of these and knew who to report to. During an interview on 12/22/2023 at 3:53 PM, CNA NNN stated that she had received recent training to include abuse, neglect, and exploitation. She was able to give examples of these and knew who to report to. During an interview on 12/22/2023 at 4:30 PM, CNA YYY stated that they had received recent training to include abuse, neglect, and exploitation. During an interview on 12/22/2023 at 5:02 PM, CNA WWW stated that he had received

Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #61) reviewed for treatment and care for diabetic assessments and supports, in that: The facility failed to identify care or support for Resident #61 needs for an insulin [a hormone that lowers the level of glucose (a type of sugar) in the blood] delivery pump, blood glucose [sugar] monitor, remote controller and lab assessments for HbA1C [ an average blood glucose (sugar) levels for the last two to three months]. Resident #61 was admitted on [DATE] with an insulin pump. The pump was designed only to be used with 100-units per milliliter insulin and was used with 200-units per milliliter insulin. The manufacturer of the pump warned not to use any other strength of insulin and warned the practice could include adverse reactions including death. The practice if using 200-units per milliliter continued from 05/01/2023 to 12/23/2023. The facility was unaware of the practice, was untrained on supporting Resident #61 with the insulin pump, and did not monitor Resident #61 blood sugar levels. An IJ was identified on 12/20/2023. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This failure placed Residents at risk for harm to include death by a failure to assess, train, and support residents needs for insulin delivery adaptive equipment. The findings included: A record review of Resident #61's Face Sheet, dated 12/18/2023, revealed an admitted [DATE] with diagnoses which included type 2 diabetes [the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high]. A record review of Resident #61's quarterly MDS assessment, dated 10/31/2023, revealed Resident #61 was a [AGE] year-old male, diagnosed with diabetes, admitted for long term care and assessed with a BIMS score of 15 out of a possible score of 15 which indicated no mental cognitive impairment. A record review of Resident #61's care plan, dated 12/18/2023, revealed, Resident #61 has Diabetes Mellitus and has an insulin pump, at risk for hyperglycemia and other complications. Further review of Resident #61's care plan did not reveal interventions for care and or support of the insulin pump. A record review of Resident #61's physicians orders, dated 12/18/2023, revealed DR. T prescribed Resident #61 insulin lispro [a fast-acting insulin used to control high blood sugar in adults and children with diabetes] to be injected subcutaneously [the injection is given in the fatty tissue, just under the skin] with an injection pen, [insulin lispro] Subcutaneous Solution Pen injector 200 units [u] per milliliter [ml]; Inject 40 unit subcutaneously before meals related to type 2 diabetes mellitus, unsupervised self-administration use with [brand name] insulin pump. May obtained B/S results from B/S; call MD if less than 70 milligrams [mg] / deciliter [dl] or greater than 250 mg/dl, Start Date-11/17/2023 1100. A record review of the insulin pumps' manufacturer's website, https://www.omnipod.com/sites/default/files/Omnipod-5_User-guide.pdf , User Guide, accessed 12/20/2023, revealed, 1.4. Compatible Insulins The [brand name insulin pump] Pump (Pod) is compatible with the following U-100 insulins: [brand names of insulin lispro 100-units per milliliter] . 1.5. General Warnings . Warning: ONLY use rapid-acting U-100 [brand name insulin lispro] insulin in the [brand name insulin pump] System as they have been tested and found to be safe for use with this system . Warning: ALWAYS be prepared to inject insulin with an alternative method if insulin delivery from the Pod is interrupted. You are at increased risk for developing hyperglycemia if insulin delivery is interrupted because the Pod only uses rapid-acting U-100 insulin . A record review of the insulin lispro 200u/ml injection pen manufactures' website; https://medical.lilly.com/us/products/answers/can-humalog-insulin-lispro-200-units-ml-be-administered-using-an-insulin-pump-36312?redirect-referrer=https%3A%2F%2Fwww.google.com%2F#reference-2918962f-8b1a-45c0-9054-805e5c1e3af0-3 accessed 12/18/2023 revealed, Can [brand Name] (insulin lispro) 200 units/mL be administered using an insulin pump? Do not administer Humalog (insulin lispro) 200 units/mL by continuous subcutaneous infusion using an insulin pump. Administration Using an Insulin Pump Do NOT administer [brand Name] (insulin lispro injection) 200 units/mL by continuous subcutaneous infusion using an insulin pump. [Brand Name insulin lispro] 200 units/mL is only available in a [pen injector brand name] presentation. Do not transfer Humalog 200 units/mL from Humalog 200 units/mL[pen injector brand name] to syringe. The markings on the insulin syringe will not measure the dose correctly. An overdose may occur, causing severe hypoglycemia (low blood sugar), putting the patient's life in danger .Date of Last Review: May 10, 2022. During an observation and interview on 12/17/2023 at 10:33 AM Resident #61 presented in his room in bed. Resident #61 was awake active with arts and crafts activity. Resident #61 stated he was frustrated by the staff and or pharmacy. Resident #61 explained he had a need for insulin injection pens to refill his insulin pump and was frustrated he would run out and the injection pens would not be available. Further interview revealed Resident #61 had a battery powered insulin pump adhered to his abdomen adjacent to a battery powered wireless blood glucose monitor also adhered to his abdomen. Resident #61 lifted his shirt to demonstrate the equipment. Resident #61 stated his endocrinologist T and NP U had supported him to use the pump by refilling the pump with insulin lispro 200u/ml via an injection pen. Resident #61 stated the nursing staff would give him an injection pen and syringes and he would draw the insulin out of the injector pen with a syringe and inject the medication into his pump every 3-4 days. resident #61 stated the equipment was controlled by a wireless application downloaded to his cell phone and communicated with Dr. T and NP U. Resident #61 stated the facility did not have information regarding the insulin pump and only provided the insulin injection pens from the pharmacy. Resident #61 stated the facility did not monitor his blood sugar levels. Resident #61 stated the facility had not given him any training for the insulin pump. Resident #61 stated he did not have lab blood work done at the facility. Resident stated he attended quarterly appointments with Dr. T and NP U at their clinic. During an observation and interview on 12/17/2023 at 2:00 PM, Resident #61 stated he had a need for 200 unit/mL Humalog insulin injection pens supplied by the facility supplied because he removed the insulin from the pens and injected it into his insulin pump. Resident #61 showed the surveyor his blood sugar monitor and insulin pump and said that they wirelessly communicated with an application on his cell phone. During an interview on 12/17/2023 at 6:21 PM, RN A stated she was Resident #61's evening charge nurse and she had supplied Resident #61 with the 200 unit/mL Humalog insulin pen and assisted Resident #61 refill the insulin pump. RN A stated she was not trained on how to refill the insulin pump and had no detailed knowledge about the insulin pump stating, he was admitted with the pump and he knows how to do it. RN A stated the physicians order for the insulin pen was for nursing to administer 40 units of the 200 unit/mL insulin three times a day prior to meals and to monitor blood glucose levels and to report to the physician any measurements outside of the physicians' parameters. RN A stated nobody, including herself, had documented the administrations or glucose readings on Resident #61's MARs. RN A stated, he was admitted with the pump and he takes care of it himself .at times he asks us to manually check his blood glucose levels so he can calibrate his wireless glucometer monitor .but he has refused to allow us [nursing staff] to check his sugars [blood glucose levels] and has refused to show his glucose levels on his phone. During interview on 12/17/2023 at 6:28 PM, ADON B stated she was RN A's supervisor and stated Resident #61 had a need for 200 unit/mL Humalog insulin pens which he self-administered. ADON B stated the facility's pharmacy would supply the resident with 200 unit/mL Humalog insulin pens and, he refills his pump .he has no need for self-administration training .he was admitted with the pump and knows how to use it, .he will not allow anyone to touch it. During an interview on 12/19/2023 at 9:28 AM Nurse Practitioner Q stated she was the NP for Resident #61, and she was responsible for Resident #61 since November 1, 2023. NP Q stated she was not aware Resident #61 was not being monitored for blood sugar levels, HbA1C laboratory results, and supervision for the insulin pump. NP Q stated at a minimum the expectations would be for Resident #61 to be monitored once a shift for blood sugar levels, once every 3 months for HbA1C blood sugar levels, and for daily supervision for care and support of the insulin pump. NP Q stated nursing staff needed to be trained to care and support Resident #61 with the insulin pump per the manufacture's recommendations. NP Q stated the risk for Resident #61 was fluctuations in blood sugar levels to include low blood sugar levels and high blood sugar levels. During an interview on 12/19/2023 at 4:19 PM Pharmacy Doctor R stated the practice of removing insulin from an insulin injection pen could not be supported by the pharmacy and were contrary to the insulin pen manufactures recommendations. A record review of the facility's Insulin Administration policy dated September 2014, revealed, the nursing staff will have access to specific instructions [from the manufacturer if appropriate] on all forms of insulin delivery system[s] prior to their use. residents who are capable of managing their glucose monitoring and or insulin administration must be assessed periodically for their ongoing willingness and ability to do so safely and effectively. any resident who is actively involved in glucose monitoring and insulin administration will be provided with diabetes self-care education [as appropriate], and supported by the staff person designated for diabetes teaching and management. This was determined to be an Immediate Jeopardy (IJ) on 12/20/2023 at 10:30 AM. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/2023. The following Plan of Removal was accepted on 12/21/2023 at 7:01 PM. LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag 684: Quality of Care. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Done for those affected: - Resident #61 was assessed by the ADON for signs and symptoms of hypo/hyper glycemia on 12/20/23 and found to be in stable condition. On 12/20/23, Resident #61 was asked by ADON if experiencing any signs of hypo/hyperglycemia and verbalized no concerns. A physicians order was obtained on 12/20/23 for assessing resident for signs and symptoms of hypo/hyperglycemia to ask resident for personal reading of blood glucose; ask resident if experiencing signs and symptoms of hypo/hyperglycemia as listed below: - Signs and Symptoms of Hypoglycemia: Shakiness, Excess sweating, Dizziness, headache, irritability, anxiety and/or fatigue - Signs and Symptoms of Hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma - Resident #61 completed endocrinologist tele-medicine appointment on 12/20/23. No change in orders given by the endocrinologist. The current order and plan of care include: - [Brand Name] Sensor to be changed out every 10 days to start on 12-21-23; Licensed Nurse will check for placement every shift. Resident will change the [Brand Name] Sensor. The licensed nurse will supervise resident to ensure the [Brand Name] sensor is applied correctly. - Tegaderm applied to abdomen site prior to new [Insulin pump] change every 2-3 days to prevent irritation by the resident and supervised by the licensed nurse. Nurse to assess every shift. - [Insulin pump] to be changed and refilled every 2-3 days by resident, supervised by staff. - [Insulin pump] Packaging provided Needle for Pod refill, resident will extract 200 units of [Insulin Lispro] from [Insulin pen] insulin and refill [Insulin pump] as instructed by [Insulin pump] Monitor follow the [Insulin pump] prompts (2 beeps) Discard Needle in sharps container. Await refill prompt from [Insulin pump] Monitor once prompted then proceed to apply as directed, Resident will then proceed to apply refilled [Insulin pump] to Tegaderm prepped area with abdomen area of choice. Wait for insertion of needle, resident will sense it and we hear a clicking noise then [Insulin pump] will turn pink to ensure proper placement of needle as per [Insulin pump] Monitor. - [Insulin Lispro injection pen] Subcutaneous Solution Pen-injector 200 UNIT/ML (Insulin Lispro) **DAW** Inject 40 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL (E11.3293) (Insulin to be administered as per [Insulin pump] Insulin Management Device) request blood sugar read from resident to be obtained from [Insulin pump] Management Device to be released as per Settings of [Insulin pump]set by [Manufacturing company]) - Self-Administration of Medication Assessment was completed on 12/19/23 by DON and resident was completely capable of self-administration as evidenced by return demonstration by resident. The Self Administration of Medication Assessment will be completed quarterly and with changes in condition. - On 12/19/23, an order was issued by the Facility Family Nurse Practitioner for blood sugar monitoring as needed if noted with signs and symptoms of hypo/hyperglycemia. - Resident #61 Plan of Care was reviewed and updated on 12/19/23 to reflect the resident's use of the [Insulin pump] insulin administration device and nursing interventions to include but not limited to monitoring of glucose readings from the device or resident before meals as ordered and as needed for any signs of hypo/hyperglycemia, notify MD notifications for any concerns and/or blood glucose outside of the physician's parameters, monitoring for signs and symptoms of hypo/hyperglycemia, Completing self -administration assessment/re-assessment to ensure resident's abilities with utilization of the [Insulin pump]; assisting resident with the [Insulin pump] insulin administration unit as needed. Identify residents who could be affected: - On 12/20/23, the ADON, audited all residents receiving automated insulin and BS management system device and no other residents were identified. - The Care Management Nurses completed a 100% review on 12/20/23 of residents with Insulin administration orders to ensure ongoing blood glucose monitoring as ordered to include documentation and notification to providers when resident glucose levels exceed parameters. Systematic Process: - Endocrinologist instructed DON on [Insulin pump] management on 12/20/23. - On 12/20/23 licensed staff who provides direct care for Resident #61 were instructed on management of the [Insulin pump] insulin management system using the manufacturer's Quick Guide and the manufacturer's online training video. - Effective immediately on 12/20/2023, DON/designee began reeducation to 100% of licensed nursing staff on the following: - Use of the [Insulin pump] Insulin Management System utilizing the [Insulin pump] Quick Guide - Assessment, documentation and monitoring of signs and symptoms of hypo/hyperglycemia Signs and Symptoms of Hypoglycemia: Shakiness, Excess sweating, Dizziness, headache, irritability, anxiety and/or fatigue - Signs and Symptoms of Hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma - Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence or PTO will be reeducated prior to the start of their next scheduled shift. The Director of Nursing/ Designee will review new orders received for insulin administration to ensure that orders are complete to include monitoring and plan of care completed during the Morning Clinical Meeting attended Monday-Friday. Additional resident and staff training will be conducted as indicated with regards to plan of care. Monitoring: - DON/designee will audit residents with automatic insulin delivery devices 2 times/week to assess for ongoing assessment of blood sugars, signs of symptoms of hypo/hyperglycemia and notification of providers when deviation from as per ordered parameters, completion of Self Administration of Medications quarterly and with change in condition and proper functioning of automatic insulin delivery device. - The results of the reviews will be presented by the Administrator/designee to the QAPI committee monthly for 3 months. The QAPI committee will make recommendations as needed. - DON/designee will visually assess the [Insulin pump] insulin administration system weekly for: - [Insulin pump] controller is charged and operational. - [Insulin pump] for proper placement - [Brand Name] sensor of the [Insulin pump] for proper placement - [Brand Name] transmitter of the [Insulin pump] for proper placement The DON/designee will monitor compliance with the process weekly. Results of the findings will be discussed in the QAPI meeting monthly for 3 months. The plan will be continued as needed. - An AdHoc QAPI was conducted on 12/20/23 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F tag 684 - Treatment and Care in Accordance with Professional Standards of Care and development of the above Action Plan. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12/20/2023. POR Verification During an interview with ADON H on 12/22/2023 at 10:36 a.m., ADON H confirmed she has assessed Resident #61 and found him to be in stable condition. Record review of Resident #61's clinical record revealed a progress note, dated 12/20/2023 which stated ADON had assessed Resident #61 and found him to be in stable condition. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she completed a Self-Administration of Medication Assessment with Resident on 12/20/2023. The DON stated Resident #61 was completely capable of self-administration as evidenced by return demonstration by the resident, and stated the Self Administration of Medication Assessment will be completed quarterly and with changes in condition. Record review of Resident #61's clinical record revealed a progress note, dated 12/20/2023 which stated the DON had completed a Self-Administration of Medication Assessment with Resident #61. Record review of Resident #61's clinical record revealed an order, dated 12/19/2023 for Resident #61's blood sugar to be monitored as needed if noted with signs and symptoms of hypo/hyperglycemia Record review of Resident #61's clinical record revealed his care plan was updated on 12/19/2023 to reflect the resident's use of the [insulin pump] insulin administration device and nursing interventions to include but not limited to monitoring of glucose readings from the device or resident before meals as ordered and as needed for any signs of hypo/hyperglycemia, notify MD notifications for any concerns and/or blood glucose outside of the physician's parameters, monitoring for signs and symptoms of hypo/hyperglycemia, Completing self -administration assessment/re-assessment to ensure resident's abilities with utilization of the [insulin pump]; assisting resident with the [insulin pump] insulin administration unit as needed. Record review of the clinical records as of 12/22/2023 of all residents who received insulin revealed only Resident #61 received insulin via BS management system. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that the ADONs completed a 100% review on 12/20/23 of residents with Insulin administration orders to ensure ongoing blood glucose monitoring as ordered to include documentation and notification to providers when resident glucose levels exceed parameters. Record review of all facility residents' clinical records as of 12/22/2023, revealed 32 residents received insulin. Record review of the clinical records as of 12/22/2023 of 10 residents who received insulin, revealed all 10 records were accurate. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she had received instruction regarding insulin pump management from Endocrinologist [Dr. T]. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that all licensed staff who provide direct care for Resident #61 were instructed on management of the [insulin pump] insulin management system using the manufacturer's Quick Guide and the manufacturer's online training video. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that all licensed staff who provide direct care for Resident #61 were educated as described above. A record review of the facility's nursing roster revealed a nursing staff of 100, to include RN's, LVN's, and CNA's. 53 staff were interviewed and a sample of the 53 from all 3 shifts were documented as follows: 06:00 AM to 02:00 PM nursing shift: During an interview on 12/22/2023 at 10:18 AM CNA FF stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 10:19 AM CNA GG stated she had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 10:20 AM CNA HH stated he received training for residents who used an insulin pump. CNA HH stated he would report to the nurse any signs of the pump making warning sounds, becoming displaced, or redness, swelling, and or discomfort to the pump site. During an interview on 12/22/2023 at 10:17 AM CNA II stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 10:21 AM CNA JJ stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 10:19 AM LVN KK stated she received training for residents who used an insulin pump from the DON. LVN KK stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 10:38 AM LVN MM stated she received training for residents who used an insulin pump from the DON. LVN KK stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. 02:00 PM to 10:00 PM nursing shift: During an interview on 12/22/2023 at 10:18 AM CNA NN stated he had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 2:04 PM CNA D stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 2:05 PM CNA OO stated she received training for residents who used an insulin pump. CNA OO stated she would report to the nurse any signs of the pump making warning sounds, becoming displaced, or redness, swelling, and or discomfort to the pump site. During an interview on 12/22/2023 at 10:18 AM CNA PP stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 2:28 PM CNA QQ stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 2:03 PM LVN RR stated she received training for residents who used an insulin pump from the DON. LVN RR stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 2:04 PM LVN SS stated she received training for residents who used an insulin pump from the DON. LVN SS stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. 10:00 PM to 06:00 AM nursing shift: During an interview on 12/22/2023 at 3:47 PM CNA TT stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 3:54 PM LVN UU stated she received training for residents who used an insulin pump from the DON. LVN UU stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 3:50 PM LVN VV stated she received training for residents who used an insulin pump from the DON. LVN VV stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 3:42 PM LVN XX stated she received training for residents who used an insulin pump from the DON. LVN XX stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview with the Administrator, DON, and Regional RN Y on 12/22/2023 at 10:36 a.m., the Administrator, DON, and Regional RN Y confirmed the DON/designee will audit residents with automatic insulin delivery devices 2 times/week to assess for ongoing assessment of blood sugars, signs of symptoms of hypo/hyperglycemia and notification of providers when deviation from as per ordered parameters, completion of Self Administration of Medications quarterly and with change in condition and proper functioning of automatic insulin delivery device Record Review of the DON's initial audit was completed, Interview was completed to ensure that she plans to continue to do so 2 times per week as per POR. During an interview with the Administrator, DON, and Regional RN Y on 12/22/2023 at 10:36 a.m., the Administrator, DON, and Regional RN Y confirmed that results of the reviews will be presented by the Administrator/designee to the QAPI committee monthly for 3 months. The QAPI committee will make recommendations as needed. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she or designee will visually assess the [Insulin pump] insulin administration system weekly for: Record Review of the DON's initial assessment was completed, Interview was completed to ensure that she plans to continue to do so 1 time per week as per POR. During an interview with the Administrator and DON on 12/22/2023 at 10:36 a.m., the Administrator and DON confirmed the DON/designee will monitor compliance with the process weekly. Results of the findings will be discussed in the QAPI meeting monthly for 3 months. The plan will be continued as needed. Record review of AdHoc QAPI meeting attendance sheet, dated 12/20/2023 revealed the committe met. The Administrator was informed the Immediate Jeopardy was lifted on 12/22/2023 at 6:08 PM. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care. Facility staff transferred Resident #2 three times after a fall before getting her in bed. Resident #2 was in pain before the transfers. Later x-rays showed resident had sustained a fractured hip. This failure placed resident in unnecessary pain and discomfort with a potential for further injury. Findings include: Record review of Resident # 2 face sheet revealed she was an [AGE] year-old female admitted on [DATE]. Her diagnoses included T cognitive communication deficit, unsteadiness on feet, lack of coordination, syncope and collapse, muscle weakness and need of assistance with ADLs. Record review of Resident #2 MDS assessment dated [DATE] revealed a BIMS score of 01 out of 15 indicating severe cognitive impairment. She required extensive assistance with ADL care. In an interview on 11/29/2023 at 02:30 p.m., Resident # 2 said she has never sustained a fall. Resident was able to answer what her name was but was not oriented to time or day. Surveyor could not continue with the interview any further due to residents' current cognitive level. In an observation on 11/29/2023 at 2:40pm, Resident #2 was observed sitting in her wheelchair, in the cafeteria, watching an activities session. Resident was well kempt and dressed appropriately for ambient temperature. She appeared to be enjoying herself and she showed no signs of distress or discomfort In an interview on 11/29/23 at 03:00 p.m., LVN A stated she was sitting at nurses' station, and Resident #2 was sitting on her wheelchair next to her when she sustained a fall. LVN A said she assessed resident per facility post fall protocol. She stated noticed an abrasion to residents' right knee and that resident was touching her hip and grimacing in pain. LVN A stated, I knew it was bad from how I saw her in pain. LVN A said she completed Resident #2's assessment. LVN A said she told CNA B and CNA C were instructed by LVN A to move resident onto a dining chair. LVN A then instructed CNS's A and B to transfer resident from the chair onto her wheelchair and taken to her room where she was placed in bed. LVN A stated she followed the resident from the fall location (nurses' station) to her room while she was being transferred because she knew the resident had sustained a serious injury and wanted to make sure CNA B and CNA C were careful with resident #1's transfer. LVN A said she received orders from doctor for X-rays of hip which were performed sometime after the fall. LVN A said X-ray revealed fracture to the right hip and Resident #1 was then sent out to hospital and surgery was recommended. LVN A said resident #2 was given pain medication. Record review of nursing documentation dated 09/12/2023 at 10:40pm Note Text: Resident noted getting up from wheelchair and lost balance due to unsteady gait, fell landing on her right side, LVN A sitting at nurses station witnessed fall but did not get to patient on time to prevent fall, assessed patient from head to toe, redness to her right knee and complain of pain to her right hip assessed head to toe, administer acetaminophen 325mg 2 tabs PO Q6 PRN, she notified nurse practitioner on call for ordered STAT X-ray to right hip and right knee and Tylenol 500mg PO BID X1 Day DX: pain, patient getting up from wheelchair constantly redirected patient to sit because she could fall In an Interview on 11/29/2023 at 04:00 p.m., CNA B stated he saw resident #2 on the floor and LVN A doing an assessment. He said LVN A asked for resident #2 to be transferred to a dining chair. CNA B said the resident then was moved to a wheelchair, taken to her room and transferred to bed CNA B stated to surveyor that he saw the resident was placing her arm on her hip and guarding against being touched there. He said Resident #2 expressed being in pain in her hip area. In an Interview at 12/30/2023 at 02:45 p.m., CNA C stated she has been trained not to move a resident until she has been cleared by the nurse on duty. CNA C stated she assisted resident from the floor to a chair once she was cleared by LVN A. She and CNA B then transferred resident to her wheelchair and then shortly after took Resident #2 to her room and then transferred her to bed. In an interview on 11/29/2023 at 04:45 p.m., LVN A stated moving a resident after a fall could cause more injury, and very likely would cause more pain. LVN A said therefore nursing staff should not move a resident if a proper assessment indicated a probability of further damage. LVN A stated that Resident #2 was in pain and was guarding her hip and while sitting on chair would try to shift weight from the right hip. LVN A stated Resident #2 was once moved off the floor onto a chair, the second time was from the chair onto the resident's wheelchair and the third time was from the wheelchair onto the resident's bed to await Dr. ordered X-rays. LVN A said during this time Resident #2 complained of pain, however pain medication was given to her. LVN A stated she followed the facility post fall worksheet when she assessed Resident #2, She also stated she was motivated to move the resident because she did not want visitors to see the resident laying on the floor, but that in hindsight she would not have put the resident through unnecessary transfers. Review of hospital documentation on 11/30/2023 at 10:30 a.m., indicated hospital physician assessment indicated resident in extreme pain and discomfort with any attempted motion of the hip. In a review of nursing documentation on 11/30/2023 at 10:00 a.m. LVN A documented that she notified the DON and NP of X-ray results with orders for patient to be transferred to hospital, notified responsible party of patient status. In a phone interview on 12/01/2023 at 05:00 p.m., with Resident #2's Doctor stated the likelihood of further damage to hip is minimal however the resident will be in pain with any movement of the hip. Doctor stated if movement must be made it should, however, be kept to a minimum. In an interview on 12/01/2023 at 05:30 p.m., with Director of Therapy stated with hip injuries movements should be kept to a minimum and if they are necessary a pillow between the knees would be ideal. Director of Therapy answered resident is very likely to experience pain during transfers. In an interview on 11/30/2023 at 01:00 p.m., with the DON stated the nurses should follow post fall protocol which included an assessment of the resident to determine whether it is safe to move the resident. DON stated that residents should not be moved if moving them would cause further injury. She stated residents should be made comfortable and await emergency medical Services (EMS) to transport resident to higher level of care. The DON also stated that nurses are in-serviced regularly regarding falls and fall prevention and if a nurse is observed to not be follow's facility protocol, that nurse would be retrained. Record review of trainings showed staff was in serviced on 09/12/2023 regarding resident falls, Topics included falls management/minimizing trips, slips and falls, Bed in lowest position, bed against wall, floor mat, call lights within reach, non-slip socks, well-fitting shoes, hipsters, soft helmet, arm sleeves., wheelchair adjustments if needed, resident monitoring. Record review of Fall prevention policy on 11/30/2023 Implemented on 8/15/22 which states the policy for the facility is that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on interview and record review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable, for one Resident (R#15) of 11 residents reviewed with pressure ulcers. R#15 was admitted to the facility with no pressure ulcers. The facility did not accurately or consistently assess R#15's skin integrity after admission, to prevent the development of pressure ulcers, or identify the beginning stages of pressure ulcer development and provide timely treatment and other interventions. R#15 developed an avoidable pressure ulcer to the sacral area (at the base of the spine and the tailbone). R#15's skin breakdown was not detected by staff until it was a Stage 3 pressure ulcer. This failure resulted in actual harm to R#15 and placed all 14 residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers. Findings included: Record review of R#15's closed record Admission Record, dated 06/24/16, revealed R#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of R#15's, Braden Scale - For Predicting Pressure Sore Risk, dated 05/03/16, revealed a total score of 14, indicating R#15 was at, Moderate Risk for developing pressure ulcers. Identified risk factors included: -Bedfast- confined to bed. -Completely immobile - Does not make even slight changes in body or extremity position without assistance. -Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction. Record review of R#15's Resident Data Set, dated 05/03/16, on admission, revealed skin treatments for R#15 included pressure redistribution devices for bed and turning and repositioning program. Record review of R#15's, May 2016 Treatment Administration Record (TAR) revealed skin checks were to be performed weekly, on Tuesdays. TAR entry dated 05/10/16 indicated, Code (1) No skin injury/wound. Record review of R#15's Admission Minimum Data Set (MDS), dated [DATE], revealed R#15: -had independent cognitive skills for daily decision making; -was totally dependent on assistance from two staff for bed mobility, transfers, toilet use and bathing; -required extensive assistance from one person for dressing, eating, personal hygiene; -had range of motion impairment to the lower extremities on both sides (hips, knees, ankles, feet); -was frequently incontinent of bowel and bladder; -had an active [DIAGNOSES REDACTED]. -received occupational therapy and physical therapy; and -had no pressure ulcers and was not at risk of developing pressure ulcers. Record review of R#15's Care plan, initiated 05/11/16, revealed R#15 was incontinent of bowel and bladder, and was at risk for skin breakdown and infection. Interventions were to: -Assess skin with ADL changes. -Monitor for infection and skin breakdown. -Provide incontinent care as needed. -Turn and Reposition. Record review of R#15's, May 2016 TAR revealed skin checks were to be performed weekly, on Tuesdays. TAR entry dated 05/17/16 indicated, Code (2) New skin injury/wound-see new Skin Integrity Report. Record review of Skilled Nursing Notes dated 05/18/16, on the 6:00 a.m. to 2:00 p.m. shift, revealed an open area was noted to R#15's left great toe. R#15's Physician was contacted and ordered Hydrogel to be applied. There was no documentation of any other skin breakdown. Record review of R#15's Physician's Telephone Order dated 05/18/16 indicated an order to apply Hydrogel and cover with dry dressing, qd (daily) for the [DIAGNOSES REDACTED]. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister) to the left lateral great toe. Record review of R#15's Care plan, initiated 05/20/16, revealed R#15 had a stage 2 to left lateral Great Toe, at risk for complications. Interventions were to assess for pain, monitor for infection, and provide treatment as ordered. There was no documentation of any other skin breakdown. Record review of R#15's, Braden Scale - For Predicting Pressure Sore Risk, dated 05/24/16, revealed a total score of 14, indicating R#2 was at, Moderate Risk for developing pressure ulcers. Identified risk factors included: -Bedfast- confined to bed. -Completely immobile - Does not make even slight changes in body or extremity position without assistance. -Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction. Record review of R#15's, May 2016 TAR revealed skin checks were to be performed weekly, on Tuesdays. Entry dated 05/24/16 indicated, Code (3) Previously noted skin injury/wound-see updated Skin Integrity Report. Record review of Skilled Nursing Notes dated 05/24/16, on the 6:00 a.m. to 2:00 p.m. shift, revealed R#15 continued with treatment to the left great toe, and that the wound was healing well. There was no documentation of any other skin breakdown. Record review of Skilled Nursing Notes dated 05/25/16 through 05/28/16 revealed no documentation of R#15 having any skin breakdown other than the wound to the left Great Toe. Record review of R#15's, Braden Scale - For Predicting Pressure Sore Risk, dated 05/30/16, revealed a total score of 15, indicating R#2 was at, Mild Risk for developing pressure ulcers. Identified risk factors included: -Chair fast- ability to walk severely limited or nonexistent. Cannot bear weight and/or must be assisted into chair or wheelchair. -Very limited- makes occasional slight changes in body or extremity position unable to make frequent or significant changes independently. -Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Record review of Skilled Nursing Notes dated 05/30/16, on the 6:00 a.m. to 2:00 p.m. shift, revealed R#15 was noted with rectal bleeding and a Stage 3 pressure ulcer to the sacral area (Stage 3 - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.). Record review of Skin Integrity Report, dated 05/30/16, for R#15 indicated the Type of Wound was, Pressure, Stage III, incontinence related. The length was 2.0 centimeters (cm) and the width was 2.0 cm. The depth was documented as zero. Surrounding tissue was macerated. The skin report was completed by LVN A. Record review of Physician Telephone Orders, dated 05/30/16 at 10:30 p.m., indicated to send R#15 to the hospital emergency room for evaluation and treatment for, Rectal bleeding, passing large clots. Record review of Discharge Nurse's Notes, dated 05/30/16, indicated R#15 was discharged to the hospital with Stage 3 sacral skin breakdown. Record review of R#15's Care plan, date initiated 05/30/16, revealed R#15 had a Stage 3 Sacral Ulcer and was at risk for complications. Interventions included to assist resident in repositioning daily, provide peri care/incontinence care as needed, and provide treatment as ordered. Record review of the Emergency Provider Report (hospital) for R#15, dated 05/31/16, indicated R#15 had an unstageable sacral ulcer, present on admission (Unstageable - full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV). Record review of a hospital Consultation Report, dated 06/02/16, revealed R#15 was scheduled for incision and drainage of a 3 x 3 cm sacral ulcer. Record review of hospital Consultation Report, dated 06/07/16, revealed R#15 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) sacral ulcer, measured approximately 5 x 5 cm, 4 cm deep. There was minimal granulation. There was some necrotic tissue in the midline. There was no purulent drainage, [DIAGNOSES REDACTED], or induration. During interview on 06/28/16 at 1:50 p.m., LVN B said R#15 had been on hall 600 when admitted on [DATE], but was transferred to hall 100 on 05/23/16. LVN B said she was the Charge Nurse for hall 600 on the 6:00 a.m. to 2:00 p.m. shift, and was also the Wound Treatment Nurse for her hall. LVN B said she did head to toe skin assessments once a week. LVN B said she entered daily notes on R#15 for dates: 05/04/16, 05/06/16, 05/07/16, 05/10/16, 05/11/16, 05/13/16, 05/16/16, 05/17/16, 05/18/16 and 05/19/16. LVN B said she did not see any pressure ulcers on R#15, and no skin breakdown except for a non-pressure wound on R#15's great toe on 05/19/16. LVN B said the facility was currently using Skin Integrity Report forms to document any pressure ulcers. During interview on 06/28/16 at 11:43 a.m., LVN A said R#15 had been transferred from hall 600 to hall 100 on 05/23/16. LVN A said she was the Charge Nurse for hall 100 on the 6:00 a.m. to 2:00 p.m. shift, and was also the Wound Treatment Nurse for her hall. LVN A said she documented on nurse's notes for R#15 on 05/25/16, 05/26/16, and 05/27/16. LVN A said her notes did not indicate any concerns with pressure ulcers. LVN A said she had provided wound care to R#15's left great toe, and the toe had been healing very well. LVN A said R#15's toe wound was not a pressure ulcer. LVN A said she did not work on 05/28/16 or 05/29/16. LVN A said that, on 05/30/16, she was notified by Certified Nurse Aides (CNAs) that R#15 had rectal bleeding. LVN A went to assess R#15, and after she cleaned the rectal area very well, she noted that bleeding was coming from R#15's rectum. LVN A said that, as she cleaned the area, she separated R#15's buttocks and then noted that R#15 had a pressure ulcer on her sacral area. LVN A said the pressure ulcer was not visible until she (LVN A) opened or separated both buttocks with her hands. LVN A said R#15's buttocks were overlapping the area of the pressure ulcer. LVN A said she measured the pressure ulcer and found the length and width of the pressure ulcer was 2.0 cm. LVN A said the pressure ulcer had no depth that she could measure. LVN A said she called R#15's Physician and informed the Physician of the rectal bleeding, which had stopped, and of the Stage 3 pressure ulcer found in the sacral area. LVN A said R#15's Physician gave orders to stop the medication [MEDICATION NAME] (blood thinner) and to follow wound treatment protocol using cleanser, pat dry with gauze and apply Santyl ointment twice a day. LVN A said she completed the Skin Integrity Report on 05/30/16. LVN A said the Charge Nurse from the evening shift reported R#15 had no more bleeding episodes. LVN A said the Charge Nurse from the night shift received a report from CNAs that R#15 had rectal bleeding. R#15's Physician gave orders to send the resident to the hospital on [DATE]. LVN A said R#15 was able to communicate and had not complained of any constipation concerns. During interview on 06/28/16 at 2:50 p.m., CNA C said she worked on the 100 hall, on the day shift. CNA C said she remembered R#15 and she would assist R#15 with repositioning every two hours. CNA C said she would document on the ADL Record Book the re-positioning and incontinent care provided to R#15. CNA C said no pressure ulcers or skin breakdown on R#15 had been observed until 05/30/16, when CNA C and CNA K were providing R#15 with incontinent care. CNA C said she noticed R#15 was bleeding in her brief. CNA C said the incident was reported to the Charge Nurse, LVN A. During interview on 06/28/16 at 3:05 p.m., Assistant Director of Nurses (ADON) D said R#15 was admitted to the facility without any pressure ulcers as indicated on her admission assessment on 05/03/16. ADON D said a wound to R#15's great toe was found on 05/18/16 and treatment for [REDACTED].#15. ADON D said a Skin Integrity Report was completed if skin breakdown was found. ADON D said no Skin Integrity Reports for R#15 were completed during the weekly skin assessments, until 05/30/16, when a Stage 3 to the sacrum was identified. ADON D said the interventions in place for the prevention of ulcers for R#15 were turning and repositioning every two hours. During interview on 06/28/16 at 3:30 p.m., MDS Coordinator N said R#15 was admitted to receive physical therapy and, upon assessment on 05/10/16, R#15 was being moved by therapy and R#15 was mobile. MDS Coordinator N said R#15 was not assessed to be at risk for development of pressure ulcers. MDS Coordinator N said R#15 was not care planned as at risk for pressure ulcers upon admit. During interview on 06/28/16 at 3:30 p.m., CNA F said she worked on the 600 hall with R#15. CNA F said she would reposition R#15 and provide incontinent care every two hours, and document all ADLs provided in the ADL Record Book. CNA F said all CNAs must check the residents' skin for breakdown when providing incontinent care. CNA F said all CNAs must report any irregular skin conditions to the Charge Nurse. CNA F said she did not remember finding any skin conditions such as pressure ulcers or discolorations on R#15. During interview on 06/28/16 at 3:45 p.m., the Director of Nurses (DON) said she was unable to locate the ADL records for R#15. During interview on 06/29/16 at 8:40 a.m., the DON said she and her staff had stayed late at the facility, looking for the ADL records for R#15. The DON said the ADL records for R#15 had not been found. The DON said the ADL Flow sheets included repositioning and incontinent care provided to residents. The DON said R#15's ADL Flow sheet records were missing. The DON said the admitting nurse for R#1 said she had created an ADL flowchart for R#15 upon the R#15's admission date of [DATE]. The DON said the CNAs had voiced to her that they had documented the ADL assistance provided to R#15 until the resident was discharged from the facility to the hospital on [DATE]. During interview on 07/12/16 at 12:10 p.m., CNA O said she worked in halls 500 and 600. CNA O said she would mostly provide residents with showers. CNA O said the CNAs must observe residents' skin conditions when providing showers and report all areas of concerns with bruising, discolorations or skin tears to her Charge Nurse. CNA O said the buttocks areas and the area in-between the buttocks were checked for skin condition. CNA O said the CNAs providing the showers must inspect all the body parts of a resident when assisting with showers. During an interview via telephone on 06/27/16 at 8:30 a.m., R#15's Family Member (FM) M said he had many concerns regarding the care that had been provided to R#15, including the staff's failure to reposition R#15 as needed to prevent the pressure ulcer that had developed on R#15. Review of the facility's policy on, Skin Integrity Management, dated 03/15/16, revealed: -The implementation of an individual's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. -The purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. -Practice Standards included: Complete comprehensive evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition. -Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. -Include all patients who have newly identified skin impairments on the Center's 24-Hour Summary Report. -Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in PointClickCare (PCC). -Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. -Implement pressure ulcer prevention for identified risk factors. Record review of In-Service Education - Attendance sheets revealed inservice training on Pressure Ulcers was provided to nursing staff on 06/03/16. Ten nurses attended the inservice, including LVN B and ADON D. Twenty-one CNAs attended the inservice, including CNA C, CNA K, and CNA O. The facility's Roster/Sample Matrix CMS 802 Form dated 07/11/16 indicated 14 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for one Resident (R#1) of five residents reviewed for accidents. The facility was aware R#1 had a history of [REDACTED]. R#1's care plan indicated to monitor for changes in R#1's condition that may warrant increased supervision and assistance. After that assessment, R#1 entered other residents' rooms and fell on four occasions, resulting in three head injuries (including bleeding in the head and a fracture to the left eye socket). The facility did not initiate any increased supervision of R#1 after any of the falls. This failure could place all 24 residents who lived in the secured unit at risk for falls and serious injuries. The findings were: Face Sheet dated 07/22/14 indicated R#1 was admitted to the facility on [DATE] and re-admitted on [DATE]. R#1 was [AGE] years old. August 2014 Physician order [REDACTED]. Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R#1: -had severely impaired cognition (never/rarely made decisions), -had no behavioral symptoms, -required extensive assistance from staff for bed mobility, transfers, and toilet use, -was totally dependent on staff for locomotion on and off the unit, and dressing, -used a wheelchair, and, -was unsteady and only able to stabilize herself with staff assistance when moving from a seated to a standing position, when moving on and off the toilet, and when performing a surface to surface transfer (i.e. transfer between bed and chair or wheelchair). R#1's care plan for Falls dated 05/04/14 indicated R#1 had a history of [REDACTED]. There were no approaches describing the type or amount of supervision staff were to provide for R#1. R#1's care plan for Falls dated 05/07/14 indicated R#1 was at risk for falls. Approaches included to remind R#1 to ask for assistance for all transfers/ambulation as needed and to: "Monitor for changes in Resident's condition that may warrant increased supervision or assistance ..." R#1's care plan for Behavioral Symptoms dated 05/07/14 indicated R#1 exhibited behaviors of pacing in the hallway of the secure unit and going into other residents' rooms and taking their possessions. Approaches included to redirect R#1 and provide diversional activities. There were no approaches describing the type or amount of supervision staff were to provide for R#1. The Monthly Incident/Accident Log and Analysis for the months of May, June, July and August 2014 revealed four incidents involving R#1: -Incident Report completed by the Administrator on 07/14/14 indicated R#1 was found on 05/29/14 in a sitting position and had sustained a laceration to the right upper back of the head that was 3.8 centimeters (cm) by 0.5 cm. The report indicated the incident was unwitnessed and was a self-inflicted injury. R#1 was unable to describe what happened due to confusion and [DIAGNOSES REDACTED]. The location of the fall was in another resident's room. R#1 was sent to the hospital for evaluation on 05/29/14. Final disposition dated 06/01/14 indicated R#1 continued with ten staples to the back of the head, "continue to monitor." The incident report did not include an Incident/Accident Investigation Post Fall. R#1's care plan, status [REDACTED]. There were no approaches describing the type or amount of supervision staff were to provide for R#1. Fall Risk Review dated 05/29/14 indicated R#1 had unsteady gait and balance and was at risk for falls. -Incident Report completed by the Administrator on 07/29/14 indicated that, on 07/13/14 at 12:00 p.m., R#1 had an unwitnessed incident. R#1 was found sitting on the floor. R#1 had no injuries. Final disposition indicated to monitor R#1 for changes in mental status and increased unsteady gait. Incident/Accident Investigation-Post Fall indicated action to be taken was to monitor for unsteady gait and continue to encourage rest periods during the day. R#1's care plan, status [REDACTED]. There were no approaches describing the type or amount of supervision staff were to provide for R#1. -Incident Report completed by Administrator on 07/29/14 indicated that, on 07/13/14 at 4:00 p.m., R#1 woke up from a nap and was found on the floor of another resident's room with minimal blood to back of the scalp, open from a previous injury on 05/29/14. R#1's family refused to send R#1 to the ER for evaluation. Final disposition indicated to monitor for changes in mental status and pain. A tilting wheelchair was provided, "to allow resident to have rest periods and prevent further falls." Incident/Accident Investigation-Post Fall indicated action to be taken included to monitor for changes in mental status and unsteady gait, and encourage the use of a wheelchair and anti-tippers. R#1's care plan, status [REDACTED].#1's head, wheelchair with tilt to encourage rest period, ice packs to hematoma, and to monitor for changes in mental status. There were no approaches describing the type or amount of supervision staff were to provide for R#1. Fall Risk Review dated 07/13/14 indicated R#1 had unsteady gait and balance and was at risk for falls. -Incident Report completed by Licensed Vocational Nurse (LVN) "B" on 08/04/14 indicated R#1 sustained an unwitnessed fall on 08/04/14 at 12:40 p.m. Two CNAs (Certified Nurse Aides) informed LVN "B" that R#1 was last seen sitting in the tilted wheelchair. The two CNAs assisted two other residents out of the dining room. Another resident called out to the CNAs that a resident was on the floor. A head to toe assessment was performed. R#1 had a laceration to the left eyebrow measuring 8.0 x 0. x 0.5. cm. Pressure was applied to the open area and steri strips were applied. Incident/Accident Investigation-Post Fall indicated the determination of investigation was left blank. R#1's care plan, status [REDACTED].#1's wheelchair. There were no approaches describing the type or amount of supervision staff were to provide for R#1. Fall Risk Review dated 08/04/14 indicated R#1 had unsteady gait and balance and was at risk for falls. On 08/07/14 at 11:00 a.m., the Social Worker from the hospital where R#1 was sent on 08/04/14 said that R#1 had been treated in the ER of the hospital. R#1 received nine stitches for the laceration of the left eyebrow sustained at nursing home on 08/04/14. As per family request, R#1 had been admitted at another facility after she was treated at the hospital. Hospital results of CT Scan of Head/Brain w/o (without) contrast dated 08/04/14 indicated the clinical history was a head injury. Findings indicated a comparison was made with the previous 05/29/14 unenhanced CT scan of R#1's brain. Impression of the CT scan was: 1. Interval development of findings suggestive of small parenchymal hemorrhages (bleeding in the functional tissue of the brain) involving the parietal lobes, bilaterally, since the previous 05/29/14 unenhanced CT scan of the brain is noted. No midline shift is apparent. 2. Suggestion of chronic ischemic findings of the white matter, and of mild to moderate central and cortical atrophy is again evident. 3. Acute mildly displaced fracture of the left inferior orbital bony wall is noted, with suggestion of maxillary sinus hemorrhage and/or disease more evident on the left. On 08/07/14 at 2:47 p.m., Assistant Director of Nurses (ADON) "B" said there were no new interventions put in place after the incident on 05/29/14. R#1 was sent to the ER for evaluation of her medical condition. ADON "B" said R#1's vital signs were taken and her blood pressure was checked after the incident on 07/13/14 at noon; there were no new interventions. No injuries were noted and R#1 continued to be ambulatory in the secure unit after the incident. After the 07/13/14 (4:00 p.m.) incident, R#1's Physician ordered a tilted wheelchair for R#1. R#1 was monitored for pain and discomfort. After the 08/04/14 incident, the Physician ordered a table top for R#1's wheelchair to help prevent R#1 from getting up from the tilted wheelchair. During an interview via telephone on 08/07/14 at 4:30 p.m., CNA "D" said that, on 08/04/14, she took R#1 in her wheelchair from the dining room and placed R#1 in the hallway close to R#2. CNA "D" went back into the dining room to bring other residents to the hallway. CNA "D" heard R#2 yell out in Spanish that a woman fell . CNA "D" and CNA "E" found R#1 on the floor at the entrance to another resident's room. CNA "D" said she did not see any object that R#1 could have hit her head/face on except the floor. CNA "D" said R#1 apparently got out of her tilted wheelchair and fell . CNA "D" said she and CNA "E" did not witness the actual fall. On 08/07/14 at 4:55 p.m., R#2 said a resident had fallen down. R#2 did not remember the name of the resident, how the resident fell , or when the resident fell . R#2's Care Plan for cognitive loss indicated R#2 had short-term memory confusion and dementia, bipolar disorder, and anxiety. R#2 lived in the secured unit. During the exit conference on 08/07/14 at 5:10 p.m., the facility was given the opportunity to present additional information regarding supervision to prevent accidents. The facility provided no additional information. The facility's Roster/Sample Matrix form indicated a census of 24 residents lived in the secure unit.

Based on observation, record review, and interview, the facility failed to provide treatment and services to increase Range of Motion (ROM) and/or prevent further decrease in ROM for two Residents (R#13 and R#19), of 14 residents reviewed with limited ROM, in that: 1) R#13 had no contractures to the hands in February 2013. By July 2014, R#13's hands were contracted into fists. The facility provided no services or devices to prevent R#13's hands from becoming contracted, or any services or devices to prevent worsening of the contractures once they developed. 2) R#19 had contractures to both hands. Physician order [REDACTED].#19's right hand and a hand roll to R#19's left hand. The facility did not apply R#19's hand splint/hand roll on two occasions. These failures resulted in R#13 developing avoidable contractures to the hands and could place R#19 and all 46 residents with limitations in range of motion or with contractures at risk for further decline. The findings were: 1. Admission record indicated R#13 was [AGE] years-old and admitted to the facility on [DATE]. June 2013 hand written Physician order [REDACTED]. Resident (MDS) data set [DATE] indicated R#13 had limited ROM to the upper extremities. Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R#13 had no impairment in range of motion to the upper or lower extremities. Resident (MDS) data set [DATE] indicated R#13 had limited ROM to the upper extremities. Quarterly MDS assessment dated [DATE] indicated R#13: -rarely/never understood others or made herself understood, -had severely impaired cognition (never/rarely made decisions), -was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, -had upper and lower extremity range of motion limitations on both sides, and, -received no ROM services or Occupational Therapy. R#13's Care plan, last reviewed 05/30/14, revealed R#13: -had limited range of motion of all extremities. Approaches were to keep R#13's hands clean and dry and provide gentle passive range of motion to all extremities twice daily and as needed. -required staff assistance with mobility due to weakness and decreased cognition secondary to Dementia. Approach was to provide the resident daily assistance with Activities of Daily living (ADLs - i.e. bed mobility, transfers, bathing, dressing, eating). Resident (MDS) data set [DATE] indicated R#13 had no limitations in ROM to the upper extremities. On 07/29/14 (Tuesday) at 1:50 p.m. surveyor, accompanied by Licensed Vocational Nurse (LVN) "Q", observed R#13 in her room. R#13's hands were contracted into tight fists. There were no handrolls or other devices in R#13's hands. LVN "Q" gently opened R#13's hands, with difficulty. Surveyor observed R#13's fingernails were long, extending approximately one half inch past the nail beds. LVN "Q" said staff usually cut the residents' fingernails on Sundays, but R#13's fingernails did not look like they were cut last Sunday (07/27/14). LVN "Q" said staff probably forgot to trim R#13's nails. LVN "Q" said, because R#13's hands were contracted, R#13 could damage the palms of her hands if her nails were long. On 07/29/14 at 4:17 p.m., surveyor attempted to interview R#13. R#13 did not respond to surveyor's questions. On 07/30/14 at 2:55 p.m., Occupational Therapist (OT) "O" said R#13 participated in Occupational Therapy in February 2013 to improve shoulder range of motion. Occupational Therapist "O" said R#13 was discharged from therapy and placed on a restorative program. Occupational Therapy Discharge Summary dated 02/19/13 for R#13 indicated dates of service from 01/18/13 to 02/15/13 in increasing Passive Range of Motion to R#13's shoulders. There was no mention of any concerns with ROM or contractures to R#13's hands. There was no documentation in R#13's medical record of any restorative therapy. On 07/30/14 at 3:05 p.m., OT "O" accompanied surveyor to R#13's room. R#13's hands were contracted in tight fists. There were no hand rolls or other devices in R#13's hands. With difficulty, OT "O" was able to slowly open R#13's hands. OT "O" said that R#13 would, "probably benefit" from therapy and adaptive devices to prevent more hand contractures. OT "O" said R#13's hands were not contracted back in February of 2013. OT "O" said she would ask for a physician referral. On 07/31/14 at approximately 9:00 a.m., Restorative Aide (RA) "V" said she had been employed at the facility for, "a few months." RA "V" said she had never worked with R#13. On 07/31/14 at 9:05 a.m., Certified Nurse Aide (CNA) "G" said she would report any changes in a resident's condition to the Charge Nurse. CNA "G" said she had not reported R#13's hand contractures to the nurse. CNA "G" said she thought the LVN knew about R#13's contractures. CNA "G" said she had not documented that R#13 had hand contractures. On 07/31/14 at 9:13 a.m., OT "O" said she was unable to find any record of R#13 having received restorative care. On 07/31/14 at 9:15 a.m., Medical Records Clerk "U" said she was unable to find any restorative care plan/program in R#13's records. On 07/31/14 at 9:18 a.m., LVN "R" said, during direct care, nursing staff should notice any changes in residents' conditions. LVN "R" said changes in residents' conditions should be reported to the Assistant Director of Nurses or the Director of Nurses (DON). LVN "R" said she had not reported that R#13's hands were contracted. LVN "R" said R#13 would probably benefit from interventions to prevent further contractures. On 07/31/14 at 9:20 a.m., the Director of the Therapy Department said R#13's name had not been mentioned to them. The Director of Therapy Department said he would follow up on the request made to the physician for assessment of R#13. The facility's undated policy, Range of Motion Exercises, indicated: -"A regimen of individualized range of motion is available to all residents of the long-term care facility." -"Range of motion exercises are used to: maintain joint mobility, prevent deformities that limit function." The facility's policy, ADL/Mobility Management dated 12/18/10 indicated: -"It is the policy of the Center that residents will be assessed for ADLs, balance, Range of Motion, and mobility. A plan of care will be developed to promote optimal independence-Initial assessment and identification of prior level of function establishes baseline..." -"Effective referral process to skilled therapy when a decline in mobility of ADL's is identified." -"Impress upon staff the vital role they play in maintaining and/or improving resident ADL/mobility performance." -"Residents will be reviewed for functional status via the MDS process quarterly and as needed." -"Staff will receive training on identification and reporting of changes in ADL/mobility." On 07/31/14 at 10:15 a.m., the Director of Nurses (DON) said R#13's hand contractures should be documented on the facility's assessments. The DON said staff addressed changes in residents' conditions at the morning meetings. On 07/31/14 at 1:30 p.m., the DON said residents were physically assessed initially at admission, then quarterly, annually, and upon significant change in condition. 2. July 2014 Physician order [REDACTED]. R#19's [DIAGNOSES REDACTED]. July 2014 Physician order [REDACTED]. "WHFO (Wrist, Hand, Finger, Orthotic) splint, apply to right hand, on @ 2 p.m. & off @ 6 p.m. Monitor for redness & swelling *Contracture to right hand." "Hand Roll, apply to left hand, on @ 2 p.m. off @ 6 p.m. Monitor for redness & swelling * Contracture to left hand." Order date was 02/07/14. Occupational Therapy Discharge Summary form signed 02/10/14 documented R#19 had OT services for Contracture Management from 01/13/14 through 02/06/14. Recommendations were for R#19 to wear a hand splint to the right hand and a hand roll to the left hand for 4 hours in order to improve Passive Range of Motion (PROM), for adequate hygiene, and to reduce abnormal tone prior to splint application. Annual Minimum Data Set (MDS) assessment dated [DATE] documented R#19: -had severely impaired cognition (never/rarely made decisions), -was totally dependent on staff for bed mobility, transfers, dressing, eating and personal hygiene, and, -had Range of Motion (ROM) limitations to both upper and lower extremities (impairment on both sides). Care Plan dated 06/29/14 indicated R#19 was at risk for further worsening/infection of hand contractures. Approaches were to: -observe for skin improvement/deterioration weekly, -monitor for skin infection, -report any significant changes to MD (physician), -conduct weekly skin assessments, -keep area clean and dry, and, -provide passive, gentle ROM to both hands. The use of splints and hand rolls was not mentioned in R#19's Care Plan. On 07/30/14 at 2:30 p.m., surveyor, accompanied by CNA "P", observed R#19 in bed. Both of R#19's hands were contracted, with her fingertips tightly pressed against her palms. R#19's hands had no splints, hand rolls, or other devices. At the time of observation, CNA "P" said he was a new employee and was not sure if R#19 needed to have hand roll or splints on her hands. At this time, surveyor attempted to interview R#19. R#19 did not respond to surveyor's questions. The facility's Physician order [REDACTED]. R#19 was identified on the list. On 07/30/14 at 4:00 p.m., surveyor, accompanied by Occupational Therapist "O", observed R#19 in bed. Occupational Therapist "O" commented that R#19 did not have her splint and hand roll in her hands. Occupational Therapist "O" said she had assessed and evaluated R#19's hands a couple of months ago for contractures. Occupational Therapist "O" said they recommended R#19 to have a hand roll applied to her left hand and a splint for her right hand. Occupational Therapist "O" said she was not sure why R#19 did not have her hand roll and hand splint on her hands. July 2014 Routine Treatment Administration Record for R#19 indicated to apply a WHFO splint to R#19's right hand daily from 2:00 p.m. to 6:00 p.m. LVN "E" initialed the flowsheet as having applied the WHFO splint to R#19's right hand on 07/30/14. July 2014 Routine Treatment Administration Record for R#19 indicated to apply a hand roll to R#19's left hand daily from 2:00 p.m. to 6:00 p.m. LVN "E" initialed the flowsheet as having applied the hand roll to R#19's left hand on 07/30/14. On 07/31/14 at 2:15 p.m., LVN "E" said she applied R#19's hand roll and hand splint yesterday (07/30/14). LVN "E" said she or another shift nurse would place the hand roll and splint on R#19. LVN "E" said she placed the hand roll and hand splint on R#19 at 2:00 p.m. on 07/30/14. Surveyor informed LVN "E" that surveyor observed R#19 without the hand roll and hand splint at 2:30 and 4:00 p.m. on 07/30/14. LVN "E" then said she could have applied R#19's hand roll and hand splint after 4:00 p.m., before LVN "E" went home. LVN "E" said she must have gotten busy and not had a chance to put the hand roll and hand splint on R#19 at 2:00 p.m. as ordered. During the pre-exit conference on 07/31/14 at 3:40 p.m., the Administrator and DON were given the opportunity to provide any additional information regarding treatment and services to prevent decline in ROM and contractures. The facility provided no additional information. Facility's Resident Census and Conditions of Residents dated 07/28/14 indicated 46 residents with contractures. Physician order [REDACTED].#19.

Based on observation, interview and record review the facility failed to ensure two Residents (R#13 and R#12) of five residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. 1) R#13 fell seven times in four months. On 05/07/12 R#13 fell and sustained a fracture to the left hip. 2) R#12 fell thirteen times in six months. The facility did not monitor for effectiveness of interventions, and evaluate hazards/risk to reduce avoidable falls. Failure to provide adequate supervision and assistance devices to prevent accidents resulted in R#13 falling and sustaining a left hip fracture and could place all 39 residents with a history of falls at risk for further falls and injury. The findings were: 1) Face Sheet indicated R#13 was [AGE] years old. Original admitted was 04/07/12. R#13 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/09/12 at 10:00 a.m. during initial rounds, accompanied by Assistant Director of Nurses (ADON) "N", surveyor entered R#13's room. ADON "N" said R#13 had a history of [REDACTED]. ADON "N" said on 05/07/12, R#13 was walking, lost her balance, and fell . R#13 was sent to the emergency room and was admitted for a fracture of her left hip. ADON "N" said R#13 was now unable to walk and required total assistance of two staff to be transferred to a wheelchair. Incident/Accident Report dated 01/12/12 at 3:20 p.m. - R#13 was walking on the hallway, lost her balance and fell . There were no injuries noted. Final disposition indicated R#13 continued to ambulate without assistive device and had poor posture. Staff was to redirect R#13 to sit on a regular chair to allow for rest periods. There were no other interventions documented to prevent further falls. R#13's Care Plan dated 02/06/12 indicated R#13 had a history of [REDACTED]. Approaches included: -low bed -assess resident's balance -involve in activities program -assess resident's need for assistive supportive device -keep call lights and bed controls within easy reach -encourage to call for assistance -answer call light in a timely manner Incident/Accident Report dated 02/07/12 at 6:50 p.m. - R#13 attempted to get up from a wheelchair in the dining room and fell in a sitting position. There were no injuries noted. X-rays were done and were negative for fractures. Post Fall Assessment recommendations to prevent further falls were to encourage rest, "resident non-compliant." There were no other interventions documented to prevent further falls. R#13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R#13: -had moderately impaired cognition (decisions poor, cues/supervision required), -required limited assistance of one staff for walking and transfers, and, -had falls since admission. R#13's Care Plan update dated 02/07/12 indicated R#13 had a fall on 02/07/12. There were no new interventions to prevent further falls other than X-rays to bilateral hips and neurochecks. Incident/Accident Report dated 02/18/12 at 7:15 a.m. - R#13 was walking in the hallway when she fell backwards, hitting her head on the carpet, sustaining a hematoma (bruise). Condition prior to incident was confused, ambulatory, with slow and very unsteady gait. Skull Xray was negative for fracture. Interventions were for staff to redirect R#13 and encourage more rest periods during the day. There were no other interventions documented to prevent further falls. Report indicated R#13 continued to walk without an assistive device, used a wheelchair at times. R#13's Care Plan update dated 02/18/12 indicated R#13 had a fall on 02/18/12. There were no new interventions to prevent further falls other than allowing the resident to rest in wheelchair and redirect to allow rest periods. Incident/Accident Report dated 03/08/12 at 7:00 p.m. - R#13 was walking down the hallway, tried to sit in a wheelchair, missed the seat, and fell on her buttocks. No injuries were noted. Final disposition was for staff to redirect resident, rest periods during the day. Recommendations to prevent further falls were to have "Hipsters" (padded undergarment) while out of bed, monitor for increased weakness. Incident/Accident Report dated 03/20/12 at 6:45 p.m. - R#13 slipped and fell while walking in the hallway, landing on her buttocks. No injuries were noted. Condition prior to incident was confused and ambulatory. Interventions section indicated R#13 continued to ambulate with unsteady gait in the hallway. There were no interventions documented to prevent further falls. Final disposition indicated, "Staff attempts to have resident interact with activities." Incident/Accident Report dated 04/20/12 at 2:30 p.m. - R#13 stood up from the wheelchair, lost her balance, and fell on her left side. R#13's left arm was twisted to her back side. Condition prior to incident was that R#13 was sitting in a wheelchair in front of the nurses station, occasionally standing up. X-rays were done to R#13's left shoulder, left elbow, left wrist, and left hip. Left Hip X-ray showed increased separations of clips to left hip. There were no interventions documented to prevent further falls. Incident/Accident Report dated 05/07/12 at 10:15 a.m. - Staff member observed R#13 turn in the hallway, lose her balance and fall on her left side. R#13 was unable to move her left foot. Condition prior to incident was that R#13 was awake, confused, and ambulating with unsteady gait. R#13 was admitted to the hospital for Left Hip Fracture. admission orders [REDACTED]. R#13's Care Plan update dated 05/07/12 indicated R#13 had a fall on 05/07/12 and was sent to the hospital for evaluation and treatment. There were no new interventions to prevent further falls. R#13's Care Plan update dated 05/14/12 indicated R#13 had a fall on 05/07/12. There were no new interventions to prevent further falls. R#13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R#13: -had moderately impaired cognition (decisions poor, cues/supervision required), -was totally dependent on two staff for transfers, -did not walk independently or with assistance of staff, -was totally dependent on one staff for locomotion, and, -had a history of [REDACTED]. On 07/10/12 at 2:40 p.m. surveyor observed R#13 asleep, with her bed at the lowest position. On 07/10/12 at 5:15 p.m. surveyor interviewed Licensed Vocational Nurse (LVN) "Q." LVN "Q" said all of R#13's falls occurred on the 400 hall. After returning from the hospital, R#13 was admitted to the 300 hall. R#13 had not had any falls since readmission. Surveyor asked "Q" how staff were made aware of which residents were at high risk for falls. LVN "Q" said falls were communicated in the 24 hour report log. Surveyor reviewed 24 hour report log and noted no notations identifying residents with history of falls, or at high risk for falls. On 07/11/12 at 3:10 p.m. surveyor observed two Certified Nurse Aides (CNAs) having difficulty arousing and transferring R#13 to a wheelchair. Surveyor noted R#13 was very stiff when getting her out of bed and into the wheelchair. On 7/12/12 at 10:25 a.m. surveyor interviewed 300 hall CNA "R." CNA "R" said when a resident fell the nurse was notified and X-rays were done. CNA "R" said, "I do not know of getting reports from leaving CNAs about residents falling down; I do not get that kind of report. Nurses don't tell me about the residents that fell down. I didn't know (R#13) had falls. (R#13) just came to the 300 hall recently." On 07/27/12 at 2:30 p.m. CNA "W" said she had only been working at the facility two months. CNA "W" said she worked on the 400 hall. CNA "W" said if a resident was not walking well or appeared dizzy, she would sit the resident down and tell the nurse. CNA "W" said she was told that the Secure Unit was more resistrictive and most residents on the unit had Alzheimer's so she should be extra careful with the residents. On 07/27/12 at 11:05 a.m. Physical Therapist (PT) "AA" said that on admission residents were screened for high risk for falls and nursing staff would notify therapy staff when there were physician's orders [REDACTED]. PT "AA" said a PT could screen for physical therapy services without a physician's orders [REDACTED]. The therapy department would evaluate the resident for balance, risk for falls, cognitive issues, decreased strength, and decreased safety awareness. PT "AA" said the therapy department would notify the nurse on recommendations on compensatory techniques, use of an assistive device like a walker, need to keep environment clear with no clutter in the room, use of highlighted tape on floor so residents could see it. PT "AA" said the therapy department would let the nurses know if residents were using walkers, wheelchairs or other devices. The therapy department would follow up if residents were not using the device and ask nursing to encourage the resident to use the device. If a fall occurred with a device, other techniques were used, like a different device, increased supervision, or medication changes. In weekly team meetings options were discussed, like use of a personal sitter, increased supervision, or placement in another facility where the resident's needs could be met so falls could be prevented. On 07/27/12 at 11:45 a.m., surveyor interviewed Physical Therapy Director "U." PT Director "U" said they tried to introduce the use of a walker or wheelchair with R#13 so staff could encourage R#13 to rest. PT Director "U" said that, prior to her hip fracture, R#13 paced constantly and her safety awareness would decline with fatigue. R#13 was "very anxious and impulsive" and could not be redirected to rest. PT Director "U" said R#13's balance was not the problem, she was physically very strong. Staff removed medication carts from the hallway, and moved residents who were in R#13's path when walking. PT Director "U" said some of R#13's medications would make her drowsy but they would not "keep her down"and it would make her safety issues worse. R#13 would go into other residents' rooms and would pace the hallway. PT Director "U" said, "I do not think we provided effective interventions on her pattern of falls. Her falls were inconsistent with time. She (R#13) walked at such a high level, I did not perceive it as a staff supervision problem." 2) Face Sheet indicated R#12 was [AGE] years old. Original admitted was 07/03/10. R#12 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/09/12 at 10:00 a.m. during initial rounds, accompanied by Assistant Director of Nurses (ADON) "N", surveyor entered R#12's room. ADON "N" said R#12 had a history of [REDACTED].#12 fell down last month. She was dizzy and lost her balance. R#12 was sent to the emergency room due to changes in her mental status. Surveyor noted R#12 ' s bed was in low position with a bed alarm. R#12's Care Plan dated 12/22/11 indicated R#12 was at risk for falls due to impaired balance and use of antianxiety and antidepressant medications. Approaches included: -assess resident's balance -involve in activities program -assess resident's need for assistive supportive device -keep call lights and bed controls within easy reach -encourage to call for assistance -answer call light in a timely manner R#12's MDS assessment dated [DATE] indicated R#12: -was able to complete the BIMS (Brief Interview for Mental Status), -was able to walk and transfer with staff supervision only, and, -had no falls since admission. Incident/Accident Report dated 01/04/12 - R#12 was getting up from bed, lost balance hit forearm and right rib area, abrasion to forearm, scrapes to right hip complain of pain to hip. Interventions: Medicated for pain, X-rays done, abdominal binder order, No interventions to prevent further falls. R#12's Care Plan update dated 01/04/12 indicated R#12 fell on [DATE]. The only new approaches were to continue with therapy services and complete neurochecks. Incident/Accident Report dated 01/15/12 - R#12 was found on the floor. R#12 said she became dizzy and fell down on her back, Xray was negative for fracture. R#12 was educated to call for assistance staff to ensure clear pathways in resident's room. No other interventions to prevent further falls were documented. R#12's Care Plan update dated 01/15/12 indicated R#12 fell on [DATE]. There were no new approaches documented to prevent further falls. Incident/Accident Report dated 02/17/12 - R#12 said she was at the edge of the bed and slid to the floor. Order was given for a bed alarm and to continue therapy services. Incident/Accident Report dated 03/05/12 - R#12 was found on the floor, and sent to the ER for a laceration to her right eye. Returned to the facility with sutures to the right eye and a fracture to her nose. No follow-up interventions for prevention of further falls were documented. R#12's MDS assessment dated [DATE] indicated R#12: -was able to complete the BIMS, -was able to walk and transfer with staff supervision only, and, -had one fall since admission. Incident/Accident Report dated 04/12/12 - R#12 slipped from the edge of the bed to the floor Interventions were to continue with the bed alarm, and remind to use the call light. Incident/Accident Report dated 04/25/12 - Nurse informed by CNA that R#12 was ambulating from the bed and felt dizzy and fell on her left side. No new interventions to prevent further falls/ Incident/Accident Report dated 05/17/12 - R#12 lost balance and fell . No new interventions to prevent further falls were documented. Physical Therapy PT Evaluation & Plan of Treatment indicated R#12 was evaluated due to difficulty in walking and Dementia on 05/29/12. R#12 was to receive therapy, including gait training, five times per week for four weeks to improve leg strength and improve functional balance with ambulation. Incident/Accident Report dated 05/30/12 - R#12 found on floor between night stand and bed. No new interventions to prevent further falls were documented. R#12's Care Plan update dated 05/30/12 indicated R#12 fell on [DATE]. There were no new approaches documented to prevent further falls. Therapy Progress Note dated 06/05/12 indicated R#12 demonstrated good rehab potential but was at risk for falls. R#12's remaining impairments included balance deficits, postural alignment control, and decreased safety awareness. Incident/Accident Report dated 06/19/12 - R#12 walked to nurses station, stating she had fallen. R#12 sustained a small laceration to her right thumb with bruising. R#12 said she stood up and became dizzy. She fell on her bed and hit her head on headboard. Interventions were to continue with therapy, monitor for dizziness. Incident/Accident Report dated 06/21/12 - Nurse heard loud noise found R#12 on the floor. R#12 said she became dizzy when getting her clothes out and fell . Resident had an injection at the Physician's office the previous day and had just returned from the emergency room , with orders for antibiotic for a urinary tract infection. Incident/Accident Report dated 06/25/12 - Nurse informed by CNA that R#12 had fallen in the morning. No injuries were noted Incident/Accident Report dated 07/04/12 - R#12 was found sitting on the floor by the room door. No injuries noted. Final Disposition was to continue with the bed alarm, call light within reach, and remind to call for assistance. R#12's Care Plan update dated 07/04/12 indicated R#12 fell on [DATE] and had recurrent falls. Interventions included bedrest for 12 hours after Lumbar Procedure, continue with bed alarm while in bed, staff to redirect resident, continue with bedrest to prevent further falls, neuro checks. Therapy Progress Note dated 07/05/12 indicated R#12 demonstrated good rehab potential but was at risk for falls. R#12's remaining impairments included balance deficits, postural alignment control, and decreased safety awareness. On 07/10/12 at 11:40 a.m. surveyor observed R#12 in bed with the call light at her feet. On 07/10/12 at 2:40 p.m. surveyor observed R#12 walking in her room. R#12 was taking clothes out of drawers and putting them in a nylon bag. Several articles of clothing were on the floor. Incident/Accident Report dated 07/11/12 at 12:20 p.m. - R#12 had returned from a physician's appointment after an injection to the lumbar spine with orders for bedrest for 12 hours. R#12 was placed in bed with a bed alarm and call light in place. R#12 attempted to get out of bed alone and was found on her right side, stating she hit her head. R#12 was medicated for pain and neuro checks were done. R#12 was assisted back to bed and reminded to call for assistance. Interventions were to continue with therapy services, use a walker to assist with ambulation, continue with bed alarm, place on 15 minute checks for 72 hours, therapy evaluation for walker and gait training, staff to encourage resident to use walker and call for assistance. Resident 15 Minute Checks form indicated every 15 minute checks were done on R#12 from 07/14/12 to 07/18/12. R#12's Care Plan update dated 07/11/12 indicated R#12 fell on [DATE]. Care Plan indicated R#12 had returned from a physician's appointment after an injection to the lumbar spine with orders for bedrest for 12 hours. R#12 was consistently getting out of bed and fell . Interventions were for staff to report significant changes to R#12's Physician and Responsible Party, do neuro checks, continue with therapy services, use walker to assist with gait and mobility. On 07/26/12 at 1:55 p.m. surveyor interviewed CNA "BB". CNA "BB" said she worked on the 300 Hall. CNA "BB" said R#12 frequently was anxious and was always moving and active. CNA "BB" said R#12 was aware of what she was doing and did not want to lose her dignity and independence. CNA "BB" said staff had to monitor R#12 but also respect her independence. CNA "BB" said residents who were at risk for falling had a Star in the ADL book. CNA "BB" said when she returned to work her coworkers and the nurse told her who had dizziness and who falls. CNA "BB" said when some residents are dizzy they say they do not feel well. CNA "BB" said she would place the resident in bed and tell her partner to stay with the resident while she told the nurse. CNA "BB" said to "redirect" was to change the place or to distract the resident from whatever they were doing. On 07/26/12 at 3:30 p.m. surveyor interviewed R#12's Responsible Party (RP). The RP said he was concerned with the number of falls R#12 sustained and had talked to the Social Worker, the DON (Director of Nurses), and the nursing staff about R#12's falls. The RP said R#12 was "very hard headed." The RP said R#12 used the walker only when she wanted to and had alarms but disconnected them when she wanted. The RP said he visited R#12 every day. The RP said R#12 was a homemaker, did not like activities like coloring or watching television. R#12 liked to wash and fold clothes, help other people and stay busy. The RP said the staff should give R#12 something to do and help others to keep her mind active and involved. The RP said he was always notified of incidents and accidents involving R#12 and he was the one who took R#12 to the doctor. The RP said the doctor would give R#12 steroid shots for her knees and back. On 07/26/12 at 3:45 p.m. surveyor interviewed CNA "DD". CNA "DD" said she worked on the 300 and 400 halls and had known R#12 for over [AGE] years. CNA "DD" said R#12 stood up and fell because she got dizzy. CNA "DD" said R#12 would not use her walker. CNA "DD" said she always got reports on the residents from the previous shift CNA and nurse. CNA "DD" was asked how she monitored residents for dizziness. CNA "DD" said many times a resident stopped when walking and held their head or would walk sideways or hold on to a chair, hallway rails or walls. CNA "DD" said when she saw this she would sit the resident down and call the nurse. CNA "DD" said the CNAs worked as a team to monior residents for falls. CNA "DD" said R#12 could be uncontrollable depending on her mood. CNA "DD" said the staff tried to distract and talk with the residents and entice them to change whatever they are doing. CNA "DD" stated, "We know them very well." On 07/26/12 at 4:15 p.m. surveyor interviewed R#12 in her room. Surveyor observed R#12 was standing next to her bed, folding some pants. R#12's posture was bent forward, leaning to the right. As R#12 walked to her closet, she was bent forward and to the right side, her back was hunched forward leaning towards the right. R#12's knees were bent at approximately 60-70 degrees and she took short shuffling steps. She did not use the walker that was next to her bed. R#12 said she was [AGE] years old and she was looking for clothes that would fit her. R#12 said she had been here since December and was getting used to being here. R#12 said she had fallen several times. R#12 said she was always in a hurry, got arthritis shots, "steroids" to her knees and back and got "sleepy" with the shots. R#12 said she had to be careful so she would not hurry because she had, "nervous energy." At this time (4:45 p.m.) R#12's RP walked into her room. R#12 walked out of the room using her walker and she and her RP went to the lobby. On 07/26/12 at 4:52 p.m. surveyor interviewed RN "EE". RN "EE" said she worked at the facility "as needed." RN "EE" said R#12 ambulated with a walker, but was non-compliant when she first received the walker. RN "EE" said R#12 could verbalize her needs and tell staff if she was dizzy or had pain. On 07/27/12 at 4:15 p.m. surveyor interviewed LVN "GG". LVN "GG" said she had been employed at the facility for one month and was the charge nurse on the 2:00 p.m. to 10:00 p.m. shift. LVN "GG" said, to her knowledge, R#12 ambulated with a walker. LVN "GG" said a new fall prevention program had been started two weeks ago, the Falling Star program. LVN "GG" said residents on the program were to be checked more frequently and monitored closely. CNAs were advised to be available for transfers and ambulation. LVN "GG" said residents with dizziness demonstrated abnormal gait, or complained of headaches or vision problems. LVN "GG" said R#12 needed a lot of redirection. LVN "GG" said around 7:00 - 7:30 p.m. R#12 started to complain that things were missing or that she could not find certain items of clothing. LVN "GG" felt that R#12 could have Sundowner's syndrome. LVN "GG" explained that a person with Sundowner's syndrome was a person who becomes more confused and disoriented in the evenings. On 07/27/12 at 5:15 p.m. surveyor interviewed PT Director "U." PT Director "U" said he assessed R#12 on 07/11/12 to discuss with her why she fell . R#12 said she had been to see the doctor and was tired. R#12 said she got out of bed to get candy from her drawer and fell . PT Director "U" said he saw that R#12 might benefit from a walker. PT Director "U" said he met with R#12's PT and R#12 on 07/13/12 and R#12 started using the walker on 07/18/12. PT Director "U" said R#12 needed to be reminded by staff to use the walker. PT Director "U" said one week ago Occupational Therapy (OT) started R#12 on safety/ falls awareness training to help her keep her mind on how to stay safe. On 07/26/12 at 2:40 p.m. surveyor interviewed the DON. The DON said all residents had a fall assessment upon admission or readmission from the hospital. The falls were followed up by the IDT (Interdisciplinary Team) members following the morning meeting. Referrals were made to Physical therapy (PT) for assessment within 24 hours after a fall. Care Plan interventions were developed during the IDT meeting within a 24 hour period of the fall and CNA assignment sheets were updated. Monitoring was done to ensure assistive devices such as automatic bed alarms, wheelchairs, pommel cushions, tilt-back wheelchairs, low beds, table tops, or self-release belts were in place. The DON said documentation could be found in the CNAs ' ADL sheets, the Restraint Assessment form, Nurses Notes, and/or the fall follow-up sheets. The DON said the Falling Star Program had been started about two weeks ago. The DON said yellow stars were placed on the resident rooms and on wheelchairs and walkers. The DON said the Falling Star Program was updated on Tuesdays. The DON said the Care Plan interventions were updated, and initialed by the Unit nurse. Undated list of residents on the Falling Star program included R#12. On 07/26/12 at 1:45 p.m. surveyor interviewed the facility Administrator. The Administrator said all residents that fell were reviewed at the morning meeting. The Administrator said the interventions were reviewed to see if they were working or if there was a need for a change. The Administrator said each floor had an assignment and ADL flow sheet which included the Falling Star List. The Administrator said the resident was referred to Rehabilitation on the first fall, the resident's medications were evaluated, and the fall care plan was developed. The Administrator said a fall assessment was part of the admission assessment and was done on all admissions. The Care Plan was updated after each event. The Administrator stated, "We are all responsible for monitoring residents for falls." Facility policy, Fall Prevention, revised 11/2005 indicated, "It is the policy of this Center to assess residents for risk of falls; to follow up and evaluate falls of residents in order to assess the resident's condition; to identify the reason for the fall and prepare a plan of care to reduce the potential for future falls." During the exit conference on 07/27/12 at 5:40 p.m., the Administrator and DON were asked if they had any information relating to fall prevention. The Administrator and DON did not provide any other information. The facility provided a Centers for Medicare & Medicaid Services (CMS) Roster/Sample Matrix form (form 802) which identified 39 residents with a history of falls.